Mariam Hanna, MD
It’s the middle of the afternoon after a few days off to enjoy the holidays. I sit and prepare to review a stack of referrals. I am both surprised and unsurprised at the eternal request of “please see for routine allergy testing.” Why haven’t primary care physicians gotten the message after all this time? Over the years my approach has changed, but one thing that has remained consistent is that this statement is usually the tip of the iceberg on a bigger issue.
Allergists are unique, because as one of my colleagues pointed out, I am certain that cardiologists don’t get requests for routine cardiac catheterization and radiologists do not receive requests for a routine whole-body CT. (Well, maybe in the United States, but not here in Canada.) And yet, over the years it has become acceptable and even commonplace to scribble these very words of “routine allergy testing” without considering the bigger question behind them.
Over the past 10 years, so much has changed in the field of allergies and our understanding of diagnosis and management that there is nothing routine about what we do!
The old days of allergy testing
Sometimes these referrals are an indication of the old ways of practicing allergy. Broad application of extracts of allergenic foods were applied in a standard panel-format in certain patient populations. This would be done in place of a targeted approach addressing a specific food of concern. The tests would be interpreted as an indication of allergy to food X or Y. The family would be counseled to avoid those foods from their child’s diet. This is a critical time of exposure for the immune system, so not only are there nutritional deficits but also, as we have learned, it may predispose the child to more food allergies. Allergists are becoming increasingly critical of avoidance, particularly as we initially thought these tests were more reliable than our current understanding suggests.
Food allergy skin tests, for example, are really markers of sensitization to specific foods, which need to be clinically correlated to make any meaningful recommendation. In this patient population, the positive skin test may represent a window of opportunity in an immune system at risk of development of that specific food allergy. Allergists confirmed this with the LEAP trial, infants who were sensitized to peanut had a 70% reduction in the development of peanut allergy at five years of age if physicians ignored the test and simply proceeded with a food challenge.
Environmental allergy testing is not simply about identifying what patients are sensitized to, it’s about marrying this with their symptoms and grading the severity so that an adequate management strategy both short term (with an expanding repertoire of medications) and longer-term therapies (immunotherapy) may be considered. This field alone has undergone a revolution with the advent of new antihistamines, nasal steroids and sublingual immunotherapy for disease management and modification. The role of the allergist in accurate diagnostics and utilization of therapies through shared decision making with families is essential.
Drug allergies have been widely reported for years. Allergists now support de-labeling patients after evaluation as up to 90% of patients have a chance of having this diagnosis removed. Avoidance of first line therapies such as penicillin, for example, may lead to less effective antibiotics being used, or those with broader spectrum which unfortunately may have more side effects or increase the rate of antibiotic resistant bacteria.
The business of modern-day medicine
There are multiple stake holders during a consultation: the patient, the caregiver, the referring provider, and me, the consultant. It’s best when we understand the concern and recognize the stakeholders.
Perhaps the request for “routine” screening is instigated by a primary physician who has not recognized the changes in the field of allergy diagnosis. Patients for years have been subjected to repeat allergy testing; the allergy is reconfirmed and a print-out of the “test results” is in a way their certificate and license to continue to their next test. This request can sometimes be a response to the demands of a family that has become used to this interaction with allergists.
Sadly, sometimes it’s a way of rushing through a visit without reinforcing education on the presentation of allergies and the role of the allergist. This education takes time and as primary care sees an ever-increasing number of patients, this becomes a way of getting through to the next appointment. It may surprise Americans with their stew of insurance plans and the 11-minutes-and-out primary care schedules that Canadians face many of the same pressures even though we have universal health care, but we do.
Finally, there is a system issue at play here, where we don’t emphasize the importance of public education efforts regarding allergies. We need to equip families with a better understanding of the role of this specialty in disease prevention, proper diagnosis and management including disease modifying therapies! When was the last time a child returned from school and explained the atopic march to their family? Public health efforts and feeding guidelines take time to produce and disseminate into the hands of the public.
The allergy pandemic
As we see new emerging diseases in medicine including allergic and autoimmune diseases, patients with vague symptoms present for screening in hopes of finding answers. These represent potentially the most challenging population for modern medicine. Their frustrations and history of previously being dismissed by medicine turns them to internet searches, social media and alternative health practitioners who make unsubstantiated diagnoses and treatments, further widening the gap between the patient and health care. When these families come to the allergist, the bottles of herbs and stacks of test results they produce from their bags is a testament to their frustrations with our current health care system and their inability to find a suitable answer or plan for moving forward medically. While allergy testing may be the last thing I do for these families, they deeply appreciate when I listen, provide suggestions as to the next best steps, and help defuse their anxieties.
Despite the frustrations, the rewards of this specialty are many. I started this article at New Years. Fast forward a few months and I’m finishing it, after a clinic day of routine testing that was anything but routine. Clinic days are long but exhilarating. Days seldom run as neatly as the schedule would suggest, but I feel each day we are equipping families, physicians and caregivers with knowledge, and for an allergist, that’s the new routine!
There’s always room for education, patient AND physician!
Take home points for primary care physicians
• When requesting an allergy consultation, indicate the clinical symptom or disease of concern for which a patient is seeking evaluation
• Consider re-evaluation in patients who have previously received screening testing without prior clinical histories
• Discuss with patients and families all the advancements in evaluation and management of allergies that have been made and the role of reassessment by an allergist to discuss their goals of care
• Patients with atypical disease presentation need care in the discussion and potential allergy assessment with opportunities for re-evaluation in the future as their disease presentation evolves.
Dr. Hanna is a Pediatric Allergy, Asthma and Immunology Specialist. She is a graduate of the University of Alberta, Canada where she obtained her MD degree and completed her post graduate training in general pediatrics. She completed her allergy and immunology fellowship at McMaster University, Ontario, Canada and is a fellow of the Canadian Society of Allergy and Clinical Immunology. Dr. Hanna is an Assistant Clinical Professor in the Department of Pediatrics at McMaster University. She is co-founder of Halton Pediatric Allergy Clinic. Her interests include early childhood allergy prevention, aeroallergen immunotherapy and oral food immunotherapy. Dr Hanna has focused her clinical practice at Halton Pediatric Allergy towards accurate diagnostics and management of food allergy.