I have been teaching medical students in my office for the past several weeks. These first year University of Arizona students have recently completed a block of studies on the immune system and are spending time in an allergy clinic to learn how memorizing a million obscure names and pathways applies to the real world of clinical medicine.
Each student spends only half a day with us so there is not much time to impart wisdom. Since this may be their only exposure to the specialty, I have tried to come up with a few important “pearls” for them to take with them.
Here is one of those pearls: “There is no such thing as an allergy test.”
Since we spend a lot of time in our practice testing patients to find out what they are allergic to, this statement is usually greeted by the students with a polite stare as if waiting for the punch line.
First year medical students are understandably a bit nervous when introduced to the real world of doctoring for the first time. They are quite sure of one thing: They do not know very much now and that somehow, over the course of just four years, they will be expected to know practically everything. They are also quite sure that they have no idea how this miracle of knowledge transfer is supposed to happen.
So the students typically smile politely and try not to say anything that would make them look any stupider than they feel. I try to reassure them and suggest that if there ever was a time to ask stupid questions, your first few years of medical school would be it.
The assumption that somehow you should know and that surely everyone but you knows is pervasive but also foolish and can be a serious hindrance to learning. Wisdom begins when we are able to put our pride in our pocket, acknowledge our ignorance, and ask the stupid question. The other students, contrary to your assumption, are also quite clueless, and certain to be relieved when you do.
Back to the point. Why is there no such thing as an allergy test and why is this so important for medical students to learn?
The answer is in the definition of allergy.
Allergy is an adverse condition and symptoms caused by immunologic sensitization and exposure to an allergen. An allergen, almost always a protein, is the thing (food, animal, pollen, mold, etc) that your immune system decides – arguable by mistake – you need to be defended against. The resulting production of specific antibodies that react with the allergen is called sensitization. Without it, you are not allergic.
Sensitization is the part that we learn from an allergy test.
However, having symptoms when exposed to the allergen you are sensitive to is also part of the definition of allergy. Without symptoms, you are not allergic. No matter what the results of an allergy test say.
A diagnosis of allergy cannot be made without a careful history. In fact, when allergy tests alone are used to make a diagnosis of allergy – which is often the case when patients ask their family doctor to order an allergy test to find out what they are allergic to – the results can be confusing and misleading and even dangerous. In my experience, this is often the case.
Inappropriate diagnosis made on the basis of allergy tests alone have led to unnecessary restriction of foods, elimination of loving pets from the home, disruptive changes at home and at school, and prescriptions for insanely expensive medications such as Epipens.
On their own, blood tests and skin tests for allergy can give falsely positive results as often as 50% of the time. That means that if an allergy test is positive for peanut, and no consideration if given to the patient’s history, there is a 50% chance that the patient is allergic to peanuts and a 50% chance that they are not.
If history is not taken into account to make the diagnosis, an allergy test is about as good as flipping a coin.
Coupled with a thorough and accurate history, however, an allergy test is an essential tool for a making a diagnosis of allergy.
The history – listening! – is the most important skill for a physician to learn. And this is why it is important for medical students to remember: “There is no such thing as an allergy test”.