From the Discovery of IgE to Modern Precision Care: Exploring a Career in Allergy/Immunology

In this episode, we discuss the remarkable evolution of allergy and immunology through the lens of a career spanning six decades. Past AAAAI President Phil Lieberman, MD, FAAAAI, explores the pivotal scientific breakthroughs in the field starting with the discovery of IgE as he started in practice and taking us through target therapy has changed the lives of his patients. Dr. Lieberman offers us both historical perspective and guidance for physicians just starting in the field. 

Find out more about Dr. Lieberman. 

Transcript

Rebecca Saff, MD, PhD, FAAAAI 0:29

And for a few core topics, the field of allergy immunology has undergone remarkable transformations over the past several decades due to our understanding of the immune system and its role and disease. These are dances of relationships to how we diagnose and manage core conditions leading to improved testing and increasingly targeted treatments. For example, I've seen how the explosion of biologics has changed how we treat patients, including the recent ADRD patient who had been after he started to film about it and his college disappeared. Today I'm welcoming Dr. Phil Lieberman to the podcast to discuss how the field of allergy and immunology has changed over the course of his career and how that can inform the care we give today. Dr. Lieberman is a clinical professor of pediatrics and internal medicine in the Allergy Immunology Division of the University of Tennessee's College of Medicine. He was the president of the American Academy of Allergy, Asthma & Immunology in 1988. Over the course of six years of service in the field, Dr. Lieberman has authored over 600 publications, mentored hundreds of students, and treated thousands of patients. He received a lifetime contribution to the AAA AI and Allergy Immunology Specialty Award this year during the AAA AI Annual Meeting. He has truly seen the evolution of our specialty, and I wanted to talk to him today about the changes he has seen in our field over that time. Dr. Lieberman, thank you so much for taking the time to join us today. Welcome to the podcast.

Phil Lieberman, MD, FAAAAI 1:44

Thank you, uh Dr. Saff, and thank you for that nice introduction. Actually, I'm past president. Uh uh correction, I'm past uh I'm retired now. So I'm a past member of the allergy uh division here uh because about one year ago I retired, but still active uh intellectually. So actually, I didn't choose fields of allergy and immunology. It sort of chose me. I had just finished my internal medicine residency and uh had planned to go into GI. In fact, I was accepted uh in the GI program uh at Chicago, and uh I went to talk to my chief of medicine then, who was Gene Stolerman. Uh uh Gene uh said to me, I don't want you to do that. Uh I think that you ought to do something different. He said, I need an allergy program here, and uh I'd like you to go train an allergy. I'll give you a couple places to look at. You come back here and tell me if you want to do it, I will try and get you into that place. Well, it was a nice offer to me because I was an asthmatic actually and had some uh practice myself taking care of myself uh back in those days. And so I took up his offer. Uh I looked at the places to train and I decided I want to go to the West Coast, where Scripps was because I like the ocean. I came back and told him, he said, No, you don't want to go there. Uh he said, you want to go to Northwestern University. No one told Dr. Stolerman no. Uh when he said something, people did it, and I did what he said. I went uh to Chicago, talked to Dr. Patterson. He said, You have eight hours, uh, go and look at the program, walk around. If you want to stay, at Gene's uh recommendation, uh you're accepted. If you don't want to stay, tell me because I have other people waiting for the job. I fell in love immediately. Uh I uh fell in love with Chicago, I fell in love with his program, and uh I thought I was in Valhalla. I told him that I accepted and uh then became uh a fellow in his program.

Rebecca Saff, MD, PhD, FAAAAI 4:00

So it sounds like the match process was very different in your day.

Phil Lieberman, MD, FAAAAI 4:03

It was extremely different. Uh and uh you had a lot of control where you don't so much these days.

Rebecca Saff, MD, PhD, FAAAAI 4:10

So then you finished that fellowship and started practicing. What did the practice of allergy immunology look like at that time?

Phil Lieberman, MD, FAAAAI 4:17

Well, when uh I started practicing, uh it was in an academic situation and uh also a private practice situation. Uh, and I actually uh participated on both ends of that spectrum, and it was uh entirely different uh than it is today. The boards of allergy and immunology were separate when I entered the field. Pediatrics were separate than internal medicine. The first board that ever combined them was the first board I took. Uh, and uh having practiced internal medicine with very little pediatrics, my scores uh reflected clearly uh my uh talents at that time. Fortunately, I knew enough to pass. At that time, there were no formal practices of emergency room of ICU or of hospitalists, there were no boards. So at that time, in practice, one took care of their patient all the way through their care. So if you admitted someone, you took him to the hospital him or her to the hospital. Uh, if they had to go to the ICU, you took care of them in the ICU. And all charts were paper, they were massively heavy, and if you wanted to take them home to complete them, you had to load them around. There were no selective beta blockers. Uh isopherinol was the only beta ainurgic. It was administered by a devilbus handheld rubber pump or by a bicycle-driven pump. For our patient, we used the handheld pump. I would carry it with me wherever I went. When I played sports, I would run to the sideline and take whisp periodically. And we had uh theosilin, tetral, quadrinal for oral drugs. They consisted of ephedrin, theosilin, and phenobarbital, with quadrantal having the additional SSKI. And we had sedating antihistamines and, of course, prednisone. So it was an entirely different practice at the time.

Rebecca Saff, MD, PhD, FAAAAI 6:25

When did inhalers start to become used in practice of asthma?

Phil Lieberman, MD, FAAAAI 6:30

The inhalers, if my memory serves me correctly, in the 19 uh seventies, the uh major dose inhalers uh and uh topical inhalers via uh uh uh topical steroids. But until that time, uh I believe we were still using uh the uh debilbus and the bicycle pump. The bicycle pump for people who had severe obstruction and might have to go to the hospital, and the debilbus for moderate asthma.

Rebecca Saff, MD, PhD, FAAAAI 6:59

That's amazing that you actually had like a handheld pump that you had to go on the sidelines and and administer so you could continue your sports game.

Phil Lieberman, MD, FAAAAI 7:06

Exactly. I do I went nowhere without that debilbus inhaler.

Rebecca Saff, MD, PhD, FAAAAI 7:11

And then what about immunotherapy? Was immunotherapy done in a similar fashion to how it's done today?

Phil Lieberman, MD, FAAAAI 7:17

It yes, it hadn't changed too much uh from the the practice when it first started uh by Cook, actually. If you go back and look at Cook's textbook, it really hadn't changed. And the practice that we did at Northwestern and later at the University of Tennessee was very much similar to that.

Rebecca Saff, MD, PhD, FAAAAI 7:37

And tell us about a patient that you might have had in the hospital with asthma, like in the 70s and 80s. How would you go about treating them?

Phil Lieberman, MD, FAAAAI 7:45

Well, uh, it was very primitive. Uh we would uh I would put them in the hospital, and of course, they were put on oral steroids, intravenous uh steroids when they became available uh early on, and had uh daily administration of inhaled bronchodilators. There was no selective beta adenergics, they uh only had isopotteranol, and uh there was no drug uh other than theosolin and corticosteroids.

Rebecca Saff, MD, PhD, FAAAAI 8:18

Yeah, it's very different. And even that, even just the fact that there were so many people hospitalized with asthma versus today where we really think about it as an outpatient disease.

Phil Lieberman, MD, FAAAAI 8:27

Uh yes. Uh the the hospitalizations reached a peak in the mid-60s. And even though we've had more uh people suffering from asthma, the uh treatment has improved so much that hospitalizations uh have gone down. We we were pretty primitive back when I started.

Rebecca Saff, MD, PhD, FAAAAI 8:47

I'm glad I have all the options now to offer my patients, but it sounded like you know you took care of the patients well with the tools that you had at the time.

Phil Lieberman, MD, FAAAAI 8:55

We uh were primitive, but we were able to keep them alive most of the time.

Rebecca Saff, MD, PhD, FAAAAI 9:01

Definitely important. And then I understand IgE had just been discovered as you kind of began your career. Can you walk us through some of the discoveries that were key in the field over time?

Phil Lieberman, MD, FAAAAI 9:13

One cannot overestimate the effect of the identification of IgE as the blood uh substance, a reagen, that is, that could transfer uh allergic activity from one person to another by blood. At that time, when I went in practice, we did the PK test uh to look for reagin as it was uh as it was described. Uh and all of my early research, especially in uh insulin allergy, was done by using the process Christner test, where I took blood out of one patient and put it in the skin of another patient, and then uh looked at effects that uh altered that ability to transfer uh reagin by blood. And in the 1970s, uh I sent a questionnaire out to all allergy training centers in the United States, and I listed every possible option I could think of as the most important single event in the history of allergy, and hands down it was a hundred percent vote for the discovery of IgE. Uh, it really changed things. Uh, it opened up testing uh and uh it had an unexpected, a very benevolent effect. It added respect to the field of allergy. Uh, the field of allergy at that time, not being scientific, it was not respected as much as it is today since we've discovered IgE because we have a better science uh available to us now.

Rebecca Saff, MD, PhD, FAAAAI 10:52

And what were the other things on the list besides IgE? I'm just curious.

Phil Lieberman, MD, FAAAAI 10:56

We had uh development of uh topical steroids, the uh increase of available to uh detect allergy by in vitro methods prior to that time. And uh Ishizaka uh had called IgA uh the uh reagen, and because of the failure of IgA uh to be the the true substance, uh we had lost respect uh in the field. So uh there was an unexpected, uh very benevolent uh effect adding to our field uh respect and giving us an adequate science background. Uh my chief of dermatology uh uh told me he uh was jealous of us, he was a dermatologist, because of the science that we had uh about uh IgE. So it did all of those things, and one can't overestimate its value.

Rebecca Saff, MD, PhD, FAAAAI 11:55

Even just you know, resident T cells in the skin, I suppose, you know, weren't known at that time. We couldn't even grow T cells, I think, until the 1980s, and IL2 was discovered.

Phil Lieberman, MD, FAAAAI 12:04

Right. That's correct.

Rebecca Saff, MD, PhD, FAAAAI 12:07

And now we have such a kind of wider understanding of allergic mechanisms. What are some of the other discoveries you think that have been really key over the last you know kind of 20 years in the field?

Phil Lieberman, MD, FAAAAI 12:18

By far, the most wonderful discovery which revolutionized uh our field and changed uh completely how we treat patients is the uh discovery of monoclonal antibodies, cytokines, anticytechine therapies. Since the availability of these drugs, so to speak, we have completely changed uh the life of patients with uh asthma and other uh allergy-based disease. Uh we lived with outside histories, so outside discoveries have been important to us as well. The internet, PowerPoint, uh up-to-date like uh uh textbooks, uh, fiber optics uh and other online textbooks, uh, the hygiene hypothesis uh and the c especially the concept of remodeling. Until that concept came on board, I could uh I I could tell people you will not develop obstructive lung disease that's permanent. But since the concept of remodeling came on board, uh we can no longer say that, although it's not emphysema, it's a different form of permanent obstructive disease. Uh there were other theories that came along that really didn't uh stick. Uh Robert Orange at Sick Children's, Michael Callender and the Annals of Internal Medicine talked about the yin-yang therapy that asthma was due to abnormalities in beta-inergic and alpha-inergic uh receptors. But uh later that theory was squelched by Tom Casaley in an article in the Annals. So we've made great strides, but the one that's been most important is the development of monoclonal antibodies. Uh and uh also uh the basic science uh of uh SRSA, anti-nucotrice have also uh helped us considerably.

Rebecca Saff, MD, PhD, FAAAAI 14:25

It's amazing how each development can have led to the next. And I wouldn't have put you know the fiber offices in the internet in my thoughts of like what has transformed the field, but clearly it has. It's transformed a whole world, how we learn, um, how our patients look up things and come in to ask us. So it's really made all the difference in how we practice.

Phil Lieberman, MD, FAAAAI 14:45

I agree. Thank you.

Rebecca Saff, MD, PhD, FAAAAI 14:48

And you've really been a leader in the field of anaphylaxis. When did epinephrine first become the the treatment for anaphylaxis?

Phil Lieberman, MD, FAAAAI 14:55

Thank goodness. Uh it goes way back. Anaphylaxis, epinephrine treatment goes back to when I entered practice, actually. The uh history is that uh it was first developed with adrenal extract, and uh later on the standard dose of 0.03 Court three milligrams uh was discovered uh using that uh adrenal extract, which was a mixture actually of uh adrenal substances, but it has been the desired treatment of anaphylaxis since the uh the written history uh and anaphylaxis itself uh was defined.

Rebecca Saff, MD, PhD, FAAAAI 15:45

Were there other treatments that were that were tried prior to that?

Phil Lieberman, MD, FAAAAI 15:49

Well, especially in prevention of anaphylaxis. Uh my calendar, and uh an uh excellent study in which he infused human beings, volunteers with histamine, found that H1, H2 blockers uh were very effective, and especially in the prevention of anaphylaxis, we use them as our major source of prevention, for example, to drugs, uh radiocontrast in specific, and also uh to uh other agents. So epinephrine is the hallmark of therapy, but for the prevention of anaphylaxis, uh H1 and H2 blockers are very effective.

Rebecca Saff, MD, PhD, FAAAAI 16:32

I'm curious about food allergy. How is that how have you seen that change as well? Because you know, we think of this really being a much more recent development. When you first started in practice, did you see patients with food allergy?

Phil Lieberman, MD, FAAAAI 16:45

Oh, did I? I have a whole family for the treat. Uh I have uh four um grandchildren and myself uh with uh allergic anaphylactic reactions uh to uh foods. Uh I have uh anaphylax uh to um snails. Uh my grandchildren have uh peanut and shellfish anaphylaxis. So uh it it I've had a lot of experience uh in uh treatment and prevention of anaphylaxis in my own family outside of the patients uh that we've seen, and they've numbered at least in the hundreds.

Rebecca Saff, MD, PhD, FAAAAI 17:28

Yeah. And do you feel like that's changed over time, the foods that you're seeing, the people that you're seeing with food allergies?

Phil Lieberman, MD, FAAAAI 17:36

Yes, uh it has changed, and we've become far more adept uh in prevention of food allergies uh uh than we were when I first started the process. Testing has helped us so much because uh we can test without risking reactions uh via in vitro testing, and we owe that again to the discovery of uh IgE.

Rebecca Saff, MD, PhD, FAAAAI 18:02

Yeah, no, that makes a definitely a big difference being able to test and know exactly what we're looking for when people are allergic. What are some of the things that you have been really constant through your career?

Phil Lieberman, MD, FAAAAI 18:16

Listen, it's been a wonderful career. Uh I by serendipity walked into it and I've uh loved every single minute of it. And the things that have stayed constant uh are number one, uh allergists are fun people. Uh we have a fun practice uh and the camaraderie involved uh has been exquisite. Uh my best friends in life have come uh from uh the the my practice, international friends, uh to this day uh that I keep in in touch with because of the uh delight of practice. We're we're very happy uh people. And uh that has not changed. I think other things that have not changed are uh the love of the specialty has uh for uh uh the basic science aspects. Uh I think I may have mentioned this, I don't remember, but uh Chief of Dermatology at the University of Tennessee would express jealousy to me uh because we had uh a basic science uh to back up our clinical practice. And uh that's one of the things that has remained constant. Uh I think we're the best practice, uh the best subspecialty of all uh in that uh vogue. Uh that is, we can bring uh the bench to the bedside uh very easily.

Rebecca Saff, MD, PhD, FAAAAI 19:49

Yeah, that translation of what we learn in the lab and then bringing it back to the patient, I think is so strong in allergy and in immunology. We've certainly seen the changes in how we identify and treat immune deficiencies as well as we can now do much more targeted treatment.

Phil Lieberman, MD, FAAAAI 20:06

Absolutely. And what I have to tell you, you asked me for favorite patients. You you brought up that several guy, put one in perspective for you that we have published. The first patient I saw in practice was a case of uh Brutin's disease with IgE synthesis remained, and penicillin allergy, who we desensitized to penicillin and treated with uh intravenous gamma globula and published that paper. That was uh just an excellent way that we have in our practice uh to me of bringing forth basic science uh to the bedside.

Rebecca Saff, MD, PhD, FAAAAI 20:48

So I'm curious about your time as the president of Quad AI. I think you were president in 1988, is that right?

Phil Lieberman, MD, FAAAAI 20:54

Yes, uh I I was. Uh I think it's the greatest honor I've received in practice, and uh I I'm just grateful to have received that honor.

Rebecca Saff, MD, PhD, FAAAAI 21:06

What were the initiatives that you took for it as during your year as president?

Phil Lieberman, MD, FAAAAI 21:10

The biggest thing I did as an initiative, and I must admit it was a mistake, and I I suffered from it, was to try and merge the academy and the college. I thought there was a lot of uh overlay and uh excessive uh repetition, and so I gave my presidential address uh about merging the two subspecialties. I made a mistake because I got a lot of negative feedback for that. So I would be president again, but I I would change uh my uh speech to something a little less controversial.

Rebecca Saff, MD, PhD, FAAAAI 21:51

Fair enough. I think that would still be controversial to this day.

Phil Lieberman, MD, FAAAAI 21:54

So I agree with you.

Rebecca Saff, MD, PhD, FAAAAI 21:57

I talked to Dr. Davis, who's the current President of the AAAAI. And one of the things she had mentioned was that she really thought about what threats to the field were. I don't know if you can think back what you thought at the time threats to the field of allergy immunology might be.

Phil Lieberman, MD, FAAAAI 22:12

Didn't really think much of it, but uh there there are some threats that uh have occurred uh and they've been related uh mainly to the uh advancement in diagnostic uh testing because it had a dark side as well as a positive uh bright side, because it gained access uh to testing to untrained people. That is, people who were not trained in the use of the test uh could use them uh to uh create treatment programs, uh, and that resulted in some um bad results where people were treated who really hadn't been allergic for people who uh were treated with doses that weren't effective. So our advances that we had that uh were uh not only good but bad for the practice uh were really related to the uh uh assessment of testing by people not trained in the field.

Rebecca Saff, MD, PhD, FAAAAI 23:24

I mean, I think that still remains an issue that we see a lot of still, you know, specific IgE to foods testing done outside of allergy, um, where people come back positive, and even though they're eating the food and are you know not having any problems with it, it gets taken out of the diet. So I think that still happens today. And our job now is to really try to get those back into the the diet, knowing what we know.

Phil Lieberman, MD, FAAAAI 23:49

I agree a hundred percent. So uh I think that it's been the most uh uh the most worrisome threat to the practice.

Rebecca Saff, MD, PhD, FAAAAI 23:59

Yeah. What do you think today there are things that we're doing that you can kind of look in the future and think, actually, I don't know that we'll be doing that in the future. Are there certain things right now that you think, okay, that's that'll probably pass on over time?

Phil Lieberman, MD, FAAAAI 24:13

Yes, I I believe they are. And um skin testing itself may not be done. I I think I mentioned this because uh with the increased testing procedures, uh, we may switch over uh just to uh testing by uh in vitro uh methods. Uh we also mentioned, and I'll re-mention, the use of uh peak flow, the use of uh FNOs, uh, use of written textbooks, uh, and I think that uh human scribes will maybe unnecessary as well.

Rebecca Saff, MD, PhD, FAAAAI 24:54

Yeah, do you think skin testing will be replaced as we better understand kind of um synthesization versus kind of allergic reactions, whether that's component testing or like oscillation patterns or something that allows us to really understand what the IDE that we're detecting means. We would need skin testing at that point.

Phil Lieberman, MD, FAAAAI 25:13

Exactly. Yeah, we're probably still a little ways from that because we don't have ways to know you know sensitization versus a true reaction, something that's truly going to cause a reaction. But I can see how that in the future will definitely be something that'll change.

Rebecca Saff, MD, PhD, FAAAAI 25:28

Agreed. Tell us about some of your other memorable patients over time.

Phil Lieberman, MD, FAAAAI 25:34

Okay, I will let me gather them. Uh I I had so many uh since the uh development of um uh monoclonals in uh for allergic disease uh because uh hundreds of patients uh have uh had a new outlook on life with these agents. Other things that patients that have uh stuck in my mind uh was a patient who left my office uh and I got a call after starting this patient on prednisone that there was ascaris in the stool. And as you know, uh prednisone is contraindicated uh in asthma. Uh, and uh I had diagnosed their asthma with a high level of IgE. Uh going home that night, uh I uh rushed up to the hospital and made sure that the prednisone was stopped and that antifungal therapy was uh uh uh instituted. Um I had a patient who lived in uh California and returned to Memphis where she was born, and the reason she returned was interesting. Um she was a hand model uh in California. They took pictures of her hands uh and uh used them to sell products, and uh most of the products that uh she uh uh uh sold had an odor. And on smelling this odor, uh she would have what was thought to be uh asthma. So she was treated with that per asthma didn't help her, and physician caring for her in California said, Why don't you return to Memphis uh and leave your job? Well, uh it what happened was this woman had had uh memories of uh sexual assault in childhood uh by an uncle who wore perfumes. And the memory of that assault uh really brought on uh not asthma uh but um focal cord dysfunction. And uh we sent her for psych when this discovery was discovered, we sent her to psychological training, and uh we had a very good uh psychologist at that time who did a wonderful job. She was able to return to uh LA and resume her job, and uh I get a uh I did got for a while a nice Christmas card from her uh each uh uh each uh Christmas. And um another thing which we had published uh was related to a very common cause of uh confusion, which was uh spirit veno cable uh syndrome. Uh uh mimicing rather not asthma, although it could, uh, but also uh angioedema. Uh we published a couple of cases uh in that regard, both of for asthma and uh angioedema. Uh they were very quite uh impressive uh patients uh because by simply uh correcting that veno cable obstruction, uh they got completely well. So though those were very interesting patients that I have uh cared for and remember.

Rebecca Saff, MD, PhD, FAAAAI 29:11

Yeah, no, absolutely. Those are very memorable. You've had so many publications. Are there are there certain publications that are very memorable for you, either putting them together or the people you worked with?

Phil Lieberman, MD, FAAAAI 29:24

Well, my love, uh if you look at my uh CD, was for uh not only anaphylaxis, but specifically systemic mastocytosis. And uh we were able to publish uh some of the very first cases uh uncovering idiopathic anaphylaxis and establishing that these uh cases were actually due to uh cases of systemic mastocytosis. And uh that was great because uh you could treat with omalismab. And uh I had a uh professor of theater uh at Omis in Mississippi, in Oxford, Mississippi, about uh an hour's drive from us, who came to me with uh episodes of anaphylaxis usually occurring once or twice a week. Uh, and uh he would simply take his epipen and uh inject himself and then go on teaching that class. And he would do this two, three times a week. And uh we discovered he had systemic uh uh mastocytosis, and omalismab was uh a complete uh quotes cure for him. Uh he took his omolysimab and finally retired with no more episodes uh of anaphylaxis, one of my most uh memorable cases. And I've had other patients who have uh been uh very similarly affected who with omalismab uh have done very, very well uh and gone through retirement successfully.

Rebecca Saff, MD, PhD, FAAAAI 31:08

If I think even just about in the last 15 years, I used to, when I was in fellowship, we always desensitized AERD patients to aspirin. And we do it so much more rarely these days because the biologics have really just transformed the disease. We know that things like dupilomab and zapellumab can make all the difference in how they do. Um so just you know, the way that the treatments have changed even recently has been so dramatic.

Phil Lieberman, MD, FAAAAI 31:33

Oh, absolutely. And uh the same uh type of advance, I think, has occurred with uh patients with familial angiodema uh with the the use of uh infusion of seawit inhibitors. Uh those were both great advances uh in our treatment of patients.

Rebecca Saff, MD, PhD, FAAAAI 31:51

Yeah, and now we're doing uh trials where we're actually looking at CRISPR technology to change the disease altogether.

Phil Lieberman, MD, FAAAAI 31:58

That's exactly right.

Rebecca Saff, MD, PhD, FAAAAI 32:00

What do you think the field will look like in 60 years as physicians who are just starting out in practice are starting to reach your stage where they're retiring? Can you envision what the field might look like?

Phil Lieberman, MD, FAAAAI 32:11

Yes. With AI, uh machine learning will uh definitely identify disease variants. Uh, there will be targeted treatment, precision medicine, uh, there will be advanced monitoring, wearables uh will come into play in greater uh frequency. I think unfortunately, we may have diminished medical school entrance uh because of the attractiveness of other fields as medical salaries decrease and individual choice salaries such as computer science increase. And uh as things began to be standardized in our treatment, thus eliminating our freedom of choice as doctors, I think the uh choices that we have will be less attractive in the practice of medicine. Uh, we're also going to see something which is threatening, I believe, more online patient critique uh of our treatment will occur. And that will result in, I think, the attractiveness again of the practice of medicine in general uh is going to diminish. Uh there will be uh continued development in spite of the lessening of doctors, continued development of plagues and infectious agents. Uh there will be more direct access to treatments for patients who don't need doctors to get their treatment. They won't need prescriptions. You can tune into television and uh order over the line medical treatments, which normally would have required a physician's prescription today. The salaries for people who are adept at obtaining pre-approvals should go up, requiring a greater percent of the budget in our practice. Um we had to hire in the last five years of our practice, we had to hire uh a full salary, full-time, just to do pre-approvals. And the uh task itself was so uh onerous to the patients we hired, we had to rehire about every six months to a year. And then I'm a I think there will be more physician advertising uh and more gathering of doctors into group practices. So there'll be, I think, some distinct changes and maybe not as nice as the what we would uh like there to be.

Rebecca Saff, MD, PhD, FAAAAI 34:54

I like to hope that people will begin to see kind of the the onerous side of medicine and we'll start to see changes in how we practice that's more humane, but we'll see.

Phil Lieberman, MD, FAAAAI 35:06

I I I hope I live long enough to see what happens. Yeah.

Rebecca Saff, MD, PhD, FAAAAI 35:11

And then what advice would you give to a physician starting out?

Phil Lieberman, MD, FAAAAI 35:15

Oh, I have great advice. Um first of all, uh, let me tell you, no matter what I have said previously, it's a wonderful way uh to make a living. And uh you couldn't find a better thing to do than offer you a way to help people on a daily basis as easily as the practice of medicine in general. And in our uh treatment, because in allergy, uh, we uh can really help people uh in a definitive manner uh to alter their life for the better. I advise that anyone entering this field treat their job as a career, not a job. Treat it as if you're going to stay in it lifelong because it'll pay off in space. You'll be very happy. I advise you to advise a physician, learn to love change, embrace change. Change is hard to accept and it brings troubles, but the change in medicine always is for the better over time, and if you embrace it, you will be a happy doctor. Think of your field as your legacy. What do you want on your tombstone? And think of it as I want on my tombstone to have been a good doctor, and that will serve you very well. You'll love what you're doing. Again, it's very important that you embrace the science. Bring the science to the bedside, you will see improvements in medicine, improve your practice. Embrace the privilege, the opportunity to do good. There's no other field but medicine where you can do this so definitively on a daily basis. And you may find this rather unusual, but choose a good spouse. It's interesting that the divorce rate of doctors is less, it's 24.3%, less than the population as a whole, and less than other professions, such as lawyers, health professionals, non-healthcare professionals. And I think personally it's because doctors marry in our field. May not be another doctor, it could be uh a technician, but someone who knows what to expect, the hours to expect, and in my own personal marriage, I married a nurse uh who I met uh during my residency uh while she was uh practicing nursing. It's been 66 years later, uh, and we have never missed a night when I'm at home where we haven't shared uh a good night kiss, and that includes last night. So uh uh choose a good nurse, uh choose a good technician, someone in the field, and uh you won't regret it.

Rebecca Saff, MD, PhD, FAAAAI 38:38

That sounds like great advice.

Phil Lieberman, MD, FAAAAI 38:42

Well, I hope so. It's been good advice from me, at least.

Rebecca Saff, MD, PhD, FAAAAI 38:47

Well, thank you so much. It was been great to hear your perspective on the field and to hear about your incredible career and all you've done for patients. Um, and really thank you for all you've contributed to the allergy immunology field, your time as president of the AAAAI. And I'm sure there are thousands of patients out there who are also thinking that that one uh that one question of, you know, actually, you don't get to go into GI, you get to go into allergy immunology.

Phil Lieberman, MD, FAAAAI 39:15

Well, I've loved it, and I wanted to thank you for asking me to uh speak about my experiences.

Rebecca Saff, MD, PhD, FAAAAI 39:22

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