By Dr. Paul Ehrlich
The British Medical Journal recently published a survey about Russian physicians and anaphylaxis. What they knew and didn’t know should surprise no one.
Surveys containing a clinical scenario pointing to food anaphylaxis went out to 707 physicians and 315 (45%) responded. Sixteen who reported training in allergy-immunology excluded from the analysis, leaving the final sample size of 299. Two-thirds (68%) were pediatricians 32% were other specialties and adult physicians. All told 33% diagnosed anaphylaxis correctly, but only 10% recommended intramuscular injection of adrenalin (English English for epinephrine).
This lack of knowledge is not confined to Russia. While I couldn’t find another survey with the same methodology for the United States, I did come across two that are in the ballpark.
In the United States, a 2012 study of internal medicine residents by a group at North Shore Jewish Health System (by coincidence this is the modern version of the hospital where my father was on staff for pediatrics for decades) surveyed 146 eligible participants, with 55 (38%) participating. 81% had not previously diagnosed anaphylaxis, 75% had not managed, 96% had not used an epinephrine autoinjector, 79% had not demonstrated autoinjector use, and 81% had not referred a patient to an allergist after an anaphylaxis. Only 52% felt confident in their ability to diagnose anaphylaxis, while 40% felt confident in their ability to manage it.
In 2013 the same group surveyed 140 pediatric residents with 61 (44%) responding. They found that 41% had diagnosed anaphylaxis, 67% had managed anaphylaxis, 7% had used an epinephrine autoinjector, 56% had demonstrated how to use an autoinjector, and 56% had referred a patient for further allergy evaluation after an anaphylaxis episode. Just 46% felt confident in their ability to diagnose anaphylaxis, while 49% were confident in their ability to manage it.
Other countries show similar levels of knowledge. In Korea, a single-hospital survey of 1,615 health provides included 128 doctors, along with nurses, students, and “health personnel.” While most of the physicians cited epinephrine as the “drug of choice,” only 48% included epinephrine within the first 3 steps of treatment.
I am intimately familiar with the shortcomings of anaphylaxis knowledge among primary care physicians. That’s why for many years I have hosted a monthly rotation for residents at NYU in my practice. One of these, Dr. Maureen Egan*, reflected on the paucity of training the average resident receives when we interviewed her following a presentation to her fellow residents.
She told us, “I would say that I knew only approximately 10% of the information presented before the allergy elective and 75% of the information I acquired through the rotation. The remaining 15% (which was mostly on the rare disorders) I learned through my reading in preparation for the presentation. You are correct that unless my fellow residents pursue an allergy elective (and many do not) they may not learn these key points. We have very little training in food allergies as part of our core curriculum.”
A few years ago I wrote about the fact that there was no common diagnosis of anaphylaxis for both emergency physicians and allergists, and no agreement on the use of epinephrine. That chasm still has not been bridged.
Too many patients. Not enough allergists. We still have lots of work to do.
*For patients in the Denver area, Maureen is now at Denver Children’s following a fellowship at Mount Sinai.