Allergy versus asthma as the focus of the subspecialty

Allergy versus asthma as the focus of the subspecialty Thomas A. E. Platts-Mills, MD, PhD, Timothy J. Sullivan, MD, and Michael A. Kaliner, MD

The current subspecialty of allergy and clinical immunology has a central mechanistic focus on broad aspects of immunology, both beneficial and pathologic. However, 90% of our practice concerns diseases caused by immediate hypersensitivity responses. Indeed, skin testing, education, and immunotherapy dominate the medical activity in our clinics. The description of skin tests dates to 1873; that of immunotherapy dates to 19!1; and the description of the association of rhinitis, asthma, and atopic dermatitis with immediate skin tests to common inhalant allergens was fully established before 1950. From 1960 to 1980 there was a dramatic increase in our scientific understanding of the immunology of allergy, purification of pollen allergens, IgE and specific IgE antibodies, basophils, mast cells, and T cells. This increased understanding was paralleled by a retrenchment of the subspecialty to focus on those conditions whose causes and mechanisms we could be certain that we understood. Since 1975 major advances have occurred in our understanding of the role of hypersensitivity in other diseases, particularly perennial asthma, atopic dermatitis, venom allergy, and drug reactions. In addition, it is increasingly clear that a real change has occurred in the pattern of disease, the most important of which is the increase in the prevalence and morbidity of asthma. The magnitude of the increase in the United States is not well documented, but today asthma is present in 5% to 10% of children (although up to 18% have had symptoms as judged by the prescription of an inhaler); asthma is the most common cause of hospital admission for children. Whether asthma has increased among adults is less clear; however, sales of asthma medicine, hospital admissions, and clinic load suggest that such an increase has taken place. During the past 10 years, evidence has been published to show that asthma is an inflammatory disease of the bronchi characterized by eosinophils and that the most common cause of this inflammation is indoor allergens. During the same period, J ALLERGYCLIN IMMUNOL

the investigation and management of asthma have become major foci of our clinics, and many allergy clinics have added asthma to their name. Asthma will become an increasingly important source of patients for the allergist. Quality-of-care measures suggest that specialist care is more cost effective for moderate-to-severe asthma than generalist care. Thus managed care organizations may divert patients with asthma to the allergist for management as a cost-saving device~ The cost saved will largely reflect reduced hospitalization and emergency room visits, which far outweigh the cost of a specialist visit. In addition, it !s likely that allergic rhinitis will become less important in the referral base for the allergist during the next two decades. This belief is based on the effectiveness of current agents and the promise of new ones to manage most patients with rhinitis. Thus the allergist may become a consultant in the management of allergic rhinitis: making the diagnosis, establishing allergy avoidance regimens, and occasionally initiating immunotherapy, but passing patient management and administration of therapy to the primary care physician. In many respects, this division of labor makes sense by permitting the allergist to serve a much larger population of patients at a lower cost. It is expected that patients with urticaria, eczema, anaphylaxis, stinging insect hypersensitivity, and drug allergy will continue to be cared for by both the academic allergist and the practicing allergist. Another disease that may become more important for the allergist !s sinusitis. Currently patients with acute sinusitis are cared for by the primary care physician, and those with chronic sinusitis are referred to the otolaryngologist. Data suggest that patients with sinusitis who are managed by allergist s have fewer treatment failures and require less surgery. The question now is whether we need to change the focus of the subspecialty either in fact or in name. The reality is that we have far more to offer in the management of asthma than any other 865

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group of physicians, a fact that both patients and primary care doctors are recognizing. However, we are an outpatient specialty with less involvement in inpatient care than ever. The "high tech revolut i o n " a n d consequent high price of our hospitals have m a d e it impossible to admit patients for investigation of asthma or anY other chronic disease. In private practice this condition leads to an outpatient focus that prevents the disruption inherent in managing hospitalized Patients. Indeed, the move of p u l m o n a r y physicians to m a n a g e intensive care units increasingly defines their subspecialty. However, without a,n inpatient presence, it is difficult to gain respect or to influence the education of medical students or residents, a n d a major concern is how to expand student and resident education in our subspecialty. Thus the issues that need to be addressed in considering the future focus of our subspecialty include the followingi • If we focus on asthma, will this include inpatient acute care? • Is a subspecia!ty based only on outpatients viable in recruiting new members, or do we need a new structure for training students and residents? • Will the addition of the n a m e " a s t h m a " to our subspecialty limit our potential to grow into the investigation and m a n a g e m e n t o f at0pic dermatitis, urticaria, a n g i o e d e m a , and sinusitis, as well as to continue our important role in the investigation and m a n a g e m e n t of immunodeficiency?

ALLERGY VERSUS ASTHMA: DISCUSSION Platts-Mills. Two key issues have been raised. First, in the past 20 years we have become aware that indoor allergens exist. The population has moved indoors, producing a genuine change in the pattern of allergic disease. Then there was the realization that asthma is an inflammatory disease, like allergy, and should be ours to treat. That phase is what is current, and many allergists have added asthma to their title. Thus at present we have to acknowledge what allergy practitioners actually do, which is to treat asthma. However, adding asthma to the definition of the specialty (i.e., asthma, allergy, and immunology) is a real problem because it may inhibit our ability to expand into other areas. We should be ready tO start to investigate and manage atopic dermatiffs, which is an obvious allergic disease, and recognize that the next opportunity for our specialty will be the treatment of sinusitis. We must ensure that we are seen a s investigating and caring for a wider range of relevant clinical entities. The second issue is how and whether to have an

impact on the inpatient setting. I do not believe that we can return to a hospital setting, because these high-tech institutions have little to do with the type of medicine that we seek to practice. I do not think the issue is getting onto the inpatient tracking services: I think the issue is getting the training of medical students and residents into outpatient clinics where it belongs. Wasserman. You feel that the allergist should move beyond the perception that they are IgE-ologists? Platts,Mills. I think it is possible that in sinusitis T-cell responses to an antigen produce the eosinophilia that is no! IgE dependent. Sullivan. The discipline is really defined by the severity of illness of the patients it serves. Generalists treat people when they are well or almost well, and specialists more often treat those who are seriously ill. I believe that our discipline needs to focus more on those who are seriously ill rather than on those who are trivially ill. One of the defining perspectives is to identify groups of sick people to whom the knowledge and skill of the discipline should be applied, thereby clarifying its clinical dimension. Traditionally, medical care has been organized according to organs (e,g., diseased livers, hearts, and eyes), but the defining characteristic of our discipline is organized knowledge of a mechanism of disease rather than every aspect of a single organ. We not only have made the clinical observations bul also have come to understand disease process in molecular detail. Is it appropriate for one !acking knowledge of immunology and immunopath01ogy to try to understand and deal with such problems as drug hypersensitivity food hypersensitivity, or insect sting anaphylaxis? These are inappropriate consignments to other disciplines. No longer can we permit the perspective that "if it doesn't have IgE and you can't give it shots, it's not allergy." The discipline is defined both by knowledge and by specific serious disease entities. I might accept the notion that allergy, immunology, and inflammation describe the knowledge and skills of this discipline. However, focusing on asthma in a sense, trivializes the discipline by looking at only one manifestation of immunologic disease. Who better should deal with disorders of immuneffector systems such as hereditary angioedema, mastocytosis, hypereosinophilic syndrome, and others? Those of you who spend time teaching about the immune system and immunopathology and inflammation realize that the subject is very difficult. To think that someone with a general medical education can intelligently apply critical princiPles without understanding them is a mistake. Not only does this discipline have the capacity to deal with these and other complex illnesses, but for many immune disorders, it is the only appropriate discipline for management of tlie seriously ill. The interpretation of immunologic data is complex. For example, even the proper clinical application of knowledge about penicillin skin tests is not simple. Abdicating the role of organizing, interpreting, and

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skillfully delivering these services would be a major mistake and totally illogical. Without physicians who have an integrated knowledge of human immunology and insight into its basic science, fundamental research can be misdirected and its translation to clinical applications delayed. A major threat to our discipline !s the disappearance of young people with such understanding from clinical academic positions. What I am arguing is that knowledge and skills developed principally over the past century have led to the logical allocation of diseases defining this discipline: specifically, inflammation-specific and nonspecific disorders. To abandon any of these illnesses to other disciplines because the disease occurs i n a n organ that can be named and described is not wise medically or scientifically. There is also an ignorance factor to be dealt with. Dr. Weiss' summary points out that five of six patients seeing an expert for asthma see an allergist. For political, economic, or marketing reasons, putting asthma in the title of the specialty is not illogical. However, if there is a new word to be added, I take it to be inflammation. Wasserman. I hear a fair amount of consensus, namely, that for many years life as an allergist was easy. The current issue may not be a political or a public relations reason to add the word "asthma" to the specialty. Rather it is for allergists and immunologists to be more complete physicians, like other internist/specialists, by taking care of sick people whatever the mechanism of the disease. There is a body Of knowledge. Dr. Sullivan made it quite clear that that body of knowledge relates to people who suffer from diseases of the immune systeml inflammation, and dysregulation of those processes, whether or not we fully understand them. Austen. I want to go back to one point that Dr. Platts-Mills touched on. My point about the physician interested in allergy appearing on the mediCal service along wit h other subspecialists is to demonstrate that as specialists, we can function competently in that setting, even though we have our preferred environment. Platts-Mills. You are assuming that we are going to stay in a world where the focus of both residency training and medical school teaching will remain on inpatients. AS long as that stays the same, then the cardiologists have one third of all the inpatients. Lockey. I have the same reservations about the word "asthma" in our title as does Dr. Sullivan. I also like the word "inflammation." We may be defining ourselves temporarily and may reach a new set of descriptions at some future time. There is a tremendous diversity in our training programs, which can be good. However, we need to better define what is Optimal and critical for the future of our discipline. Lichtenstein. I share with Dr. Austen the notion that the specialty is in trouble. Let me talk about admitting why we are in trouble. I was always very impressed with the difference between the way two very bright peopl e , Tom van Metre and Char!ie Reed, practice allergy.

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Everyone who goes to Dr. van Metre's office gets shots. No one who goes to Dr. Reed's office gets shots. I have been studying immunotherapy for 30 years. I am interested in it, b u t w h e n I practice medicine I very rarely use it except to treat venom hypersensitivity. I would guess that 90% of the people in the practice of allergy make most of their income by giving shots. Frank Adkinson has done a study showing that in children immunotherapy for asthma is not useful. Peter Creticos and Phil Norman showed that immunotherapy for asthma in adults is not useful. Rhinitis can be treated more effectively with corticosteroids than with shots. So what about the proposition that we come out of this meeting saying, "Let's stop immunotherapy?" Kaliner. One of the issues that we are having difficulty with in this discussion is the issue of academics versus clinical practice. As someone who has done both, I can state that they are very different subspecialties. It is not the academics thai define the practice; in reality, practice defines the academics. The vast majority of interns and residents who are looking to their future ask. "Is there a future in allergy? Can I make a living?" Only a fraction ask. "Can I do science? Will I be able to investigate things?" That is the bottom line, Liehtenstein. Can you earn a living practicing allergy without giving shots? Kaliner. Most people in practice see patients with allergic rhinitis. I recently talked to a well-respected physician who runs a very high-powered practice. He sees about six to eight new patients a day, overwhelmingly for rhinitis, and he puts most of them on immunotherapy. He makes 40% of his net profit from immunotherapy, both in the preparation of extracts and the administration of immunotherapy. I asked him what would happen if he lost his immunotherapy. He said he would go out of business. In the Washington area. where there are too many allergists for the size of the population. the bulk of their practice is immunotherapy and allergic rhinitis. Austen. Is that cost-effective? Kaliner. It has nothing to do with cost-effectiveness. This is the way people make a living. Venable. It may be of interest that other medical practitioners and those who pay for medical care are moving to disease-based management. Dr. Sullivan commented that those who are seriously ill should be seen by a specialist. One of the difficulties with that is capacity. I can tell you that in the past 15 years there has never been an allergist on call with me in the emergency room to help with the patient with severe asthma who arrives at 2:00 AM. Moreover, if primary care physicians are coming out of training unable to handle serious illness, why are you in the academic institutions not training them appropriately through your various boards and deans? One of the things we must do is cooperate. However. everything I have heard today tells me that in a managed care plan I need one allergist on cal! via computer. The justification of a specialty cannot be based purely on the

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special nature of the knowledge. I think disease-based management is exactly where you are going, and you could actually be captains of the disease-based management ship in a number of ways. Kaliner. I think that primary care doctors will take over mild allergic rhinitis and treat it effectively. There is no reason why we can not train primary care physicians in a cost-effective manner to treat mild rhinitis and mild asthma. Ansten. Are you saying that within the framework of disease management, the allergist should identify as his or her specialty the more difficult diseases that cannot be managed easily by primary care physicians, in conflict with what the bulk of the allergists now do? Kaliner. I think that is where things have to go. The bulk of the allergy community is taking care of patients with diseases that can be treated more cost-effectively by a family practitioner or primary care doctor. The market will determine who takes care of those patients, and the allergists wi!l not take care of patients with mild or easily controlled disease. We need to work out an appropriate relationship with primary care givers who see the patient, identify those patients whose care needs expert advice, obtain a consultation and a management plan, and then manage the patient. The market will determine the cost-effectiveness of that approach. That will be the approach 5 years from now in the United States for hay fever and mild asthma. Wasserman. I agree that primary care doctors will take care of a lot of mild allergic disease. The problem with a diseased-based approach is that the physician must understand the disease to know who needs a referral. We have done a dismal job of training primary care physicians in certain disease areas. Furthermore, much of primary care is done by specialists in internal medicine who are providing primary care to chronically ill patients. The marketplace will define patient allocation. In a managed care network with withholds in

capitation, the specialist may be better for managing certain patients, but this will need to be proved. Kaliner. We began talking about asthma versus allergy. I made the argument that the specialty cannot look to a future of taking care Of patients with allergic rhinitis but can look to a future of taking care of patients with asthma. In the Washington area, one of the largest health care providers has given asthma care to a panel of allergists. They will be looking strictly at hospitalization rates. This managed care group had 210 hospitalizations per 100,000 members per year over the last 5 years. The national average is about 182. They are giving a 3-year contract to the allergists to see if hospitalizations and associated costs will decrease. All asthma care for any patient previously hospitalized for asthma was assumed by an allergist, starting on Feb. 1, 1995. This is an incredibly important project. If it is successful, we can define our future. If young physicians know they can make a living treating asthma, which is an exciting disease to take care of, they will want to become allergists. Shearer. I sense there is a fundamental dichotomy in the whole field of allergy and immunology, and it is certainly reflected in the discussion so far at this table. We in the university or in hospital-based practices are careful to include immunology in all of our thoughts of how to prepare people for the future. Yet, the market, as amply documented around the table, clearly pays little attention to the entire field of immunology. Most of the problem, as I see it, is that the practice of our field in "real life" is far removed from what we are trying to do at the university; perhaps what we are trying to do at the university is far too broad. It may be that the entire field of immunology cannot be compressed into a specialty, particularly at a time when options are being restricted by managed health care. Austen. Dr. Shearer has basically just introduced topic number two, justifying a mechanism-based specialty.

Justifying a mechanism-based specialty N. Franklin Adkinson, Jr., MD, Robert R. Rich, MD, and Lawrence M. Lichtenstein, MD

A l l e r g y / i m m u n o l o g y is u n i q u e a m o n g m e d i c a l specialties in claiming a n d training for e x p e r t i s e in the p a t h o p h y s i o l o g i c m e c h a n i s m s that u n d e r l i e diseases across t h e entire s p e c t r u m o f m e d i c a l pathology. T h e answer to the question, " c a n we justify a m e c h a n i s m - b a s e d specialty?," d e p e n d s o n w h o asks the question.

F o r the A m e r i c a n B o a r d o f M e d i c a l Specialties a n d t h e A c c r e d i t a t i o n C o u n c i l for G r a d u a t e M e d ical E d u c a t i o n , we have d e f e n d e d o u r claim well enough. Clinical i m m u n o l o g i s t s a r e n o t likely to s u c c e e d in c r e a t i n g a n o t h e r b o a r d b e c a u s e : (1) p r o l i f e r a t i o n o f subspecialty m e d i c i n e is n o t politically c o r r e c t in the c u r r e n t climate, a n d (2) t h e r e