By Dr. Paul Ehrlich
Baseball fans know the story told by Moneyball, book and movie, of how Billy Beane, general manager of the Oakland Athletics, and a protégé shook up baseball by replacing the star system and traditional measures of player success like home runs and high batting averages, building a team instead by recruiting players who could contribute in bits and pieces at much lower salaries than the big-name players. The old-timers in the A’s organization were furious because they considered themselves the best judges of talent based on the traditional numbers and on intangible player qualities only they could discern. The new approach carried Beane’s A’s to the brink of ultimate success in their first season and has changed baseball ever after.
So what does this have to do with allergies? My colleague Henry Ehrlich has been presenting me with examples of how the quest for “hard numbers” to indicate an ideal decision-making process for managing and/or treating allergies—especially food allergies—is causing confusion among patients and parents. The biggest problem is that doctors, pediatricians and other general practitioners as well as allergists, are employing a variety of tests that don’t even measure the same things, and when they do show something similar, different vendors have different valuations. Doctors will share raw scores and fail to interpret them, or they will over interpret them, or in some cases they won’t share them at all. Either way, they don’t answer the questions they get from parents, such as how sick is my child and when will he or she get better? And maybe that’s the way some doctors want it, because they can’t answer these questions with any certainty. If you read medical literature, it’s full of built-in qualifiers like “could represent,” “may be associated with,” and “appears to be.” These are correct, although annoying.
Dealing with anxious parents, it’s easier to hide behind numbers than it is to say, “I don’t know” or “I’m not sure.” It’s more convenient to impose blanket abstinence on a whole category of food than it is to measure and calibrate the risks of sub-sets that might afford an element of comfort and ease in feeding a child. But there’s really nothing wrong with being equivocal as long as you are honestly and knowledgeably equivocal.
Allergists do a lot that’s right. We’re better at treating environmental allergies than general practitioners are as well as patients along the asthma spectrum, and we’re better at treating allergic asthma than pulmonologists are—although there are plenty of respiratory issues for which pulmonologists have an advantage. But we have our work cut out for us. The science is moving fast, and many of us haven’t caught up. I have a book called The Atlas of Allergic Diseases by two of the giants in the field, Phil Lieberman and Michael Blaiss, that was published in 2002 and it doesn’t even mention eosinophilic esophagitis—gastritis yes, but esophagitis no. Keeping up with this and other burgeoning allergy issues is a struggle.
The 2010 NIAID guidelines for food allergies say “the routine use of measuring total serum IgE should not (emphasis added) be used to make a diagnosis of FA.” Yet, it is clear from the chatter out there that parents are still agonizing about tests that show this. The guidelines recommend the use of allergen-specific IgE tests, but warns that they are not sufficient for a diagnosis. Parents also discuss the size of wheals for skin-prick tests and the peanut epitopes Ara h1,2,3,6, and 8 very knowledgeably, which is the purview of ThermoFisherScientific’s uKnowpeanut test. But knowing the terminology and being able to actually diagnose a food allergy are not the same thing. I can show you how to hold a baseball to throw a split-finger fastball—or I could if I studied the right diagram–but I couldn’t throw one (and I certainly couldn’t hit one). Knowing the numbers and knowing what they mean are different things, and applying them under game conditions is something else entirely. (Brad Pitt is not a former major leaguer but he plays one in the movies.)
As an old-timer, I have a great deal of sympathy for the grizzled scouts in the face of new statistical methods for running a baseball team, especially when they are wielded by smart asses from Yale as in the book and movie. But as an Ivy League graduate myself, I have to sympathize with a more scientific approach (especially when $150 million in Yankee payroll has spent much of the season on the disabled list).
However, my patients’ health is not a game. It is my job to take those numbers and filter them through my years of clinical practice and tell people what they mean. I think it’s inexcusable for my fellow allergists to leave mothers at the mercy of Facebook to arrive at the truth on their own.
Photo by http://en.wikipedia.org/wiki/Split-finger_fastball