Interview with Dr. Brian Schroer
We recently came across an article in In Practice called “Low Rates of Tree Nut Allergy in Peanut-Allergic Patients”. This was a review of a study by Dr. Christopher Crouch, Dr. Tim Franxman, and Dr. Matthew Greenhawt published in the Annals of Allergy Asthma and Immunology, which found that most people with diagnosed peanut allergy pass food challenges to tree nuts despite having positive skin or blood tests to the tree nuts. The gist of both articles is that most patients who have taken the precaution of avoiding tree nuts with no clinical history of reactions to them may be doing so unnecessarily. The authors of the new article are Dr. Kara B. McNamara and Dr. Brian Schroer of Cleveland Clinic. It happens that Brian and I are both frequent participants in a Facebook group called Food Allergy Treatment Talk (FATT) founded by the dynamic Stacey Cohen Sturner. I have been bugging Brian for two years to contribute to this website. It seemed like a good opportunity to call in my marker. — Henry Ehrlich
AAC: Thanks, Brian, for finally sitting still for our readers. I am so impressed with your work in FATT and the way you manage to give information without actually giving medical advice. I do that, too, but then I’m not qualified to give advice. You are. How do you tread the line and do you have any pointers for other doctors who might get involved in social media?
Brian: Henry, thank you for the opportunity to discuss this issue with you and your readers. Do not sell yourself short. Though you may not be able to give specific advice your platform is effective for transmitting scientific information to people in a way they can understand the often-complex issues of allergies. That being said, even as a physician being on social media is a blessing full of pitfalls. Being on platforms such as Facebook and Twitter can be a great way of interacting with patients and other physicians in a way that I can contribute to discussion of medical topics such as food allergy. However, even I have to be careful not to give specific advice about diagnosis, or management to individual members of those communities. The way I balance the need to spread a message but not to treat individuals is to speak broadly about concepts. I try to make complex studies easier for patients and physicians to understand. How they take those ideas and apply them to their lives or practices is up to them. I would suggest to other physicians that we need more of us out there and when doing so do it in a way that broadens the public understanding of medicine in general. While doing that, interact with people like you would at a crowded restaurant, talk to the group, and avoid specific personal advice or recommendations.
AAC: I know from your Facebook posts that you are aggressive in pushing for food challenges, which happens to be pertinent for your new article. Many allergists are reluctant to challenge, and as a result many patients ending up avoiding more foods than they need to, which takes a toll on nutrition and quality of life. What is the basis of your emphasis on this kind of procedure? Was there a particular case that stayed with you? Was it the accumulation of what you have seen? Does it really lighten the load on patients and their families?
Brian: As you have heard on the FATT group and on Twitter, when I see a patient my motto is, “Look for reasons to do a challenge.” As opposed to what I had been taught which was “Look for reasons to NOT do a challenge.” The biggest reason I changed my own mindset was my personal experience with my son who has anaphylaxis to milk. He was diagnosed during the end of my fellowship. As any food allergy parent knows, avoiding one single food ingredient is a life-changing experience. It requires constant vigilance and heightened awareness from buying food, to preparing food, to containing food (like keeping an allergy free hand), to being prepared to recognize and treat a reaction. I knew from my experience that avoiding one food was hard and that more than one would be that much harder. I knew that if there was anything I can do to prevent someone from avoiding a food unnecessarily I was going to offer it to my patients. Food challenges are the tool that allows me and my patients to know two major things–1) Which foods they HAVE TO avoid and 2) which foods they can eat safely. This was my mindset before the LEAP study showed that eating peanut at an early age can prevent kids who are at high risk for developing food allergies from becoming allergic to peanuts. One way of thinking about that is that eating peanut early and often is a “treatment” with a positive benefit. Another way of looking at that study is that avoiding peanut unnecessarily causes some kids to become allergic. Then avoiding food has a negative risk–causing the peanut allergy. That study was the first to show evidence that eating foods is safer than avoiding foods.
Other practical aspects of this philosophy is that if you are avoiding a food you may as well be allergic. In addition, not knowing if you HAVE to avoid the food may increase risky behaviors by the patient or other members of the family, which can lead to a severe reaction if they are actually allergic. Therefore knowing if you have a food allergy through a failed challenge has a benefit of knowing you have to avoid that food. There are other studies that show psychosocial benefits to a failed challenge. Patients may be more comfortable recognizing a reaction because they felt it and watched it happen in a controlled setting and then they can see how well the medications can work to treat a reaction. Therefore, if a parent is willing to do a challenge and I feel there is less than 100% chance of a reaction then I am still willing to do the challenge.
This is all a big departure from the way most practicing allergists were trained. But with new information about food allergies being published, we need to adjust our practice quickly to be able to practice up to date evidence based medicine.
AAC: How did you and Dr. McNamara come to write your review? We’re used to seeing movie and book reviews. Is this a standard practice in medical research? Was it your idea or the editorial board?
Brian: The article we wrote is a regular feature in the JACI In Practice journal called Practice Options Beyond Our Pages. It was developed by other editorial board members Julie Wang, MD and Matthew Rank, MD. It is specifically designed for allergy fellows to find articles published in other journals that can provide evidence for changing practice now. Dr. McNamara is one of our excellent second-year allergy fellows at Cleveland Clinic who is interested in food allergies. All of our fellows have published since this feature began two years ago. Julie and I will be teaching a session utilizing a number of these articles at this year’s AAAAI annual meeting in Orlando.
AAC: My favorite factoid in medicine is that it takes an average of 17 years for a clinical breakthrough to make its way into half the medical practices in the country. I can see how for the first decade or so of the modern food allergy epidemic doctors would caution patients with peanut allergies to avoid all nuts even though they rationally knew that peanuts aren’t nuts. They were being cautious and old habits die hard. What will it take to get the kind of data you and Crouch et al have found into wider practice?
Brian: I do believe that tools such as social media have allowed providers both to learn about new information faster and to interact with other providers who can provide the cultural safety net to convince them they can change their practice and still be within the “standard of care.” In addition, it is clear that many patients have a targeted understanding of the up-to-date medical literature. Something that Stacey Sturner and FATT members are so good at. Because of this physicians will have to change much faster. It is already the case that members of Twitter or Facebook are making recommendations to find other providers if someone says they were told older information. So if those providers do not stay up to date, the patients will find providers that do.
AAC: What’s the next step in this conversation about peanuts and tree nuts. Does someone write a practice parameter or a guidance? How many more steps will it take?
Brian: When it comes to practice parameters, the level of evidence needed to support the recommendations that most physicians should follow is rightly set high. However, it remains the case that there are many more questions than answers. In that real-life scenario, the art of medicine is taking the little information we have about a subject and practicing within standard of care while discussing the lack of evidence with patients. For me, speaking about this article and the evidence it presents, it is not high level evidence. It does give evidence that supports the strategy of having patients eat foods they are not known to be allergic to when it comes to tree nuts. When there is not a lot of good evidence, as is the case here, it is important to have a dialogue with patients about whether they want to introduce tree nuts if they have a peanut allergy. As we wrote in the article, doctors should discuss two specific benefits of introducing tree nuts, one certain and one hypothetical: eating the nuts will expand their diet with a tasty and healthy way, and theoretically it may decrease their risk of becoming to the tree nuts. It prevents them from having to read labels and worry about foods that contain tree nuts. They should discuss that this benefit has to be weighed by the real but rare risk that the tree nuts may be contaminated by peanuts, or that patients or others may not be able to differentiate between peanuts or tree nuts. In my clinical practice there are patients who had never been given that option. In that case the doctor made the decision for them–avoid peanuts and tree nuts. I feel that most patients appreciate the ability to make the choice on their own. Many do want to introduce the tree nuts, however there are some that feel more comfortable continuing to avoid both. Both decisions are correct if the patient is the one making it.
AAC: Many patients are reluctant to do food challenges. Could you tell our readers about the give and take in your clinic that typically leads an uncertain patient or patient’s parent to make a decision to challenge?
Brian: Every patient is an individual. Every conversation is different. As I have said above, the decision is always up to the patient and parent. I just guide the conversation leading up to the decision. When patients are scared to do a food challenge, I normalize that fear. No one wants to have a reaction, no one wants to be in the situation where they would need a shot to feel better. I ask what they have heard about challenges. As I listen to them, I encourage them to expand and clarify what they have been saying. Then I provide clear concise information about what the procedure involves and what we would do if a reaction occurs. Then I reassess what else they want to know. Once that conversation is done I ask them to teach back what they heard so that we all know we are on the same page. Then I ask what they want to do. It is rarely an emergency to do a challenge. If they need more time to make a decision then they get more time.
AAC: Even after a successful challenge, many patients must worry that their walnuts or pecans will be processed in the same facilities where their real problem such as peanuts are processed. How do you help them get over these fears?
Brian: This is can be a long discussion filled with facts and studies. I try to keep it simple. Yes there is risk but it can be mitigated. One way is to find producers of the various tree nuts who do not also process peanuts. There are websites available that have lists of peanut free tree nut producers. Another option though less desirable is to buy shelled versions of the tree nuts. Or the tree nuts which may be contaminated by peanuts could also be washed, though I am not aware of any studies confirming the effectiveness of washing peanut powders and contaminants out of tree nuts. I emphasize there is real risk for peanut contamination to cause a reaction when a precautionary label says it may have peanut in it. It does not matter what the precautionary label says. I discuss that the decision to include the tree nuts is something you would really only do at home. I caution people about going to restaurants and telling the chef or waiters that I can eat tree nuts but not peanuts. It will be very hard to know if the tree nuts have the potential for peanut contamination. But if the patient wants to try–that is their decision. Food allergy parents are very good about asking for information and preventing reactions. I trust them to go out and eat food in ways that are comfortable and safe for them and their families.
AAC: Thank you for your time.
Brian Schroer, MD is a staff physician at Cleveland Clinic Children’s Hospital. He sees both kids and adults in clinical practice. He trained in allergy at Cleveland Clinic and internal medicine and pediatrics training at The Ohio State University and Nationwide Children’s hospital. He attended medical school at the University of South Florida College of Medicine and did his undergraduate studies at Duke University. His clinical focus is on children and adults with food allergies as well as other general allergic conditions. He teaches medicine to allergy fellows, pediatrics residents and medical students in the allergy clinic. Outside of clinic he teaches communication skills to medical students during their first and second years and to staff at all levels of experience. Finally, he is a member of the Editorial Board for JACI In Practice and reviews articles for that journal.