Allergist Interview: Dr. Arthur Vegh on Taking the Time and Remembering the Basics
This month, we enjoyed talking with Dr. Arthur Vegh of Tacoma, Washington. His answers reminded us of one of the most compelling reasons people need to go see an allergist: the time an allergist spends unraveling often perplexing problems. Rather than just prescribing allergy or asthma medication, allergists are equipped to understand the intricacies that are often characteristic of allergic conditions.
Furthermore, as many of our allergists have noted, Dr. Vegh emphasizes the importance of patient education. We hope this interview gives you a bit more knowledge and power when it comes to your health.
Please tell me a little bit about yourself and your history as an allergist.
|"I went to medical school at the University of Washington and my residency and fellowship were done in the Midwest. Along the way, I became interested in asthma and related conditions. This specialty works better for the way I think: I do best at methodically thinking through things rather than having down times and then going fast, as in some other medical areas. And I can see all ages from infants to older people. Other subspecialties don't do this as much."|
How big is your practice? Is there a particular type of allergy or treatment your practice specializes in?
"We've been around for a while. We are known in the area for taking care of hereditary angioedema. It's a rare disease associated with recurrent swelling that doesn't respond to normal therapy. I've been doing studies with it for 20 years.
"I enjoy working on very complicated cases, things that make me think. Often I see patients who aren't doing well, who have certain problems that don't respond to typical treatments, people with whom the normal cookie cutter approach doesn't work. For instance, patients who continue to have sinus and breathing problems despite being on very adequate therapy.
|"Environmental issues are a really complicated bag. Sometimes people focus so much on feeling sick and what seems to make them feel ill that they make themselves sicker and become less treatable. However, sometimes the environment does overwhelmingly trigger symptoms and no matter what is done, nothing will get better until the patient gets out of that environment."There's a group of people who just feel sick in certain environments, such as in buildings with a lot of water damage and mold, or around gas fumes, and it's hard to define what's exactly going on. There are also other groups of individuals whose symptoms are, at least in part, psychosomatic. They focus so much on the odors and suchlike in the environment that they progressively magnify symptoms. For example, they smell something and this sensation causes them to panic and hyperventilate, which greatly amplifies the difficulties they experience.|
"Psychosomatic,' inorganic,' symptoms, when they occur, sometimes seem to involve how the specific individual interprets some sensations. In addition, there is controversy about when certain symptoms are considered organic and when they are inorganic. Those with a number of 'inorganic' difficulties often have a mindset that can make their problems very difficult to work with. On the other hand, it may be a disservice to some to consider their symptoms as being only psychological. We doctors have done some disservice over the years to some by calling problems completely psychological without adequately exploring the situations. I don't ever want to be so arrogant as to do such a wrong by a patient.
"I believe the patient should be given the benefit of a doubt. To me, the patient is boss. I consider myself a consultant rather than an authority figure of the patient. I am here to serve my patients. I listen and try to help them."
What do you love about your job?
"I like taking care of people. I like it when someone feels a lot better and their quality of life improves. When I can solve a puzzle that someone else can't, that's very gratifying. Spending the time can be more important sometimes than brilliance. Some people just need to have the time spent on their case in order to find out what's going on.
"One patient I had made multiple trips to emergency rooms and to various physicians' offices (including previously to mine) with swellings and hives. After again sitting down and talking for another half an hour, I finally found out that the patient had an allergy to various shampoos. Her marked improvement, despite having had repeated problems, was extremely gratifying. These are the sorts of things you can find if you spend the time and go through the history in detail."
If you could suggest one thing for your patients what would it be?
"Understand your disease. When you know what's going on, it causes less consternation and fear and anger. Asthmatics who are used to getting up in the night because of their asthma often either overreact or under react and are in danger. If they don't know what's going on, they are more likely to get in trouble. Controlling the diseases and knowing what to do prevents problems.
"The person who understands why, what, and where is happier and more likely to do the right thing. Write down emergency plans. I do this with all my asthma patients, after their initial training. We go over an action plan: parameters for calling in and what to do to intervene when symptoms flare up. This way, we can keep our patients out of the hospital and the emergency room most of the time.
"I find it fun to educate my patients; I'm a bit of a frustrated teacher. With medicine in the United States, it has been increasingly getting harder to spend this kind of time because of the way insurance companies control payment. The average doctor sometimes can't take the time he or she needs to with some difficult patients and situations. It's unfortunate because some patients just need the time; it's the only way to get an explanation for their condition. I stay in the office until late, sometimes 1 AM in the morning, doing what is considered the required charting, so I can put in the time. Again, compulsiveness and time can be more important than brilliance. I've seen people who have been to multiple different specialists, for example, without getting adequate relief, but I can clean up their asthma because I take the time and effort."
What questions should patients be sure to ask their allergist?
"'What's going on?' Patients must find out why, how, when, and where certain things happen the way they do. Making sure the physician is board certified in the specialty is important."
What is your favorite allergy relief product?
"I'd like to think I'm a bit of a champion of tailoring the product to the patient. Some asthmatics inhale certain medications better than another, for example. I believe in tailoring various aspects of treatment to the patient, finding what works best for each individual in certain situations.
"I often find that allergic rhinitics who see me respond well to topical low-dose nasal corticosteroids, which are designed to not be absorbed. If these are used correctly, my patients can feel wonderful. Their airways are normalized and they are able to get back to normal life. To make somebody feel more normal is the idea of medicine."
See Sinus Problems Solution Guide
Where do you see allergy treatment going in the near future? In the distant future?
"In the future, I see better diagnostic techniques such as through pinpointing the specific allergenic proteins that individuals are sensitive to. We are at the beginning of science being able to adequately identify these. For example, there are cross-reactive proteins such as some that are found in different plant pollens, and sometimes even in foods. One example of such proteins is the ones responsible for an individual who is ragweed allergic and experiences an itchy mouth when eating melons or bananas, or the ones involved with the birch tree allergic individual whose mouth itches when eating apples. When we are able to identify the allergenic protein rather than just the pollen type or the food, treatment can become more targeted.
"I believe in the future we will also be able to define which allergic subgroup patients belong to genetically. This way, we will be able to see which therapies and medications will work best on them. We'll be able to send patients' blood in and find out their treatment/disease genotype, and it'll be easier to tailor the treatment to the patient.
"There is some evidence that allergic antibodies may be found only in the airways, that there are 'local IgE' reactions. In the future, I think we will be able to diagnose specific allergies not only with skin tests, but through samples of nasal secretions - but that's just my crystal ball, which isn't always correct."
Is there anything else you'd like to add or discuss?
"It's so easy to rely on medications and forget to pay attention to other simple solutions like the fact that the cat sleeps in the bedroom. The obvious treatment is to remove the cat. Often, the fancier the treatment, the less attention is paid to the basics."
See Pet Dander Solution Guide
"My allergy and immunology training program director, Dr. Hal Richerson, told me something that I thought at first was just a platitude. He said that 'Your patient is your best teacher.' He also said that 'the importance of listening to the history and details from the patient is easy to lose when one is focusing on the fancy diagnostic.' Over the years, the statement that 'your patient is your best teacher' has been one of my more important lessons. You have to read and listen and then you figure out what's going on."