This morning after finishing the Sunday paper, I browsed through one of my recent pediatric journals Contemporary Pediatrics Volume 26 . I was attracted to the ‘Your Voice’ article by Dr. Amar Dave of Ottawa, Ill titled above, the sad loss of the patient history. I applaud Dr. Dave for the comments. The issue so adroitly pointed out the knack of physicians to depend on some sort of test especially when making a simple diagnosis.
The context is the always fascinating ‘Puzzler’ cases that are submitted by the readers. The case appeared in the September issue of the journal. The letter points out that the case is a “blatant example of what is happening to medical education”. The basic elements of our encounters with patients are the history of the illness and the physical examination. Dr. Dave points out that these skills are disappearing and are replaced by tests, radiographic studies, and more tests. Sometimes the tests are performed prior to taking a history and doing an examination. In this case, a thorough history and physical examination may have revealed the diagnosis. Tests sometimes beget more tests and this may not always be necessary and may be costly.
I see this way too often in the practice of allergy. Allergy tests are done prior to visiting with the physician, they are done as panels, and they are sometime performed in the operating room. Sometimes no relevant history is taken and the tests are used to make the diagnosis and treatment plan. In some situations this may work, however I have seen children who were denied foods that they enjoyed (and needed), families who were told to make drastic changes in their lives, animals that were sent elsewhere, and a significant amount of money spent not only for the test but also for special diets and gizmos to alter the environment. This is not fair nor is it the proper way to do an allergy evaluation!
An allergist/clinical immunologist spends a significant amount of time deciding if the complaints fit a template or pattern of allergic disorders by taking that detailed history and doing an appropriate physical examination. The relevant allergens are then selected for testing. What is ‘relevant’? What I mean by relevant is that they are items that the child is exposed to and with that exposure there will be a reliable set of symptoms. Cause and effect relationships need to be established. For example, if milk is taken everyday and with the drinking of milk there are no symptoms of allergy, then the test should not have been done (given this history) and if the results were positive, then they are irrelevant. The value of the test results is only as good as the story or history that supports it.
Remember, the tests make no child allergic. The test only means that antibody is made or has been made. The allergic child has a set of symptoms consistent with allergy with positive tests to relevant allergens. I go more into this topic in the What is Allergy and Testing pages on this site.
Thank you Dr. Dave for lamenting the possibility of lose of an important part of medical training.
Leickly Stories 