Medical Program: Maximizing Team Effectiveness in Food Allergy Care

Announcer: This is ReachMD. The following episode in the series, Cracking the Code on Peanut Allergies, is brought to you through an independent educational grant from Aimmune Therapeutics. Here’s your host, Dr. Amy Mackey.

DR. AMY MACKEY: Despite the growing prevalence of food allergies, there’s currently no treatment options available, which makes it much more important that members of the patient’s care team work together to help reduce the risk of exposure, but what does that care team look like and how do you use this approach to your advantage? Welcome to Cracking the Code on Peanut Allergies on Reach MD. I’m Dr. Amy Mackey and joining me to discuss best practices for managing patients with food allergies are Drs. Jay Lieberman and Alan Goldsobel. Dr. Lieberman, Dr. Goldsobel, welcome to you both.

DR. JAY LIEBERMAN: Thank you.

DR. ALAN GOLDSOBEL: Thank you.

DR. AMY MACKEY: Let’s start with you, Dr. Lieberman. Who do you work with when managing patients with food allergies, and what are their roles on the team?

DR. JAY LIEBERMAN: I think there is a wide variety of how people manage it from simply one doctor treating one patient. At our center, I’m at an academic center and we have physicians in training, from medical students to residents, to allergy and immunology fellows who all can be seeing the patient and the families with me. Typically, I will see each of the new patients for food allergies. We will have the nurse perform any allergy testing that needs to be done, and then if we need food challenges to be done, I typically do this myself or I will have the fellows in training to do this, as they need to get experience in that form of their training. For some allergies that are life long and patients are coming back just for annual visits, they may be seeing a nurse practitioner just for annual skin testing or refills of epinephrine autoinjectors, and, finally, at our academic center, we do have nutritionists and dieticians on staff for more complicated cases, multiple food allergies and, for example, I run a eosinophilic esophagitis clinic with a gastroenterologist, and we have a nutritionist there for any patient on dietary therapy.

DR. AMY MACKEY: Now, how about your care team, Dr. Goldsobel? What does that look like and how does it differ from what Dr. Lieberman described?

DR. ALAN GOLDSOBEL: I’m in a pretty traditional private practice setting as an allergist. I’m in with seven other allergists, single specialty, but we do have a large practice. We see a number of patients, children and adults, but primarily children with food allergy like Dr. Lieberman does, I know.  But we have a nursing staff. Our nursing staff consists of both MAs, LVNs, and RNs, and they assist us in the seeing of the patients in terms of doing vital signs or aiding in taking a history, I do see the new patients and the follow-up patients with food allergies. The nursing staff certainly helps with performing any allergy skin testing that may be needed and then, as Dr. Lieberman mentioned, we do a lot of food challenges and the nursing staff is very experienced and perform the food challenges under my supervision. We do have a nurse practitioner who works a as a link between the patients and their physician. Often, these families have a lot of questions and issues, and they can come in and see the nurse practitioner to go over those things. They act as a bridge – She acts as a bridge between the patients and myself. Also, we do not have a nutritionist in our private practice as Dr. Lieberman does at his center, which would be wonderful if we could. We do have one resource available that may not be available in all areas, but it has been extremely valuable. We happen to have a therapist, a marriage and family therapist in our community who works part time at Stanford at the Food Allergy Center and part time in private practice, and she’s very experienced in dealing with children and families who have issues in terms of food aversion, anxieties, and so that’s been a wonderful resource to have if you can develop that in your community.

DR. AMY MACKEY: So, what should physicians look for when providing treatment recommendations for patients, and how do you communicate those choices with other members of the care team? Let’s hear first from Dr. Lieberman.

DR. JAY LIEBERMAN: So, as of right now, current guidelines within the United States suggest that patients with food allergy practice avoidance of the food and have epinephrine readily available. So, at this current time, outside of research studies, that’s how we manage food allergies in our clinic, so the treatment recommendations, therefore, are essentially avoid the food, make sure everyone on the care team understands that this is not something that, oh we can try a little bit at home and it may be okay, and  making sure everyone’s on the same page within our care team of that. It gets a little tricky with some other types of food allergies. For example, eosinophilic esophagitis in which the food may trigger that, but it’s not an anaphylactic-type allergy in which they can eat a little bit. So, it gets a little more gray in that area, but outside of that for the classic immediate-type food allergy, it’s avoidance and having epinephrine readily available and making sure everyone’s on the same page regarding that. What will happen is, hopefully, as allergists, and some practitioners are already practicing this, will have immunotherapy available to treat the food allergy, and at that point, I think, in my opinion, the team then switches from the care team to involving the family. Meaning the care decisions should all involve the family and the patient at that point and have a little less to do with the provider, and then just using the shared decision making with the family.

DR. AMY MACKEY: That’s a lot to consider! And how about you, Dr. Goldsobel? Anything else to add?

DR. ALAN GOLDSOBEL: I think Dr. Lieberman expressed it quite well. The basic tenets are certainly correct to avoidance of the food and have epinephrine available. I might add in our current environment, unfortunately, sometimes even making epinephrine available is a little bit of a problem for some people, depending upon insurance coverage and other things like that, but I think he expressed the breadth of treatment and hopefully coming treatments very well.

DR. AMY MACKEY: For those just tuning in, you’re listening to Reach MD. I’m Dr. Amy Mackey and today I’m speaking with Drs. Jay Lieberman and Alan Goldsobel about how we can maximize team effectiveness in food allergy care. Now, obviously, approaching food allergy care as a team is beneficial. But I’m sure it’s not without its obstacles or challenges. So, from your vantage point, Dr. Goldsobel, what are some of the most common challenges you and your team face?

DR. ALAN GOLDSOBEL: I think that it is difficult, as I mentioned, sometimes to have access to patients and make sure that all the medications that they need are available to them. They are very rewarding families to see, but I think that helping them to avoid the foods that they’re allergic to is an ongoing process that our whole team is helping them to meet that goal.

DR. AMY MACKEY: Do you also face these challenges, Dr. Lieberman? And if so, what strategies do you use to overcome them?

DR. JAY LIEBERMAN: Yeah, so I would echo the sentiment that one issue with food allergy is that when they leave your office, it’s still the burden of avoiding the food and all these little situations that families couldn’t ask about when they were in clinic. So, that becomes a difficult part, and using care teams that have understanding nurses that patients can call in to get those answers, if possible, and not having to make a visit to the clinic just every time there’s a small question about a certain food. One challenge that Dr. Goldsobel didn’t mention that I find very hard is current social media and Dr. Google with food allergy. There’s a lot of misinformation, I think, out there on the internet or easily found or easily passed around within social media sites. And I spend a lot of my time in clinic with families changing the way they think about their food allergy or correcting myths that they misunderstood regarding food allergy based on websites and social media and being online.

DR. ALAN GOLDSOBEL: I think that’s an excellent point, Jay.

DR. AMY MACKEY: Before we wrap up, I’d love to hear any takeaways both of you might have. How about we start with you, Dr. Goldsobel.

DR. ALAN GOLDSOBEL: Well, I find that these are very rewarding children and families to deal with. They have a great number of needs, but when it’s all done successfully, they’re very happy and grateful and healthy, and I know all allergists see many food allergy patients and, hopefully, new FDA-approved therapies are anticipated to be available in the future that we all may be able to use.

DR. AMY MACKEY: Wow, that’s interesting. That’s a lot to think about. Is there anything else you would like to add when it comes to the importance of your care team?

DR. JAY LIEBERMAN: One final point I would add is that it is very important from a team-based approach, because, in my opinion, many of these families have a lot of questions and rather than seeking out these questions with friends or social  media, it’s wonderful to have a strong care team, all of which that is knowledgeable and understanding of food allergy to be able to answer these questions that families have without having to come in regularly. And so, having nurses, nurse practitioners, or multiple members of the care team who are willing to answer these questions that families have is vital.

DR. AMY MACKEY:  Well, those are all great things for us to keep in mind, and I want to thank my guests for joining me to discuss a team-based approach to food allergy care. Dr. Lieberman, Dr. Goldsobel, it was great having you both on the program.

DR. ALAN GOLDSOBEL: Thank you.

DR. JAY LIEBERMAN: Thank you, very much.

Announcer: The preceding program was brought to you through an independent educational grant from Aimmune Therapeutics. To access other episodes in this series, visit ReachMD.com/PeanutAllergies. This is ReachMD. Be Part of the Knowledge.