By David Stukus, MD
We recently came across news of a study showing definitively what allergists have long known—that physicians in general practice don’t know enough about allergies. Dr. Ehrlich blogged about the study here. It turns out that our new friend and contributor, Dr. David Stukus of Nationwide Children’s Hospital in Columbus, Ohio is a co-author of the study so we reached out to him to give us a bit of the story behind the story.
AAC.com: Thanks, doctor, for taking the time for our readers. We have made it a big part of our mission to spread the word on allergies to doctors as well as patients and parents, so this study is welcome. What we’d like to know, first of all is why now? And how did you and your co-authors make the decision to study this problem?
First of all, thank you for the interest! I truly appreciate the opportunity to discuss our work in a little more detail.
I have been interested in misperceptions surrounding allergic conditions for quite some time. There are some recurring themes with patients and the questions they ask during visits or with their own self-management. But more alarming to me is the number of referring providers who seem to perpetuate certain allergy myths through their own practice, particularly in regards to diagnostic testing or therapeutic decisions.
Over the past few years, I have spent considerable time learning more about the origins and pervasiveness of these misperceptions both in regards to peer-reviewed medical publications, but also from internet resources as well. I have given talks regarding this topic both locally and nationally, which always seem to gather a lot of interest from audience members. Finally, I decided to try to gather my own data to gain a better understanding of the prevalence of some of these misperceptions among physicians.
Basically, this has evolved from a personal curiosity to a platform for discussion and education.
AAC.com: Allergists frequently encounter new patients with problems like failure to thrive from overly cautious food-avoidance strategies and poorly controlled asthma because of misdiagnosis and one-size-fits-all treatment strategies. Did such observations from your own practice suggest the choice of questions?
This certainly played a role. Unfortunately, I have seen many patients who have experienced very poor outcomes and low quality of life due to poor management of their allergies or asthma. The most common example I see involves recurrent emergency room visits due to asthma for patients who were never prescribed controller medications or recognized to be in poor control. The most extreme examples involve malnutrition, poor quality of life, and severe anxiety from misdiagnosis of multiple food allergies that didn’t exist in the first place.
AAC.com: Why were there three extra questions for pediatricians?
Some of the allergy misperceptions in regards to food allergies pertain more to children, as opposed to adult patients. The types of foods that more commonly cause childhood food allergies (milk, egg, wheat, soy) are different from adult onset or persistent food allergies (peanuts, tree nuts, fish and shellfish). Recommendations for dietary introduction and advancement, or even avoidance, often pertain to infants and young children as well as mothers who are breast feeding. In my experience, there is often a lot of confusion in regards to these recommendations. In all fairness, there have been frequent changes in recommendations regarding this topic.
There are many misperceptions in regards to the validity, usefulness, and safety of skin-prick testing in young children, which is the most common way to diagnose allergies at the point of care. Skin prick testing has been utilized for decades and is a proven method to accurately diagnose food or inhalant allergies, at any age. I often hear from parents that their young child was not referred for testing as their pediatrician told them that ‘testing is unreliable until children are 3, or 4, or 5 years old’. This is just plain false but yet a significant barrier to young children receiving optimal care and a proper diagnosis.
In addition, many parents express concern about the safety of skin prick testing. During this test, a small drop of allergen is introduced to the top layer of skin, usually on the back or forearms, by using a plastic ‘prick’ device – not a needle. If a person is allergic, their allergy cells in the top layer of skin will release histamine, which causes a localized hive; a red, itchy welt that is confined to that area. Test results are determined within 15 minutes and the local itching/discomfort is typically gone within one hour. There is no evidence to support the notion that skin testing to allergens is a way to actually cause the onset of allergy for things like foods or inhalant allergens in someone who may have never been exposed. Regardless, it is still best practice to use skin prick testing thoughtfully and not as a screening test for a large number of indiscriminate allergens.
As you can see, given the unique allergy challenges specific to children, we thought it warranted additional questions specific for pediatricians.
AAC.com: We have harped on the observation that it takes an average of 17 years for a clinical breakthrough to find its way into half of general practices. Yet, standards about how knowledge spreads are often shaped by Internet time. Allergy parents will surely look at your study and wonder, “If I know this, why doesn’t my doctor know about it?” Did you look at the data and ask yourself, “How could anyone not know this?” With all the publicity that food allergies have gotten, particularly, did the shortfall in general knowledge surprise you?
Not really. In defense of all the wonderful primary care pediatricians and internists out there, they have a very challenging job to do. They face many obstacles that specialists like myself may not have to worry about. This includes pressure to see more patients each day, which amounts to less face to face time for questions and education. More importantly, they need to be trained and aware of hundreds of conditions, including pathophysiology, diagnostic testing, treatment options, whereas specialists are much more focused and can learn more details while staying up to date with current literature for a much smaller number of diseases. It’s purely a numbers game from that standpoint.
I have tremendous respect for primary care providers for the great, challenging work that they do. This study was not designed to pick on them or highlight their deficiencies, but really to identify if a knowledge deficit exists, and to what degree. More importantly, it will provide a framework to begin to better understand how allergists can help support pediatricians and internists to stay more current with specific conditions. Now that we’ve identified some areas to focus on, we can begin to think about what the best opportunities may be to develop targeted interventions.
AAC.com: Two years ago we published an interview with a pediatric resident who had spoken to her fellow residents on food allergies. She said that 75% of what she know she would never have heard if she hadn’t done an allergy rotation in Dr. Ehrlich’s private practice. With allergies increasing and training programs dwindling, what do you think we can do to teach the next generation of internists, family practitioners, and pediatricians?
Interestingly, in our study, we did not find significant differences in the responses from physicians who had participated in Allergy/Immunology electives versus those that did not. That’s not to say that these experiences aren’t valuable for physicians in training. These hands on clinical rotations allow trainees to see a higher volume of patients and focus their learning on allergy specific conditions, which is invaluable.
However, I think we also need to be aware of the stark changes that the current generation of medical trainees exhibit in regards to the way they learn. Medical education is evolving and needs to continue to evolve. The days of sitting in a classroom for a didactic lecture will likely soon be gone. Today’s generation of learners rely on technology to assist their understanding and memory. Everyone has smartphones and with that, volumes of information available within seconds. This presents a real opportunity to develop allergy specific information/education designed for mobile health or similar resources that better connect with today’s learners.
Another area of focus includes preparation for board exams. All physicians must take and pass multiple levels of certifying examinations in order to obtain a medical license and practice medicine, regardless of specialty. This is a rigorous process that includes significant preparation time. Making sure that pertinent and current allergy related information is included on board examinations, and especially in the prep work, would help ensure that these topics are at least addressed at some point.
AAC.com: You surely have a long list of things you wish every general practitioner knew about allergies and asthma. Could you give our readers a list of the top three?
I’d be happy to, although it is a challenge for me to limit my response to only three!
1. Specific IgE testing by skin prick and/or serum testing, in and of itself, is NOT diagnostic for allergy. Misinterpretation of allergy test results is the most common, and most dangerous, misconception that I encounter on a weekly basis. These tests frequently have falsely elevated and clinically insignificant results. They are very poor screening tests and over interpretation of “positive” results leads to significant misdiagnosis and unnecessary treatment or avoidance. The history is the most important factor which can help lead to targeted specific IgE testing, which then may help establish or rule out a diagnosis of “allergy”.
2. When allergies are suspected, confirmatory testing and/or evaluation by a board certified allergist should be considered to ensure an accurate diagnosis. Many symptoms, especially gastrointestinal symptoms after eating certain foods, are attributed to “allergy” but may be unrelated, or due to other causes. This is very important with suspected medication allergy and the variety of symptoms that may be attributed to an allergic reaction, but may be completely unrelated. For most food and medication allergies, the only treatment is strict avoidance. This may limit diet or lead to less effective, more expensive treatment options for medical conditions. Thus, if a true allergy does not exist, then avoidance or alternative treatment options may not be necessary.
3. Recognition of poor control of asthma and/or allergies is paramount to providing the best possible care for our patients. My best example is in regards to asthma; many do not recognize that persistent cough, particularly at night, is a strong indicator for poor asthma control. Knowing the proper questions to ask and correct interpretation of the answers can help determine whether patients are poorly controlled. Without this starting point, improving outcomes and the lives of our patients cannot occur.
AAC.com: Thank you 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.
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