November 7, 2023 • 24 mins
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Food allergy is a complex medical condition, so it's no surprise that navigating life with food allergies can be challenging. Shared decision-making can help.
Join Dr. Alice Hoyt as she interviews colleague Dr. Sakina Bajowala on shared decision-making, especially as it pertains to food allergies and immunotherapy.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:06):
Hello and welcome to the Food Allergy and your Kiddo
Podcast.
I am your host, dr Alice Hoyt,delighted to be joined today by
Dr Sakina Bajawala.
She is a board-certifiedpediatrician and allergist who
practices in the western suburbsof Chicago.
She is a fellow of the AmericanAcademy of Allergy, asthma and
(00:27):
Immunology and she is anabsolute boss when it comes to
immunotherapy.
And part of what I think makesher a boss getting to know her
some is really her approach toworking with families and really
what we're going to talk abouttoday, which is shared
decision-making.
So, dr Bajawala, thanks so muchfor coming to the podcast.
Speaker 2 (00:51):
Well, thank you so much for having me.
I'm really looking forward totalking to you today.
Speaker 1 (00:57):
Me too, so let's just dive right in.
How do you really define likeyou internally, as a physician,
as a kiddos doctor?
How do you really define shareddecision-making?
Speaker 2 (01:14):
So to me, in my practice, shared decision-making
essentially means that I askfamilies what their goals are
and I give them all of theiroptions.
We comprehensively discuss therisks and benefits of all the
(01:38):
options that are available tothem, I let them know which
option I believe would be mostlikely to meet their goals and
their expectations, and then Ishut my mouth and I sit back and
(01:59):
I listen and wait for them toask me questions and I answer
them.
But it is not my job as thephysician or allergist to make
the call on what it is we aregoing to do.
It is my job to share theinformation and be an advisor,
(02:20):
and it is the patient's and thefamily's job to together come to
a decision on which of theoptions I have presented that
they want to pursue.
Speaker 1 (02:35):
That is very pretty much straight in line with the
way I try to approach myfamilies as well is sort of I'm
a guide and I'm a very wellresearched and expert guide and
I'm going to present the optionsand present them as how I think
(03:01):
would best serve that patientand discuss things especially.
You know, let's just dive intosome cases here.
I've certainly had kiddos cometo me who's the family was
interested in oral immunotherapy, but the kiddo, who was maybe a
tween or a teen, was just likeabsolute no go, like they're a
(03:23):
very important part of shareddecision-making and the team and
so OIT is just not an optionfor them right now because
they're not on board with it.
And so then we discuss with theparents and with the kiddo too.
Like you know, this doesn'tseem like this is a good option
right now, and that's okay.
(03:45):
I think sometimes social mediahere comes a tangent y'all.
I think sometimes with socialmedia treatments or you know the
latest thing, it gets sosensationalized and people think
everyone should do it orwhatever the case may be.
People have heard me on talkabout the advertisement for
(04:06):
palforzia be proactive aboutyour child's food allergy.
That ad is absolutely bonkersto me because you can be
proactive about your child'sfood allergy and not have your
child on palforzia and not seewhat it at all and you're still
being proactive so standard ofcare remains avoidance and
(04:27):
preparation with emergencymedication.
Speaker 2 (04:29):
That is a standard of care.
Now the standard of care may bechanging, right, and it is
changing very much so and veryrapidly.
But it's really important toemphasize to families when we're
talking to them that your onlyoptions are not different
treatment options, right, thefirst and foremost, the option
(04:51):
available to you is to do whatyou've already been doing and we
can help you do it moresuccessfully which is avoidance
and preparation and awareness ofhow to recognize an allergic
reaction and springing to actionquickly so in the event and
hopefully unlikely event of anaccidental exposure, you rapidly
(05:15):
identify the symptoms and yougive the appropriate treatment
without delay.
That's option number one always.
Speaker 1 (05:25):
I think that's so important that families hear
that.
You know so if you're listeningto this and you've been told by
three different food allergymom friends that they're doing
OIT, oit and SLIT and you knowwhen are you going to do this
with your child and it's andit's just not the right time for
(05:46):
y'all to do it.
I want you to hear what DrBajawala just said, that if it's
not the right time, it's notthe right time, and that
avoidance is absolutely afantastic management strategy
for food allergy.
Speaker 2 (06:05):
And especially if you've already been doing it
successfully, right?
Yes, and from initial diagnosisall the way up until you're at
the allergist's office andyou've never had a reaction from
accidental exposure, you havebeen successful and maybe you
don't need treatment.
Maybe the return on investmentof a treatment in your
(06:31):
particular case the calculationsdon't pan out and you're better
off just continuing what you'vealready been doing.
Quite well.
Speaker 1 (06:41):
I think this probably really speaks to parents of
tweens and teens, in whomstarting oral immunotherapy at
least would be significantlylife altering in a way that
isn't necessarily positive.
The reason I say that is becauseof the safety window that has
(07:03):
to be followed.
If you're doing oralimmunotherapy in my office
that's one hour before, twohours after the dose you're not
doing anything that's raisingyour heart rate or your body
temperature.
Anytime you have a fever, takeMotrin, a whole slew of things
you're not dosing and that justis not consistent with a good
(07:24):
quality of life for many tweensand especially many teens who
are doing so many super coolbefore school and after school
activities and it's really notfeasible for them to do the OIT
and keep doing activities.
And we would never want them tostop doing those activities and
(07:48):
then thinking about okay, whatabout when they go to college?
Just say they're a junior or asenior in high school and they
want to start OITs or somebodyin their family wants them to
start OIT.
Then what's going to happenwhen they go to college?
Nothing good with OIT.
Speaker 2 (08:07):
And it's a very different scenario If you have a
child who began OIT when theywere five or six.
They reached maintenance bysecond or third grade and
they've been in maintenance foryears before they leave the nest
and go out to functionindependently.
By that point, most of mypatients are only dosing maybe
(08:29):
three to four times a week andI've already started shaving
down their exercise restrictionbecause they have been so
successful for so long inmaintenance.
That is a very differentscenario than showing up in my
office when you have a highschool junior which is, in my
opinion, after experiencing thisnow the most stressful year of
(08:52):
high school and saying, okay, wegot to do this now and we need
to be done before we go tocollege, otherwise I'm not going
to let him go.
Then I have to say, okay, let'stake a step back.
Who am I treating here?
Am I treating the child or arewe treating parental anxiety?
Because if it's parentalanxiety that we're treating, I
(09:17):
don't need OIT to treat that.
We have other tools at ourdisposal to help with that other
the big toolkit of things wecan do to help with that.
Speaker 1 (09:33):
Absolutely.
I want to ask you when you arepracticing shared decision
making, which I imagine with youis just literally second nature
, it's just how you practice.
Medicine is through shareddecision making.
You're never walking into aroom telling a family.
This is what you're doing.
You're walking into a roomequipped to discuss all of the
(09:57):
different management options.
How do you do that with littlekiddos compared to with your
tweens and then also with yourteens?
Speaker 2 (10:09):
I think it is vital that, even though they may not
be at the age of consent, oflegal consent, that young
patients are actively involvedin the decision making process
and that they have an agencyover their own bodies.
(10:32):
For that reason, for any childin our practice, if they're over
the age of 12, we get a sentwritten, a sent from the child.
So there's consent which iskind of legal informed consent,
and anyone 18 and up must dotheir own informed consent.
(10:57):
Parents cannot do the informedconsent for an 18 or 19 year old
, but for patients who areyounger than that but still very
capable of having an informeddiscussion, of asking questions,
of having very strong opinionsabout what their goals are and
(11:18):
how they would like to achievethem, I have made it quite clear
that without a sent from thepatient, their permission to
move forward with this treatment, it doesn't matter if the
parents say don't worry about it, we're signing, we consent, it
doesn't matter.
I need a sent from that childand I will go through the same
(11:43):
shared decision making processas I would with an older patient
with these younger children.
Just the words are different.
Right, the conversation is at alevel that kids can understand,
because I need to know thatthey're motivated to do this and
(12:04):
they're not just doing it toplease the adults that they love
.
Children, by very nature oftheir existence, want to please
the adults who they love andrespect.
That includes their parents andtheir teachers and their
(12:26):
coaches, and also their doctors.
They never want to be adisappointment and they, when
pressed enough, will give youthe answer that they think you
want to hear, and so it'svitally important that,
especially at that like nine to17 year age group, that we don't
(12:51):
stop asking just because weheard the answer we wanted, that
we press a little further andtry to hook holes in the ascent
and say okay, but you understand, these are the ways in which
your life will change, at leasttemporarily.
Are you okay with that?
Okay, but you understand thatthere's a strong possibility
(13:15):
that you're really going to hatethe taste of nuts and you're
not going to particularly enjoydosing every day.
Are you okay with that?
Right?
You understand that you'regoing to have this exercise
restriction.
So if your friend knocks onyour door and says let's go ride
bikes, you might need to say Igot to wait a little bit, right?
These scenarios, theseconversations, need to be
(13:39):
explained to younger patients ina very concrete way and not in
the abstract way that we discussthem with adults saying, well,
there might be an exerciserestriction or this or that with
kids.
You need to give specificexamples and then sit back and
wait for their reaction andtheir response.
(14:02):
And you have to be able to pickup a nonverbal cues, because
you might have someone who issaying yes, but their eyes are
saying no, and you have to pushand press when you see that and
say I hear you saying yes, butI'm looking at your face and I
(14:23):
can tell that you're hesitatinga little bit and I'd like to
talk about that a little more.
Tell me, that's so good.
I want to ask you about theidea of pursuing this process
and then, once again, sit backand listen.
Right, ask the question, butthen don't just keep talking.
(14:43):
Right, you have to wait andhear what the patient has to say
and then address their concerns, because that's your primary
responsibility.
The patient is yourresponsibility, right?
Speaker 1 (14:56):
no-transcript.
That is so good and it reallycomes back to transitioning from
the pediatric care model to theadult care model, and one you
know there's not many benefitsto having a food allergy
compared to not having a foodallergy, but one potential
(15:17):
benefit is that if we, asallergists, are doing our jobs
correctly and doing it well,then when we see these kids once
or twice a year, or if they'redoing OIT sending, seeing them
multiple times per monthsometimes then we are assessing
where they are in their carejourney and, over time, helping
(15:39):
them grow in that transitionfrom being the kiddo where mom
is making the decisionsdepending on the age, definitely
having us since and themtotally in on the process too,
but really getting them to alsowhere they know that they need
to call to make an appointment,getting to where they know how
(16:00):
to obtain their epinephrineautoinjector.
And these are life skills thatsometimes with our healthy
kiddos that don't necessarilysee the doctor except for like a
physical every now and then,those kids don't necessarily
learn and then it seems like allof a sudden a kid's 18 and mom
(16:22):
can't do things so much anymore.
The kiddo needs to do itbecause the kiddos now an adult
right.
Or so does the government right,and so if we're doing our jobs
well and correctly, then whenwe're seeing these kids, we are
helping them transition, andthat really begins with that
(16:44):
beautiful description of shareddecision making that that you
just laid out.
It's that we're not going tobulldoze them.
As well meaning as lovingparents can be, it has to be
shared decision making, and Ithink, too, what that tells the
child, whether they're eightyears old or 17 years old, is
(17:09):
that you matter.
Your voice matters.
This is your body, and what youare doing with your body
matters, and you are the boss ofit.
Speaker 2 (17:23):
And what I will emphasize is the shared decision
making process is not a singlepoint in time.
It is not something we only doat that first or second visit,
when we're doing an informedconsent or obtaining ascent and
talking about risks and benefitsof a treatment and signing on
the dotted line right.
(17:44):
This is an ongoing processbecause people's goals and
priorities will change andevolve as they grow and evolve
and as their life situationchanges.
So you may have a five or sixyear old who did beautifully
with OIT and now they're 11 andthey're hiding peanut M&M's
(18:09):
under the couch cushions and weare sitting down and the parents
say we need to get back on OIT,and of course that's their
first instinct.
You need to help us get back onOIT.
And my instinct is well, maybewe don't need OIT anymore
because clearly the patientdoesn't want it anymore.
(18:29):
So before I start to try tofigure out what dose we're gonna
resume OIT at, let's sit downand talk about why these peanuts
are in under the couch insteadof in your belly, and then we
can go from there, because maybeall of a sudden the patient
says you know, I find them sodisgusting I can't, I dread it
(18:51):
all day.
It's ruining my quality of life.
I am looking for any excuse tonot do this anymore, but I was
afraid my mom was gonna cry if Itold her I didn't wanna do it.
And lo and behold, mom issitting in the corner crying
because she feels guilt, and dadis sitting there saying, oh my
(19:12):
gosh, how do I fix this?
Yes, mom's crying, kid's hidingpeanuts, and I think I want
people to know that they havepermission to change their minds
.
It is okay to change your mindand say this thing I wanted
before, I don't want thatanymore, and that's why it can
(19:37):
be so beneficial to havemultiple treatment modalities at
our disposal.
You know we've talked about,and you've talked about,
subliminal immunotherapy on yourpodcast before.
But this is a scenario when youhave significant oral aversion
(19:57):
but the patient and the familystill desire some layer of
protection, that a transitionfrom oral immunotherapy down to
subliminal immunotherapy mayactually make a lot of sense.
But historically we've alwaysthought well, subliminal
immunotherapy is lower dose, weget on that for a while and it's
(20:18):
a bridge to oral immunotherapy.
But it can go both ways andwhen we have the flexibility to
pick and choose from thisenormous toolkit of treatment
options, we can serve ourpatients better, but only if
they know that these options areavailable to them.
Sometimes the patient doesn'trealize, and the family doesn't
(20:45):
realize, that if this thingisn't working out, all we have
to do is pick up the phone andcall our allergist and say, hey,
we need some help, this isn'tworking for us, instead of
trying to power through right,because, come, sit, talk to me,
I will help you figure it out.
Maybe you don't need to beeating 10, eight peanuts every
(21:07):
day.
Maybe one will get the job done.
Or maybe we switch tosublingual, or maybe we say
listen, o-i-t.
Oral immunotherapy served itspurpose during a time in your
life when you needed it, beforeyour frontal lobe was fully
developed, when you were moreimpulsive, when you were
(21:27):
surrounded by peanut butter andjelly sandwiches at school, when
you were going to bake salesand play dates.
But now you're 17,.
You're 18, you can read yourown labels Heck.
You know how to cook, you canself-administer your own
epinephrine, right?
And you've decided that youhave no desire to eat this food.
(21:49):
It's not a failure.
It's not a failure.
It's not a failure.
You've decided to stop now.
And all of that work, all ofthat time, all of that money you
put into that treatment was notfor nothing, right?
I think that's what people areafraid of that if we quit, all
(22:10):
of that work we put in is a wash.
It did no good, and that's nottrue.
It served its purpose during atime when you needed it for
safety, when you needed it forpeace of mind, when you needed
it for quality of life, andmaybe now you don't need that
anymore, and that's okay.
Speaker 1 (22:29):
And that's okay.
And that's okay I know thatthere is a mom who needs to hear
this, and that's okay.
And things change and seasonschange.
We talk a lot about your seasonof life and this might not be
the right season of life for OITor SLIT, but maybe there's
another season coming later andit will be, and it's all about
(22:52):
safety and quality of life.
Absolutely, dr Bajwala.
I have loved our conversationtoday about shared
decision-making.
Thank you so much for coming onthe podcast.
Speaker 2 (23:04):
Of course it's my pleasure.
Thank you so much for invitingme.
Speaker 1 (23:10):
That's the episode.
Thanks so much for tuning in.
Of course I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned on this
episode and visit us atfoodallergyandyourkiddocom,
where you can submit yourfamily's questions.
God bless you and God blessyour family.
Hello and welcome to the Food Allergy and your Kiddo
Podcast.
I am your host, dr Alice Hoyt,delighted to be joined today by
Dr Sakina Bajawala.
She is a board-certifiedpediatrician and allergist who
practices in the western suburbsof Chicago.
She is a fellow of the AmericanAcademy of Allergy, asthma and
(00:27):
Immunology and she is anabsolute boss when it comes to
immunotherapy.
And part of what I think makesher a boss getting to know her
some is really her approach toworking with families and really
what we're going to talk abouttoday, which is shared
decision-making.
So, dr Bajawala, thanks so muchfor coming to the podcast.
Speaker 2 (00:51):
Well, thank you so much for having me.
I'm really looking forward totalking to you today.
Speaker 1 (00:57):
Me too, so let's just dive right in.
How do you really define likeyou internally, as a physician,
as a kiddos doctor?
How do you really define shareddecision-making?
Speaker 2 (01:14):
So to me, in my practice, shared decision-making
essentially means that I askfamilies what their goals are
and I give them all of theiroptions.
We comprehensively discuss therisks and benefits of all the
(01:38):
options that are available tothem, I let them know which
option I believe would be mostlikely to meet their goals and
their expectations, and then Ishut my mouth and I sit back and
(01:59):
I listen and wait for them toask me questions and I answer
them.
But it is not my job as thephysician or allergist to make
the call on what it is we aregoing to do.
It is my job to share theinformation and be an advisor,
(02:20):
and it is the patient's and thefamily's job to together come to
a decision on which of theoptions I have presented that
they want to pursue.
Speaker 1 (02:35):
That is very pretty much straight in line with the
way I try to approach myfamilies as well is sort of I'm
a guide and I'm a very wellresearched and expert guide and
I'm going to present the optionsand present them as how I think
(03:01):
would best serve that patientand discuss things especially.
You know, let's just dive intosome cases here.
I've certainly had kiddos cometo me who's the family was
interested in oral immunotherapy, but the kiddo, who was maybe a
tween or a teen, was just likeabsolute no go, like they're a
(03:23):
very important part of shareddecision-making and the team and
so OIT is just not an optionfor them right now because
they're not on board with it.
And so then we discuss with theparents and with the kiddo too.
Like you know, this doesn'tseem like this is a good option
right now, and that's okay.
(03:45):
I think sometimes social mediahere comes a tangent y'all.
I think sometimes with socialmedia treatments or you know the
latest thing, it gets sosensationalized and people think
everyone should do it orwhatever the case may be.
People have heard me on talkabout the advertisement for
(04:06):
palforzia be proactive aboutyour child's food allergy.
That ad is absolutely bonkersto me because you can be
proactive about your child'sfood allergy and not have your
child on palforzia and not seewhat it at all and you're still
being proactive so standard ofcare remains avoidance and
(04:27):
preparation with emergencymedication.
Speaker 2 (04:29):
That is a standard of care.
Now the standard of care may bechanging, right, and it is
changing very much so and veryrapidly.
But it's really important toemphasize to families when we're
talking to them that your onlyoptions are not different
treatment options, right, thefirst and foremost, the option
(04:51):
available to you is to do whatyou've already been doing and we
can help you do it moresuccessfully which is avoidance
and preparation and awareness ofhow to recognize an allergic
reaction and springing to actionquickly so in the event and
hopefully unlikely event of anaccidental exposure, you rapidly
(05:15):
identify the symptoms and yougive the appropriate treatment
without delay.
That's option number one always.
Speaker 1 (05:25):
I think that's so important that families hear
that.
You know so if you're listeningto this and you've been told by
three different food allergymom friends that they're doing
OIT, oit and SLIT and you knowwhen are you going to do this
with your child and it's andit's just not the right time for
(05:46):
y'all to do it.
I want you to hear what DrBajawala just said, that if it's
not the right time, it's notthe right time, and that
avoidance is absolutely afantastic management strategy
for food allergy.
Speaker 2 (06:05):
And especially if you've already been doing it
successfully, right?
Yes, and from initial diagnosisall the way up until you're at
the allergist's office andyou've never had a reaction from
accidental exposure, you havebeen successful and maybe you
don't need treatment.
Maybe the return on investmentof a treatment in your
(06:31):
particular case the calculationsdon't pan out and you're better
off just continuing what you'vealready been doing.
Quite well.
Speaker 1 (06:41):
I think this probably really speaks to parents of
tweens and teens, in whomstarting oral immunotherapy at
least would be significantlylife altering in a way that
isn't necessarily positive.
The reason I say that is becauseof the safety window that has
(07:03):
to be followed.
If you're doing oralimmunotherapy in my office
that's one hour before, twohours after the dose you're not
doing anything that's raisingyour heart rate or your body
temperature.
Anytime you have a fever, takeMotrin, a whole slew of things
you're not dosing and that justis not consistent with a good
(07:24):
quality of life for many tweensand especially many teens who
are doing so many super coolbefore school and after school
activities and it's really notfeasible for them to do the OIT
and keep doing activities.
And we would never want them tostop doing those activities and
(07:48):
then thinking about okay, whatabout when they go to college?
Just say they're a junior or asenior in high school and they
want to start OITs or somebodyin their family wants them to
start OIT.
Then what's going to happenwhen they go to college?
Nothing good with OIT.
Speaker 2 (08:07):
And it's a very different scenario If you have a
child who began OIT when theywere five or six.
They reached maintenance bysecond or third grade and
they've been in maintenance foryears before they leave the nest
and go out to functionindependently.
By that point, most of mypatients are only dosing maybe
(08:29):
three to four times a week andI've already started shaving
down their exercise restrictionbecause they have been so
successful for so long inmaintenance.
That is a very differentscenario than showing up in my
office when you have a highschool junior which is, in my
opinion, after experiencing thisnow the most stressful year of
(08:52):
high school and saying, okay, wegot to do this now and we need
to be done before we go tocollege, otherwise I'm not going
to let him go.
Then I have to say, okay, let'stake a step back.
Who am I treating here?
Am I treating the child or arewe treating parental anxiety?
Because if it's parentalanxiety that we're treating, I
(09:17):
don't need OIT to treat that.
We have other tools at ourdisposal to help with that other
the big toolkit of things wecan do to help with that.
Speaker 1 (09:33):
Absolutely.
I want to ask you when you arepracticing shared decision
making, which I imagine with youis just literally second nature
, it's just how you practice.
Medicine is through shareddecision making.
You're never walking into aroom telling a family.
This is what you're doing.
You're walking into a roomequipped to discuss all of the
(09:57):
different management options.
How do you do that with littlekiddos compared to with your
tweens and then also with yourteens?
Speaker 2 (10:09):
I think it is vital that, even though they may not
be at the age of consent, oflegal consent, that young
patients are actively involvedin the decision making process
and that they have an agencyover their own bodies.
(10:32):
For that reason, for any childin our practice, if they're over
the age of 12, we get a sentwritten, a sent from the child.
So there's consent which iskind of legal informed consent,
and anyone 18 and up must dotheir own informed consent.
(10:57):
Parents cannot do the informedconsent for an 18 or 19 year old
, but for patients who areyounger than that but still very
capable of having an informeddiscussion, of asking questions,
of having very strong opinionsabout what their goals are and
(11:18):
how they would like to achievethem, I have made it quite clear
that without a sent from thepatient, their permission to
move forward with this treatment, it doesn't matter if the
parents say don't worry about it, we're signing, we consent, it
doesn't matter.
I need a sent from that childand I will go through the same
(11:43):
shared decision making processas I would with an older patient
with these younger children.
Just the words are different.
Right, the conversation is at alevel that kids can understand,
because I need to know thatthey're motivated to do this and
(12:04):
they're not just doing it toplease the adults that they love
.
Children, by very nature oftheir existence, want to please
the adults who they love andrespect.
That includes their parents andtheir teachers and their
(12:26):
coaches, and also their doctors.
They never want to be adisappointment and they, when
pressed enough, will give youthe answer that they think you
want to hear, and so it'svitally important that,
especially at that like nine to17 year age group, that we don't
(12:51):
stop asking just because weheard the answer we wanted, that
we press a little further andtry to hook holes in the ascent
and say okay, but you understand, these are the ways in which
your life will change, at leasttemporarily.
Are you okay with that?
Okay, but you understand thatthere's a strong possibility
(13:15):
that you're really going to hatethe taste of nuts and you're
not going to particularly enjoydosing every day.
Are you okay with that?
Right?
You understand that you'regoing to have this exercise
restriction.
So if your friend knocks onyour door and says let's go ride
bikes, you might need to say Igot to wait a little bit, right?
These scenarios, theseconversations, need to be
(13:39):
explained to younger patients ina very concrete way and not in
the abstract way that we discussthem with adults saying, well,
there might be an exerciserestriction or this or that with
kids.
You need to give specificexamples and then sit back and
wait for their reaction andtheir response.
(14:02):
And you have to be able to pickup a nonverbal cues, because
you might have someone who issaying yes, but their eyes are
saying no, and you have to pushand press when you see that and
say I hear you saying yes, butI'm looking at your face and I
(14:23):
can tell that you're hesitatinga little bit and I'd like to
talk about that a little more.
Tell me, that's so good.
I want to ask you about theidea of pursuing this process
and then, once again, sit backand listen.
Right, ask the question, butthen don't just keep talking.
(14:43):
Right, you have to wait andhear what the patient has to say
and then address their concerns, because that's your primary
responsibility.
The patient is yourresponsibility, right?
Speaker 1 (14:56):
no-transcript.
That is so good and it reallycomes back to transitioning from
the pediatric care model to theadult care model, and one you
know there's not many benefitsto having a food allergy
compared to not having a foodallergy, but one potential
(15:17):
benefit is that if we, asallergists, are doing our jobs
correctly and doing it well,then when we see these kids once
or twice a year, or if they'redoing OIT sending, seeing them
multiple times per monthsometimes then we are assessing
where they are in their carejourney and, over time, helping
(15:39):
them grow in that transitionfrom being the kiddo where mom
is making the decisionsdepending on the age, definitely
having us since and themtotally in on the process too,
but really getting them to alsowhere they know that they need
to call to make an appointment,getting to where they know how
(16:00):
to obtain their epinephrineautoinjector.
And these are life skills thatsometimes with our healthy
kiddos that don't necessarilysee the doctor except for like a
physical every now and then,those kids don't necessarily
learn and then it seems like allof a sudden a kid's 18 and mom
(16:22):
can't do things so much anymore.
The kiddo needs to do itbecause the kiddos now an adult
right.
Or so does the government right,and so if we're doing our jobs
well and correctly, then whenwe're seeing these kids, we are
helping them transition, andthat really begins with that
(16:44):
beautiful description of shareddecision making that that you
just laid out.
It's that we're not going tobulldoze them.
As well meaning as lovingparents can be, it has to be
shared decision making, and Ithink, too, what that tells the
child, whether they're eightyears old or 17 years old, is
(17:09):
that you matter.
Your voice matters.
This is your body, and what youare doing with your body
matters, and you are the boss ofit.
Speaker 2 (17:23):
And what I will emphasize is the shared decision
making process is not a singlepoint in time.
It is not something we only doat that first or second visit,
when we're doing an informedconsent or obtaining ascent and
talking about risks and benefitsof a treatment and signing on
the dotted line right.
(17:44):
This is an ongoing processbecause people's goals and
priorities will change andevolve as they grow and evolve
and as their life situationchanges.
So you may have a five or sixyear old who did beautifully
with OIT and now they're 11 andthey're hiding peanut M&M's
(18:09):
under the couch cushions and weare sitting down and the parents
say we need to get back on OIT,and of course that's their
first instinct.
You need to help us get back onOIT.
And my instinct is well, maybewe don't need OIT anymore
because clearly the patientdoesn't want it anymore.
(18:29):
So before I start to try tofigure out what dose we're gonna
resume OIT at, let's sit downand talk about why these peanuts
are in under the couch insteadof in your belly, and then we
can go from there, because maybeall of a sudden the patient
says you know, I find them sodisgusting I can't, I dread it
(18:51):
all day.
It's ruining my quality of life.
I am looking for any excuse tonot do this anymore, but I was
afraid my mom was gonna cry if Itold her I didn't wanna do it.
And lo and behold, mom issitting in the corner crying
because she feels guilt, and dadis sitting there saying, oh my
(19:12):
gosh, how do I fix this?
Yes, mom's crying, kid's hidingpeanuts, and I think I want
people to know that they havepermission to change their minds
.
It is okay to change your mindand say this thing I wanted
before, I don't want thatanymore, and that's why it can
(19:37):
be so beneficial to havemultiple treatment modalities at
our disposal.
You know we've talked about,and you've talked about,
subliminal immunotherapy on yourpodcast before.
But this is a scenario when youhave significant oral aversion
(19:57):
but the patient and the familystill desire some layer of
protection, that a transitionfrom oral immunotherapy down to
subliminal immunotherapy mayactually make a lot of sense.
But historically we've alwaysthought well, subliminal
immunotherapy is lower dose, weget on that for a while and it's
(20:18):
a bridge to oral immunotherapy.
But it can go both ways andwhen we have the flexibility to
pick and choose from thisenormous toolkit of treatment
options, we can serve ourpatients better, but only if
they know that these options areavailable to them.
Sometimes the patient doesn'trealize, and the family doesn't
(20:45):
realize, that if this thingisn't working out, all we have
to do is pick up the phone andcall our allergist and say, hey,
we need some help, this isn'tworking for us, instead of
trying to power through right,because, come, sit, talk to me,
I will help you figure it out.
Maybe you don't need to beeating 10, eight peanuts every
(21:07):
day.
Maybe one will get the job done.
Or maybe we switch tosublingual, or maybe we say
listen, o-i-t.
Oral immunotherapy served itspurpose during a time in your
life when you needed it, beforeyour frontal lobe was fully
developed, when you were moreimpulsive, when you were
(21:27):
surrounded by peanut butter andjelly sandwiches at school, when
you were going to bake salesand play dates.
But now you're 17,.
You're 18, you can read yourown labels Heck.
You know how to cook, you canself-administer your own
epinephrine, right?
And you've decided that youhave no desire to eat this food.
(21:49):
It's not a failure.
It's not a failure.
It's not a failure.
You've decided to stop now.
And all of that work, all ofthat time, all of that money you
put into that treatment was notfor nothing, right?
I think that's what people areafraid of that if we quit, all
(22:10):
of that work we put in is a wash.
It did no good, and that's nottrue.
It served its purpose during atime when you needed it for
safety, when you needed it forpeace of mind, when you needed
it for quality of life, andmaybe now you don't need that
anymore, and that's okay.
Speaker 1 (22:29):
And that's okay.
And that's okay I know thatthere is a mom who needs to hear
this, and that's okay.
And things change and seasonschange.
We talk a lot about your seasonof life and this might not be
the right season of life for OITor SLIT, but maybe there's
another season coming later andit will be, and it's all about
(22:52):
safety and quality of life.
Absolutely, dr Bajwala.
I have loved our conversationtoday about shared
decision-making.
Thank you so much for coming onthe podcast.
Speaker 2 (23:04):
Of course it's my pleasure.
Thank you so much for invitingme.
Speaker 1 (23:10):
That's the episode.
Thanks so much for tuning in.
Of course I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned on this
episode and visit us atfoodallergyandyourkiddocom,
where you can submit yourfamily's questions.
God bless you and God blessyour family.
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