“It’s Not All Runny Noses!” – An Allergy/Immunology Director


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SS 147: "It's Not All Runny Noses!" - An Allergy/Immunology Director

Session 147

Dr. Melinda M. Rathkopf talks about her specialty of Allergy and Immunology. Know more about the typical day of an allergist/immunologist, life outside of the hospital, future major changes in the field, and more!

If this is something you might be interested in, check out the American Academy of Allergy, Asthma, and Immunology. See if there’s an annual meeting that you can get to, whether it’s virtual in these times of COVID or it’s in-person once they’re out of this pandemic.

For more podcast resources to help you along your journey to medical school and beyond, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:13] Interest in Allergy and Immunology

Melinda did her pediatric residency in the Air Force. They have a unique program called the Allergy Extender Program. Basically, the small bases where a lot of primary care military physicians are stationed are too small to support a full-time allergist. But they have allergy patients that need to be taken care of.

What the military does, both the Army and the Air Force, is that trained primary care providers do a little extra training in allergy-immunology so they can take care of basic allergy and asthma patients. 

After her residency, she did a couple weeks extra training in allergy-immunology from the military so she could oversee the allergy patient stationed at that base. She realized that she really enjoyed it so she did a half day week of an allergy clinic. Then she found herself referring her own patients into that clinic because she had a little more time to spend on their asthma, food allergies, and allergic rhinitis issues.

Miranda oversaw allergy shots at that base so she became very interested in the field at that time. She did a couple of years of general pediatrics before she went back and did a fellowship and allergy-immunology.

[02:58] Two Challenges Miranda Faced

Miranda had two big issues to get over. The first was her first allergy fellowship, which she thought was a hazing ritual. They had to sit through a three-hour lecture on CD markers on literally a list from CD1 up to 247, at that time.

There was a little brief self-questioning when she first went back into academic mode after being out in general practice.

The second issue was when she learned they have to see adults again. You actually have to do internal medicine or pediatrics before you can sub-specialize. But they’re a little unique and they’re not a pure subspecialty of either. They’re considered a joint board. You have to be board-certified in pediatrics or boards-certified in internal medicine to sit for the boards in allergy-immunology.

But the majority of them ended up seeing both adults and kids once they came out of practice. 

“Every allergist-immunologist is either a pediatrician or an internist first.”Click To Tweet

Obviously, if you went somewhere like a major tertiary center pediatric hospital, you would only see kids. Or you might end up in a location where you would only see adults in your later career. But for training purposes, everybody is trained to see both adults and kids regardless of what their primary specialty was.

MIranda realized she’s still the expert whether the person on the other side is an adult or a child. She still finds herself doing some primary pediatrics with her patients if they think they have an ear infection. Instead of requiring them to go see their pediatrician later that day, she takes care of it and does some basic diaper rash questions and things like that. Whereas she tends not to do that with her adult patients.

[06:04] The Biggest Myth or Misconception About the Field

From a patient perspective, the biggest misconception about this field is around food allergies. Everyone thinks they have a food allergy. And if you ask the general public, it can be up to 20% to 25% self reported. When in actuality, it’s probably 8% to 10% of kids and only 2% to 3% of adults who have true food allergies. 

Miranda spent a lot of time on definitions of what is a true food allergy versus an intolerance or sensitivity, unconventional testing and food allergies especially depending on what region of the country people are from and what some health beliefs are in that area.

“It's not all runny noses.”Click To Tweet

There’s a perception that they just take care of rhinitis and do a lot of runny noses. There are days she wishes a runny nose would come in and it was that easy because there’s a perception that it’s not as rigorous or as challenging.

[07:40] New Diagnosis vs. Pre-Diagnosed Cases

They handle the bread and butter allergic rhinitis. Miranda is in Alaska and they’re about to be in their tree pollen season. They have some of the highest birch pollen in the world recorded in Alaska so they have rhinitis every year.

They also do food allergies and a lot of immunodeficiencies. They do mast cell disease and hereditary angioedema.

And there is this overlap with other specialties. But she tells patients that everyone has an immune system. They don’t really need to see them but everyone has an immune system and therefore has some response to themselves or their environment. So she finds herself being the diagnostician which is what she really enjoys.

“There's a lot of detective work with some of the more unusual clinical situations.”Click To Tweet

[09:19] Typical Day and Life Outside of the Hospital

Miranda’s typical day is 98% to 99% outpatient. She does have privileges at four different hospitals and they’ll get an occasional inpatient consult. There are five physicians in their group, two PAs and a nurse practitioner. And four of them physicians alternate calls.

They’re on call a week at a time 24/7 for any inpatient calls, consults, or walk-in kind of situations. But her average day is about six new patients and about eight follow-up patients. She has the luxury of having a little more time with her patients. 

Miranda feels that she has enough time for life outside of the hospital. She has two kids, a 20-year-old and an 18-year-old. Her oldest was born at the end of her second year of residency. Everyone was starting to look at fellowship options by the end of the 2nd year and beginning of 3rd year. And she was just trying to learn how to raise a baby and manage a marriage while being a pediatric resident.

She wasn’t in a position to consider going into fellowship at that time, and trying to balance all of that. So she had to take some time and do some general practice before turning around and looking into a fellowship.

[11:36] Training Path

You could either be an internist or a pediatrician, so you could do internal medicine, pediatrics, or med-peds. If you’re interested in allergy-immunology, you need to choose one of those three core residences. You couldn’t do a family practice or OB-GYN and then do allergy-immunology.

You want to start out on that path of your basic specialty, your residency. And then after that it’s two years of subspecialty fellowship. Some places have a third year. If you do research, you could do a third year but it’s at least two years. You train seeing both adults and kids.

Every program is a little different. Miranda did her fellowship in the military. But through the American Board of Allergy-Immunology, they have the core competencies and areas of expertise that they trained in. Most training programs involve some research and publications along with clinical care.

[14:51] Subspecialty Opportunities

There aren’t formal ones anymore that she’s aware of when she went through a fellowship about 18 years ago when she finished. There was still an optional third year called clinical and laboratory immunology. So it was a little bit more if you wanted to specialize in immunology within allergy-immunology. She doesn’t think they offer that anymore though.

“It really depends on where you train.”Click To Tweet

If you were at some of the other more academic centers, you could do that additional year on a research project you’re interested in or match with a faculty doing research. You can make your practice according to what you want.

The community needs are obviously for adults and pediatrics. But depending on what type of practice setting, you could go into working in research. You could go into working with pharmaceutical companies. You could go into a pure academic center. There are a lot of different options.

[16:30] Are There Procedures Involved?

“There are a lot of procedures involved in this field, which is why adopting telemedicine right now is a little challenging.”Click To Tweet

They do a lot of skin testing. They basically look for type I hypersensitivity reactions. They do a lot of skin tests for environmental and food allergies, drug allergies, as well as patch testing.

Additionally, they do patch testing for Type IV hypersensitivity reactions like contact dermatitis. An oral challenge might be to have food to determine if you’re allergic to that food. They also do drug challenges. They might do a vaccine challenge if you had a reaction to a vaccine.

[17:40] Message to Future Primary Care Physicians

Everyone has an immune system and therefore the potential for an allergic response and up to 20% of the population has some form of allergy.

A single referral to determine what someone’s allergic to could be very helpful. But they don’t need to see all these patients back. For moderate to severe cases, they follow regular food allergic patients at least annually.

“It's not as simple as just putting everyone on an oral antihistamine and that's all they need.”Click To Tweet

As Miranda has mentioned, they have a lot of overlap with other specialities like ENT, gastroenterology, dermatology, and pulmonology.

Most of their pediatric asthma is taken care of by them, not by their pulmonologist. So it depends on where you are.

A lot of their patch testing contact dermatitis are taken care of by them, not their dermatologist. They also take care of rhinitis cases more so than their ENT provider just by the nature of referrals. And this could differ in different communities.

[19:13] Turf Wars Among Different Overlapping Specialties

In terms of turf wars between over these things, Miranda thinks it depends on what is considered the standard of care in your community. She joined an already existing practice that had been in business since she came there in 2006. So it was already well established and well respected.

That being said, she definitely hears about a lot of turf wars, especially probably between ENT that are offering allergy shots and allergic rhinitis care versus allergists that are offering allergy shots and allergic rhinitis care.

“Ultimately, it's about building those relationships and building that trust.”Click To Tweet

[21:10] Opportunities Outside of Clinical Medicine for Allergy-Immunology

Miranda has friends that have gone into pharma working in either research with pharmaceutical companies. One of her colleagues who practiced in Seattle has now joined that company and is doing pharmaceutical work. You can also go into research and academic medicine.

“There is variety and you can build your practice.”Click To Tweet

You can somehow tailor your practice but it will depend on the size of your community and the demand of the community, of how profitable that might be, and how sustainable that might be.

[22:39] What She Wished She Knew that She Knows Now

Miranda says she has learned more of the art of medicine and about listening to your patients, and meeting the patient’s needs. It may not be food allergy or that it’s not indicated, but there’s meeting the needs of the patient too. 

For example, chronic urticaria is almost never due to a food or environmental allergy. And if she can convince the patient with just her words and talking to them, then they don’t do allergy testing for those patients.

But if she has someone come in who really believes it’s due to a handful of foods and they’re avoiding those foods, she might test them to show them that it’s not.

[23:42] Most and Least Liked Things About Allergy-Immunology

Miranda loves patient care. She enjoys having time with her patients. She loves general pediatrics. She misses her well-babies and the interaction but she loves having more time and not feeling quite as rushed, as she did in primary care.

“There's some pride with knowing that in your community, you're the one they're going to call when they have a patient with condition x or something.”Click To Tweet

Specifically, mast cell disease has drawn her interest and there’s a lot of hype about the disease right now. There are some facts but there are also a lot of fiction. And it’s the tailoring that she has enjoyed.

On the flip side, what she likes the least is bureaucracy and the paperwork. There are barriers in terms of documentation requirements and insurance. The cost of some of the medications she uses is just astounding, but they are life-changing so the challenge is how to balance that.

[25:56] Major Changes Coming to the Field of Allergy/Immunology

The biggest area they’ve seen in the last few years is biologics in their field. The immunology aspect is really important in the whole field within diseases of really endotyping, and getting down to personalized medicine.

They still treat every mild to moderate asthmatic the same as well as every moderate to severe asthmatic the same. But now they don’t. They look at phenotyping them and coming up with really specialized care. Those are very unique and limited to allergists and pulmonologists.

Allergists-immunologists don’t have a single organ and the entire body has an immune system. So they have the potential in immunology as they add more scientific rigor.

[28:40] Final Words of Wisdom

If she had to do it all over again, Miranda would still be an allergist/immunologist. She recommends going into the subspecialty. She thinks those two years she did as a general pediatrician were invaluable. It not only cemented her decision to go into a subspecialty, but it also gave her this sense of respect for the primary care provider that you need as a specialist.

She considers herself to have two kinds of people that she’s answering to: the referring provider and the general pediatrics.

Miranda strongly recommends you find an allergist-immunologist and rotate with them if this is something you’re interested in.

“It can be challenging in certain communities to find an allergist-immunologist in the academic setting, not every medical school has an allergist-immunologist.”Click To Tweet

Explore and find someone and if you think you want to go into academic allergy-immunology, then find a rotation with an academic allergist-immunologist. If you want to do outpatient, there’s a lot of them that allow students and residents to rotate in their clinical outpatient office. You want to immerse yourself in that area to see if it’s what you like.

And it’s never too late to change your mind. You can always start down one path because it’s the rest of your career. So don’t be afraid to try it. See how it goes.

Expose yourself to that field and try to find different types of allergist-immunologist careers and see what it’s like talk to them.

Links:

Meded Media

American Academy of Allergy, Asthma, and Immunology

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