Editorials from the Executive Medical Director

Irreverent opinions: How will nasal steroids going over the counter affect you?


July 22, 2013

The FDA has decided that a bunch of drugs are going to go over the counter as part of its initiative to shape the medical system. Is that bad or good for you? Or does it make any difference at all? It’s not a new thought. We heard it a decade ago, when Claritin made the switch, but somehow most doctors never really thought that important and potentially dangerous medications, such as those used to treat migraine, hypertension, cholesterol issues, and allergy, would ever be entrusted to the unwashed masses. To go over the counter, a disease must be self-diagnosable, which includes allergy, asthma, gun shots, migraine, hypercholesterolemia, and hypertension. The drugs and devices must be generally recognized as safe and effective, which means antihistamines, asthma inhalers, Band-Aids, anti-cholesterols, and anti-migraine drugs are under consideration.

Irreverent opinions: Your EMD’s career-ending mistake


June 26, 2013

“Code blue! Code blue!” my assistant nurse was yelling. My patient was flopping on the floor, clutching her throat, and screaming between gasps, for epinephrine. Her eyes were popping out, she was red faced and sounding really bad. The nurses had their cell phones poised for 911. People were coming from the waiting room to offer help. I decided to wait a bit.

It was another one of those people you see all the time, “I have a reaction to something.” But in talking with this 40-year-old lady accompanied by her husband the week before, the plot began to thicken.

Irreverent opinions: I used to want to work for Home Depot; now I want to be the Wal-Mart allergist


May 23, 2013

To be truthful, I’ve always wanted to retire and work in the hardware department at Home Depot. I figured I could bring my amazing knowledge of how to “fix” almost anything (although not always in the most aesthetically pleasing manner) to the world as my final gift. But, with things as they are, I may have to work until my late 90s with my dream unfulfilled. That is, until I saw that Wal-Mart and Walgreens were going to add chronic care to their repertoire of services.

Sam’s Club set the precedent. You can now get RAST testing done there periodically, and it’s cheap. Get 10 RAST tests for $49.95. And, some days, they will throw in a gallon of non-E. coli peanut butter for free. Such a deal! We heard rumblings in 2011:

Irreverent opinions: Lanier and The Rockford Files


April 24, 2013

Those of you who are older — and those like Phillip Lieberman, MD, FACAAI, and me, who publically admit to loving television — may remember James Garner playing a tricky private detective in The Rockford Files. Garner was part detective and part con man, who kept a little machine in his car to make business cards. If he was investigating a dry cleaner, he would print up an OSHA card. If the suspect was a builder, he might become the CEO of a supply company. It was a technique that gained him entry into any office.

Irreverent opinions: Everybody is going to be an old allergist one day


March 27, 2013

James Claflin, MD, FACAAI, an older allergist trying to “run out the clock,” and Stephen Wasserman, MD, FACAAI, the San Francisco-based ABAI guru, are at it again. Sparks fly and semantics sizzle as these two key opinion leaders meet on the field of MOC for mortal conflict. This year’s email from Steve to Jim designating him as “Certified but not participating in MOC” led to this exchange:

ABAI: We are writing to inform you that as of Feb. 1, 2013, your ABAI Maintenance of Certification (MOC) status is “Certified, Not Meeting MOC Requirements.”

Irreverent opinions: A breathless way to teach your staff about anaphylaxis


February 27, 2013

Looking for a way to do education for your staff that is less painless than a formal lecture series? You used to do this, didn’t you? You faithfully presented some topic once a month at lunch for your staff. And then you missed a month. And pretty soon nothing at all, right?

When times are good, you might even bring a bunch of staff members to the ACAAI Annual Meeting. But when that’s not economically feasible, it’s back to the lunch-and-learn!

Everyone has crash cart drills, but there is a richer, more fundamentally interesting recipe for educating your staff and having a good time.

Irreverent opinions: Are you going to see urticaria in the future?


January 23, 2013

You might think, “Well sure – I don’t like it, but I’ll see them.”

The reason I ask is that recent literature suggests that screening lab work just isn’t justified from cost effectiveness. Now make sure you get this: “testing” doesn’t mean skin testing – it means any lab. Lectures given during the annual ACAAI meeting quoting data from Tarbox et al suggested that screening testing of any type in chronic urticaria was rarely helpful in management of this disorder. This concept was reinforced with the joint AMA/AAAAI program of “Choosing Wisely,” which the College did not endorse.

Did we make a mistake? You’ll get your chance to comment on the leadership decision in the mini-survey below.

Irreverent opinions: Put on your big boy pants and keep trucking


November 28, 2012

I admit freely to drinking generously of the Fox News Kool-Aid and being stunned by the results of the election. But like the rest of you, we’ve all decided to put on our “big boy pants” (a term introduced to me by the wife of my most respected allergist friend) and get on with it. The ACAAI Annual Meeting was the first step in my rehabilitation. It felt good to have friends around me.

FITs are the most enjoyable part of the Annual Meeting for me. I asked one particularly cocky young FIT how much he learned about eosinophilic eosophagitis during the meeting. He confidently answered, “I now know everything in the world about EE. Ask me.”

Ah-hah! A challenge from a whippersnapper to a graybeard — and I took the bait.

Irreverent opinions: Patients were right on asthma? Asthma guidelines challenged by new studies and FDA


October 24, 2012

Somewhere there is a graveyard full of truths and commandments carved in stone.

“Thou shalt use theophylline as thy first line anti-inflammatory.”

I think you will find it right after the one that touts cromolyn as an effective controller. We heard those truths and we preached those truths. But the Asthma Guidelines we thought were “Truth” with a capital T have always been doubted by patients. Now the FDA and new independent large studies add their weight. How will the truth about asthma evolve?

Irreverent opinions: Severing your relationship with a patient: Be careful


August 22, 2012

A crusty, old otolaryngologist once stealthily followed a consistently abusive patient out to the elevator following a visit.

He had just removed a foreign body from the fellow’s ear and emplaced a drain. Instead of being grateful, the guy berated the staff on the way out, as usual. With his nurse in tears, the doctor reached his threshold. As the elevator dinged, the old doctor snatched with tweezers, in a deft stroke worthy of a Samurai, the drain he had just emplaced in the patient’s ear. He didn’t have to say anything. He didn’t write a letter of termination, he just did it old school, in what is known as “cowboy termination.” The story is forever a portion of this surgeon’s legacy, but it’s doubtful any one of us could get away with that today.