Allergy Testing in the Primary Care Clinic: A Practical Addition, Easy Day-To-Day
For the overwhelming majority of primary care practices there’s no practical obstacle to adding allergy testing and treatment as a service line. On the contrary, comprehensive allergy skin tests are easy and routine, and require no specialty techniques or knowledge. Whether it be in family medicine, pediatric, functional medicine, internal medicine, or concierge clinic, the process is straightforward, it takes very little time, and an MA can do the whole thing with just a little training by video conference. In the broader context of allergy testing in primary care, this is one of the clearest reasons the service fits so naturally into normal clinic operations.
Obsolete Concerns: Outdated Service Options Really Were Disruptive
Concerns about adding allergy as a service line in primary care settings usually come from one or both of two sources. First, clinicians get very little exposure to allergy in medical school or subsequent residency, but often they do remember something about danger. Second, those who were exposed to allergy in actual practice in the past usually saw a lousy business model that made it a poor fit. Those two issues explain much of the hesitation discussed in why primary care sees allergy everywhere but rarely tests for it.
In medical school, most future doctors get two to four weeks on immunology. Allergy itself is only a small part of that already small allocation of time. To quantify that more precisely, one group of researchers found immunology education was limited to 21 hours in one case, 44 in another.i After med school, allergy is almost never part of residency. ACGME (Accreditation Council for Graduate Medical Education ) doesn’t require allergy in core residency rotations, even for internal medicine and pediatrics. No wonder allergy is not top of mind when physicians with or without residency go on to practice primary care.
Those few primary care physicians who have encountered an allergy program IRL, so to speak, often encountered a botched or otherwise suboptimal version. In the roughly half of US States where it’s even legal, many physicians saw allergy programs based on third-party technicians planted inside primary care clinics. Such programs are often a poor fit for lack of control over selection of that technician, scheduling issues, real estate shortages, long term contractual commitments, and difficulties with process integrations, among other challenges.
Other physicians with unpleasant memories of allergy programs remember the other end of the spectrum: allergy testing as an unsupported commodity purchase. That is, some primary practices attempted to run an allergy program by simply buying supplies from a big distributor, and hoping for the best. If the distributor provided training, it may or may not have been effective but almost certainly was not repeated. Consequently, if the program got off the ground at all it later crashed as soon as any well trained staff moved on, and was likely a little rocky while it lasted for lack of expert allergists to consult when questions arose. To keep cost-per-test down, such programs also came with a ridiculous amount of materials that created huge storage hassles. Allergens come in 5ml vials. The applicators to match that much allergen would fill whole closets, not just multiple cabinets, let alone just one.
Either one of these outdated service models—third party invasion or allergy as commodity—really did disrupt the essential functioning of a primary care practice. Worse, they left a lingering distaste for or unexamined resistance to any allergy program, even one that integrates beautifully into the workflow.
Optimal Model: Comprehensive Program You Run Easily Yourself
A proper allergy testing and treatment program integrates seamlessly and easily into existing practice flows using existing clinical staff in the ordinary course of the day-to-day without filling up all available space. It includes the necessary, manageable two to three hours of training, right there in-house, as often as necessary. It includes consults with a Board-Certified Immunologist. It includes all the necessary materials. And it requires no long-term contracts or capital investment. A proper, self-staffed, comprehensive allergy testing and treatment program accordingly renders the most common concerns about adding allergy as a service line outdated and obsolete.
Easy In-House Training of Existing Staff
Perhaps the biggest problem with both obsolete allergy service models is the lack of training for existing staff. Use of third-party technicians presumes the technicians are already fully trained, though one is entitled to question that presumption. Allergy-in-a-box “programs” from a distributor presume existing clinic staff is already trained. The former cuts existing staff out altogether. The latter sets them up to fail.
To make an allergy program sustainable, easy, and profitable, training should be provided for existing staff in a manageable manner as often as needed. That is, recognizing that MAs tend to move on eventually, the practice should be able to have new MAs (or PAs, or NPs, or MDs, etc.) trained as soon as they join the practice, whenever new providers join the practice. And, ideally, that training should be both effective, easy to manage, and at no additional cost.
MRS Allergy training includes three sessions (optionally combined into one), each about 40 minutes long. The first introduces the MRS Allergy portal and allergy testing process. The process is key, starting with routine screening of all patients for allergy symptoms as part of medical history on intake, and annually. The second session is clinical training—how the allergens are applied, and reading the results. The third session pertains to treatment and includes Q&A with the Board-Certified Immunologist, primary care physician, and allergy expert who designed the MRS allergy program. All are typically conducted by teleconference, eliminating travel time and greatly reducing scheduling difficulties.
One Cabinet, One Lil’ Bit of Fridge
The most easily solved issue with obsolete allergy models is the storage challenge. It’s true that allergens come in 5ml vials, which are generally enough for 400-450 allergy tests. A test for 78 allergens, with two controls, also requires 80 applicator tips, which depending on the design will require 8 to 14 applicators, or something like 5,000 of them, which would fill a substantial space. MRS Allergy instead typically ships 25 tests worth of applicators along with the allergens to start. The allergens occupy about as much space in a refrigerator as a good sized lunch box. (Regular break room or medical grade fridges are both fine.) So the applicators fit in a single cabinet. Then, as applicators are used up, just order 25 more. Higher volume clinics often make alternate arrangements. The point is that the store challenge is now moot.
Two Weeks From PO to 1st Test
Standing up a comprehensive self-staffed allergy testing and treatment program is not only easy, it’s fast. Usually the only constraint is availability of clinical staff to be trained because the materials arrive within just a few business days. Allergens ship refrigerated so they arrive essentially overnight, applicators, skin markers, and other materials ship ground at the same time, typically arriving just a few days later. When clinic staff makes the time available, MRS training can be completed shortly after receipt of those materials. In fact the first training session can be completed even before the materials arrive. Thus a self-staffed allergy program can be up and running, completing its first actual patient test, within two weeks of placing the initial order. For clinics comparing that model with in-clinic allergy testing vs lab referral, the operational difference is substantial.