Primary Care Physicians: What Do They Know About Allergies and When Do They Know It?

Leafing through the journals I neglected over the summer, I noticed an article by our contributor Dr. David Stukus titled “Deficits in allergy knowledge among physicians at academic medical center.” This is a topic near and dear to us at Asthma Allergies Children World Headquarters because one of our founding tenets was to help busy pediatricians and other GPs as well as parents keep up with developments in allergic medicine. So I reached out to Dr. Dave with a few questions. –Henry Ehrlich

AAC: Thanks for taking time to talk with us. I know that a lot of research begins with researchers making observations about what they see around them, and I further note that one of the two academic centers you studied was your own home base, Nationwide Children’s Hospital in Columbus (the other was University of Pittsburgh). Without being unkind about the hospital, what did you hear and see at Nationwide that prompted you to study this topic?

Dave: Thank you, Henry, I’m honored that you thought of me! Allergic rhinitis, food allergy, drug allergy, stinging insect hypersensitivity, asthma, and eczema are the bread and butter conditions that most allergists treat. With each of these conditions, there are nuances and constantly shifting and emerging evidence that change the way allergists evaluate and treat them. I became fascinated with the questions being asked by referring providers that were based upon dated and since refuted, or non-evidence based, information. While there are a lot of misconceptions regarding the pathophysiology of allergic conditions, poor understanding of the utility and interpretation of diagnostic testing for specific IgE is widespread. A lot of referrals are for patients who already had specific IgE testing performed, typically for foods, and are being sent to help with interpretation.

In addition, families often relay information they received from health care professionals or from their own searches that is either contradictory to standard practice or based entirely in myth. After spending many office visits reversing previously held beliefs, I started to question where these beliefs came from and why they were so pervasive. All of this led me to try to better characterize the knowledge of common allergy related conditions among physicians.

AAC: Was there any single incident or set of incidents that really set this topic in your mind?

Dave: It was really based upon recurrent situations over years that prompted me to further investigate this topic. It is truly amazing to me how the same set of misconceptions continues to arise over and over again. What’s even more fascinating is how these misconceptions are spread among physicians in primary care and subspecialties, across different generations, and all areas of practice, including academicians and private practitioners.

AAC: You cite as a shortcoming of the study the fact that your sample only included academic hospital physicians, not private practitioners. Why is this a weakness, and what do you think a survey of private doctors would reveal? Do you think they would be more knowledgeable or less?

Dave: It is a weakness as physicians in private practice may have different levels of experience and/or knowledge base compared with academics. The model of private practice traditionally involves many more patient encounters during each day with less time devoted to academic pursuits such as research, journal clubs, and education of trainees. There are certainly many physicians in private practice who have found a way to incorporate all of these aspects into their careers, but by and large, academic physicians spend less time with patients and more time on other pursuits.

I would be curious to see how the knowledge of private doctors compares with those in academia. On one hand, they may do better due to their extensive patient care experience. On the other hand, they many not do as well based upon much more limited peer interaction and potential to not stay up to date with current evidence-based guidelines.

AAC: Some of your data is really eye-opening. For example, no one got an A+ (100%) and 50 respondents (12.3%) didn’t get a single question right. Only one question was answered correctly more than 50% of the time (64%). Were you surprised? If not, why not?

Dave: Yes! I figured we would see the typical bell-shaped curve in regards to distribution of correct answers. But to have zero out of 408 physicians correctly answer all 6 (internal medicine) or 9 (pediatric) questions correctly was definitely surprising! I was also surprised to see so many with zero correct answers.

AAC: One of the items that you single out is the decades-old misconceptions about radio contrast and shellfish allergy and about iodine being the allergen. I have thought about this one a great deal because we have written about it ourselves. Dr. Paul Ehrlich, my cousin and co-author, has written about it in our pages and in the New York Times. The other Dr. Ehrlich I know—my sister Anne—is a radiologist and she managed to learn her lesson a long time ago. Why do you think this is so stubborn?

Dave: This is one of my favorite allergy myths due to its pervasiveness among physicians, resiliency over the past 40 years, and oh, by the way, the fact that it was based upon a single report of survey data and never corroborated. It’s quite possible that physicians helped create this myth about iodine to help explain the previous belief of shellfish allergy increasing risk of allergy to radiocontrast media. I suppose it made sense on some level and then became mantra among physicians. Once it became incorporated as common knowledge, it was then taught to generations of medical students and residents, which then propagated the myth with their own teachings. Even with numerous peer reviewed articles and media attention over the past few years, the undoing of a myth is incredibly challenging. It will take another 10-20 years to successfully undue, if we’re successful at all.

AAC: My favorite statistic is that it takes an average of 17 years for a clinical breakthrough to make it into half the general practices in the country. Can you name a few items that should be priorities for the rest of us to push with our doctors and our readers to try to shave a few years off that timetable? Is there a list somewhere of ten things every internist and pediatrician ought to know about allergies and asthma?

Dave: Great question and this is exactly what the Choosing Wisely series is attempting to accomplish. The list published in conjunction with the American Academy of Allergy, Asthma and Immunology focuses on ten common errors in regards to testing or treatment for allergic conditions. This includes over use and improper interpretation of food specific IgE levels, improper ordering of IgG (memory antibody) levels for evaluation of food allergy, and ordering numerous tests in the evaluation of chronic idiopathic urticaria. Other topics include inappropriate use of sinus CT scans for sinusitis, lack of spirometry in the management of asthma, avoidance of influenza vaccination in egg-allergic individuals, and overuse of IgG replacement therapy when proper diagnostic evaluation for underlying immune deficiency has not been performed.

AAC: You lecture, you Tweet, you write beautifully (including for us). Do you see any new media out there, social or otherwise, that you think will help bring the rest of us up to speed?

Dave: Well, thank you for the compliment. I thoroughly enjoy educating all levels of learners, from practicing physicians to the general public. I believe that the expanse of social media offers physicians a real opportunity to connect with one another as well as our patients. People are so thankful for any doctor who takes the time to reach out in this manner, it is extremely rewarding.

While I can’t predict the next new thing in regards to media outlets, I do believe that physicians, including medical organizations, are starting to realize the benefit of social media. Almost every major medical conference uses hashtags for attendees to post tweets, which then allows anyone to follow along with the latest research from across the world. I hope the value continues to be recognized, and also rewarded by traditional academic organizations and their consideration for promotion and tenure. I am very lucky to work for a forward thinking institution at Nationwide Children’s Hospital who has supported me from the start.

AAC: Thanks for your time.

David Stukus, MD, is board certified in Allergy/Immunology and is an Assistant Professor of Pediatrics at Nationwide Children’s Hospital and The Ohio State University in Columbus, Ohio. His clinical and research interests focus on asthma and food allergies, especially improving education and adherence for patients and families. As part of his research, Dr. Stukus has created novel technology and educational tools using mobile health apps to improve the care of patients, for which he was recognized with the Nationwide Children’s Hospital Department of Pediatrics Junior Faculty Award in November 2013. Dr. Stukus has been an active member of the medical advisory team for Kids with Food Allergies since 2009 and was elected to the Board of Directors for the Asthma and Allergy Foundation of America in 2014. Lastly, Dr. Stukus actively engages with food allergy support groups and participates in social media on twitter through @AllergyKidsDoc.