Correspondence: 'Screening'; bpac recertification; Allergy testing

Dear Editor,

I opened the latest Best Practice Journal (Feb, 2012) and read the article about HbA1C in the diagnosis of diabetes with interest – finally some common sense being applied to the diagnosis! So well done. However, you persist in using the term screening badly, and use the absolute nonsense term "opportunistic screening".

There is no such thing as "opportunistic screening". Either one screens – asymptomatic population, acceptable test (sensitive/specific) appropriate intervention, better outcome and all that – or one doesn't. What you are actually referring to is the use of an investigation in a patient who presents in the context of their clinical care. It is not screening, it is a test, with a particular pre-test probability. It needs to be used appropriately, but it is not screening – it is an investigation.

What would be really useful is a rigorous critique of screening – I think you'll find that virtually the only programmes for which there is evidence are cervical screening and the neonatal metabolic tests. The trouble with saying this out loud is that professing the lack of evidence for say, breast cancer screening, will incur the wrath of the politically correct.

Dr Wayne Cunningham,
General Practitioner, Milton

Dear Editor,

A lot of General Practitioners are very upset about the new Medical Council of New Zealand levy to support BPAC and pay for us being (yet again) certified. There is a ground swell of opinion coming from my colleagues that this levy is a "rip off".

The $1200 levy applies to doctors who are not members of the Royal College, and that is a huge number of doctors. Maybe you can tell me how many?

To spring this unpleasant surprise on us without any warning was upsetting. Upset is probably an understatement, angry is more like it with a few of my mates. I really value BPAC but the constant money grabs (beyond just BPAC) is creating unhappy doctors – and I think maybe your PR needs to improve in order to "sell" the whole idea. Perhaps the MCNZ is more responsible here.

We already have over a half a dozen "professional bodies" looking after our "interests", and to have to pay another one really sticks in the side.

Dr Alex Luft
General Practitioner, Napier

Dear Editor,

I was pleased to see Allergy Testing reviewed in Best Tests (Dec, 2011), but have some concerns. The most important part in treating allergies is recognition and education, and general practice is ideally placed to provide this. Recognition is mainly based on clinical history, but testing can be useful, in particular if wheat, dairy or multiple food avoidance is being suggested for more than a few weeks test period. Dr Vincent St Aubyn Crump has written an excellent guide to diagnosing allergies in General practice which is available at:

www.allergy.org.nz/site/allergynz/files/GP%20diagnosis.pdf

My concern is that if the allergy is not accurately diagnosed the patient may not be receiving adequate education. Education should involve action plans, antihistamines (and occasionally adrenaline), avoidance advice and follow-up. Schools are required to have action plans for children with allergies and we will be increasingly asked to complete them, which is a good thing for best practice. The Australasian Society of Clinical Immunology and Allergy (ASCIA) action plans and the New Zealand School Guidelines, along with many other resources, are available at: www.allergy.org.nz

In a recent large study in Melbourne,* 10% of the 2,884 one-year-olds had food challenge proven IgE food allergy. Food allergies are increasing, more people have multiple allergies and they are lasting longer. So "containing" the budget as suggested may not be feasible, but aiming to have a balanced approach of judicious testing based on appropriate clinical history from an informed medical workforce is.

Further resources:

ASCIA provides excellent online training for health professionals, which takes about an hour and is endorsed for CME points: http://etraininghp.ascia.org.au/

There are also two excellent books I would recommend for anyone interested in finding out more, both are also available from Allergy New Zealand:

"Allergies. New Zealand's growing epidemic" by Dr Vincent St Aubyn Crump, 2009.

"The Allergy Epidemic. A Mystery of Modern Life" by Dr Susan Prescott, 2011.

Dr Kylie Morse
General Practitioner Wellington, Allergy NZ board member

* Osbourne N, Koplin J, Martin P, et al. Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and pre-determined challenge criteria in infants. J Allergy Clin Immunol 2011;127(3):668-76