As a physician with a background in public health and ethics, I have always kept my eye on costs of testing and procedures. Not just in the monetary sense, but also with regards to consequences and adverse physical and psychological effects. Really I started noticing a problem with overtesting back in medical school. I think the culture of medicine is to do as much as we can for patients, but when does it become too much?
It was in my allergy/immunology fellowship that I first started noticing overtesting specifically within my speciality related to food allergy. It would drive me crazy when I was referred a patient who came in with stacks of paperwork, showing me unnecessary tests and procedures ordered by another health care provider, or a patient who came to see me who spent their own money on unproven allergy tests. All this unnecessary testing can result in avoidable food restrictions, food aversions, and even vitamin and mineral deficiencies.
Since starting out as a new allergist/immunologist about 6 years ago, I have always tried to balance the patient’s wishes for testing with my own experience and knowledge. I think I have become much better at addressing these overtesting issues with patients, but it definitely takes time. Now I always discuss the risks and benefits of testing, why testing is not always indicative of an allergy, and how I can help the patient move forward. I try to meet the patient where they are in the process. Food allergy can be a very scary diagnosis!
A common scenario I run into involves a patient who comes to see me because they’ve been avoiding a particular food for years. It’s possible that they had a broad panel of allergy testing performed when they were younger. If their new testing indicates they can safely undergo a food challenge, I will have them back in clinic to eat the food in a monitored setting. If they pass, they can now safely incorporate the food they were avoiding back into their diet, and both of us are truly so excited. It’s possible that they were allergic to a different food than they were avoiding, they outgrew the allergy, or they were never allergic to anything at all, but because of overtesting, they then avoided this food. The best part of my day is being able to alleviate any unnecessary food restrictions for my patients.
The American Board of Internal Medicine (ABIM) started the Choosing Wisely campaign to help patients and clinicians choose care that is supported by evidence, free from harm, and truly necessary. The AAAAI’s Choosing Wisely list of recommendations includes two statements regarding overtesting in allergy: “Don’t perform food IgE testing without a history consistent with potential IgE-mediated food allergy” and “Don’t perform unproven diagnostic tests, such as IgG testing, or an indiscriminate battery of IgE tests, in the evaluation of allergy.” In addition, the American Academy of Pediatrics Choosing Wisely list also addresses overtesting in allergy, stating “Don’t perform screening panels for food allergies without previous consideration of medical history.”
I believe education is needed regarding the use and interpretation of food specific testing, and that’s why I’m passionate about the work done with the Choosing Wisely campaign. The clinical history of the patient is the most important diagnostic tool, and that’s not always shown in a test.
Kristin Sokol, MD
Allergy & Immunology, Pediatrics
Dr. Sokol is a guest writer for InCrowd. She is a board-certified allergist/immunologist and board- certified pediatrician specializing in the care of both adult and pediatric patients with a variety of allergic and immunologic disorders. She was named an AAAAI Choosing Wisely Champion in 2016 for her work with the Choosing Wisely campaign, bringing awareness to the need for reducing overuse in healthcare. To read more about Dr. Sokol please visit: Schreiber Allergy.
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