- Email: [email protected]
FUTURE ROLE OF THE ALLERGIST-IMMUNOLOGIST
ALLERGY AND IMMUNOLOGY
00954543 /98 $8.00
+ .OO
FUTURE ROLE OF THE ALLERGIST-IMMUNOLOGIST Dean D. Metcalfe, MD
An allergist/immunologist is a physician trained in either internal medicine or pediatrics, who has completed training in allergy and immunology and subsequently received a passing score in the examination given by the American Board of Allergy and Immunology. In examining the present requirements to become a specialist in allergy and immunology and to examine the future of this specialty, it is useful to review the current ABAI definition of an allergist/immunologist: “A certified specialist in allergy and immunology is a physician who has fulfilled the requirements and received certificationas a Diplomate of the American Board of Internal Medicine and/or the American Board of Pediatrics followed by additional certificationby the American Board of Allergy and Immunology, a conjoint Board of Internal Medicine and the American Board of Pediatrics.”
The American Board of Allergy and Immunology, which certifies competence in this discipline, is sponsored by the American Academy of Allergy, Asthma and Immunology, the American Academy of PediatricsSection on Allergy and Immunology, the American College of Allergy, Asthma and Immunology, the American Medical Association-Section Counsel of Allergy and Immunology, and the Clinical Immunology Society. These organizations nominate individuals for possible membership in the Board of Directors of the American Board of Allergy and Immunology.
From the Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases; and the Allergy and Immunology Training Program, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland PRIMARY CARE VOLUME 25 *NUMBER 4 * DECEMBER 1998
885
886
METCALFE
TRAINING IN ALLERGY AND IMMUNOLOGY
The training requirements in allergy and immunology are quite specific and are set forth by the Residency Review Committee in Allergy and Immunology as governed by the Accreditation Council for Graduate Medical Education. Allergy and immunology training requires 12 months of clinical experience, 6 months of education or research, and 6 months of re~earch.~,~ Specialists in allergy and immunology must be able to manage patients with allergic diseases of the respiratory tract, including allergic rhinitis, sinusitis, and asthma, and their complications. They must be able to evaluate and treat atopic skin diseases, including acute and chronic urticaria, and allergic and contact dermatitis. They further are expected to understand and manage gastrointestinal disorders caused by immune responses to foods. These include immediate hypersensitivity reactions to foods and food additives, and food protein-induced enterocolitic syndromes of newborns and infants. Specialists in this discipline also learn how to diagnose and treat hypersensitivity pneumonitis and other disorders that may be caused by an adverse reaction to environmental insults, including those occupationally acquired. Similarly, allergy and immunology specialists must be able to take care of comparable clinical problems to the above, including vasomotor rhinitis and hereditary angioedema. Allergic and Immunologic Disorders Allergic diseases allergic rhinitis urticaria anaphylaxis hypersensitivity pneumonitis atopic and contact dermatitis allergic gastrointestinal disorders comparable clinical problems (vasomotor rhinitis, hereditary angioedema) Clinical immunology inborn and acquired defects of host resistance autoimmune diseases bone marrow and solid organ transplantation gene replacement therapy adverse drug reactions other conditions associated with an abnormality of the immune system The allergist/immunologist is a specialist in the problems of clinical immunology also. This includes skill in the diagnosis and treatment of inborn and acquired defects of host resistance, autoimmune diseases,bone marrow and solid organ transplantation questions, gene replacement therapy, the diagnosis and treatment of adverse drug reactions, and other allied conditions associated with an abnormality of the immune system. As with allergic diseases cared for by the allergist/immunologist, these
FUTURE ROLE OF THE ALLERGIST-IMMUNOLOGIST
887
disorders of clinical immunology encompass both problems in pediatric and adult medicine for which the allergist/immunologist is cross-trained. Accompanying the need to diagnose and manage disorders of allergy and immunology, the allergist/immunologist must master a number of procedural skills that are not taught routinely in pediatric and internal medicine training programs. Skills include the application of immediate hypersensitivity skin testing to aeroallergens, foods, antibiotics, vaccines, and insects. If appropriate, specific allergen immunotherapy may be ordered and is a skill learned during allergy and immunology training. In some cases, drug desensitization may be indicated and is performed by the specialist in allergy and immunology. The allergist /immunologist must also be able to perform routine pulmonary function studies, including methacholine and allergen challenge, in the evaluation and diagnosis of pulmonary diseases. Other skills acquired by the allergist /immunologist include patch testing, rhinoscopy, oral food challenge, and immunomodulatory therapy. Procedural Skills immediate hypersensitivity skin testing: aeroallergen, food, antibiotic, vaccine, insect delayed hypersensitivity skin testing specific allergen immunotherapy: aeroallergen, insect drug desensitization pulmonary function testing; challenge intravenous immunoglobulin therapy patch testing rhinoscopy immunomodulatory therapy oral food challenge Accompanying the need to acquire specific procedural skills is a need to understand, perform, and supervise specific clinical laboratory tests. Clinical and Laboratory Test Proficiency serum immunoglobulin determination functional antibody measurement lymphocyte subset analysis using monoclonal antibodies and flow cytometry lymphocyte proliferation assays chemotaxis assays molecular diagnostic techniques: RT-PCR, Northern blotting, Western blotting, sequencing knowledge of misuse of standard tests and of controversial tests These include the determination of serum immunoglobulin levels, functional antibody measurements, and complement component and function assays. The practitioner in allergy and immunology is trained in flow cytometry and lymphocyte subset analysis using monoclonal antibodies. Additionally, standard lymphocyte proliferation assays used in
888
METCALFE
the evaluation of a number of disorders must be mastered, as must chemotaxis assays and molecular diagnostic techniques. Molecular diagnostic techniques include RT-PCR, Northern blotting, Western blotting, and sequencing. As in other areas of medicine, the practitioners of allergy and immunology must also understand the misuse of standard tests and their proper application, and the controversial tests in the discipline. The evolution of medical care delivery has made it imperative that all physicians, including those specializing in allergy and immunology, understand clinical principles and analytic methods. Thus, as part of all training, the allergist/immunologist learns to understand those procedures that protect human subjects. Interpretation of the evaluation of safety, toxicity, efficacy and outcomes of drug treatments are reviewed. The principles and methods of epidemiologic studies must be mastered. FUTURE OF ALLERGY AND IMMUNOLOGY The future of allergy and immunology, in large part, rests on research conducted within allergy and immunology training programs, as well as research into the diagnosis and treatment of immunologic disorders at universities, foundations, pharmaceutical companies, and government institutions. Within allergy and immunology training programs, the clinical research focuses on clinical trials; the diagnosis of allergic and immunologic disorders, the natural history of disease; and the application of advances in molecular biology, cellular biology, and pharmacology to the understanding of human diseases. It is quite clear that basic and clinical research on immunologic disorders is increasing the diagnostic and therapeutic options available in the treatment of a number of disorders. These include diseases classically considered within the expertise of the specialists in allergy and immunology, such as asthma. Here, for instance, leukotriene-modifying drugs have led to new and novel approaches in the treatment of asthma. Similarly, current advances in induction of tolerance offer promise in desensitization to allergic disorders and in the management of other clinical conditions, such as those caused by reactions against self and those related to the rejection of transplants. Although some advances are incorporated into the medical expertise of other disciplines, there is sufficient complexity and evolution in the understanding of the basis of immunologic disorders and their treatment that specialists with expertise are clearly required. Allergy and immunology career advantages thus include expertise in the management of allergic and immunologic disorders and in the treatment of individuals of all ages. Research and evolution in the clinical science of immunology will, in part, take place within the specialty of allergy and immunology and will offer the promise of an expansion of allergy and immunology into the management of a number of additional clinical situations. Similarly, allergy and immunology offers cost-effective management to major disorders including asthma. Currently, manpower needs to fill the positions of allergists retiring
889
FUTURE ROLE OF THE ALLERGIST-IMMUNOLOGIST
from practice cannot be met. There is also a documented academic undersupply of the allergist /immunologist, and there are multiple opportunities within the pharmaceutical industry and within government regulatory b ~ d i e sThus, . ~ the average number of jobs (4.5) available to 1995/96 graduates was the same as during 1985/86. Also, in an HMO-capitated, managed-care format, allergy and immunology is distinct in that more positions are required to serve the needs of the HMO population than are generally available to serve a similar number in the United States population (Table 1).4,5 CONCLUSION
The specialty of allergy and immunology is a challenging, interesting and evolving discipline. It offers significant career opportunities in practice, academics, regulatory agencies, and pharmaceutical companies to those who train within the discipline. There is substantial satisfaction in improving the lives of patients of all ages who have allergic and immunologic disorders. In the final analysis, the patient care options presented by the allergist/immunologist offer the best reason for electing to train in Table 1. WORKFORCE REQUIREMENTS: HMO SETTING COMPARED WITH UNITED STATES SUPPLY OF THAT SPECIALTY+ Multiple of United States Supply Required in HMO Setting Medical, Surgical or Hospital-Based Specialty Allergy/lmmunology Dermatology Rheumatology 0toIaryngoIogy Radiology Gastroenterology Pathology Emergency Medicine Urology Hematology/Oncology Anesthesiology Ophthalmology OWGYN Orthopedic Surgery Neurology General Surgery CardioIogy Pulmonary Plastic Surgery Neurosurgery Psychiatry
Goodman et al
Weiner
Multiplet
Rank
Multiplet
Rank
1.5X 1.4X 1.2x 1.2x 1.ox 1.ox 1.ox 1.ox 0.9 x 0.9 x 0.9 x
1 2 3 4 5 6 7 8 9 10 11 12
1.2x 0.9 x 0.6 x 1.ox 0.8 X 0.7 X 0.6 X 1.ox 0.9 x 1.ox 0.6 X 0.6 X 0.9 x 0.7 X 0.5 X 0.5 X 0.5 X 0.7 X 0.2 x 0.5 X 0.4 X
5 12 2 8 11 15 3 7 4 13 14 6 9 18 16 17 10 21 19 20
0.8 X 0.8 X 0.7~ 0.6 X 0.5 X 0.5 X 0.4 X 0.4 X 0.3 X 0.2 x
13 14 15 16 17 18 19 20 21
1
'Rank is based on most-needed in an HMO setting: 1 = most needed.
tfrorn Metcalfe DD,Anderson J: The future of the subspecialty of allergy and immunology. J Allergy Clin lmmunol 100:441, 1997; with permission.
890
METCALFE
allergy and immunology. Here, the future offers an expanding scope of practice and the ability to successfully treat individuals with a wide diversity of allergic and immunologic diseases. References 1. Goodman DC, Fisher ES, Bubolz TA, et al: Benchmarking the US physician workforce.
JAMA 276:1811,1996 2. Huston DP: Core curriculum outline. J Allergy Clin Immunol90:992, 1992 3. Metcalfe DD, Anderson J: The future of the subspecialty of allergy and immunology. J Allergy Clii Immunol 100:441, 1997 4. Shearer WT, Adelman DC,Huston DP, et a1 Core content outline for clinical and laboratory immunology. J Allergy Clin Immunol, 94993,1994 5. Schearer WT, Blaiss MS, Diaz JD, et a 1 Training program directors committee position statement on health care reform. J Allergy Clin Immunol98:719, 1996 6. Weiner JP: Forecasting the effects of health care reform on US physician workforce requirement. JAMA 272222,1994
Address reprint requests to Dean D. Metcalfe, MD NIH/NIAID/LAD Building 10, Room llC205 10 Center Drive MSC 1881 Bethesda, MD 20892-1881 e-mail: [email protected]
00954543 /98 $8.00
+ .OO
FUTURE ROLE OF THE ALLERGIST-IMMUNOLOGIST Dean D. Metcalfe, MD
An allergist/immunologist is a physician trained in either internal medicine or pediatrics, who has completed training in allergy and immunology and subsequently received a passing score in the examination given by the American Board of Allergy and Immunology. In examining the present requirements to become a specialist in allergy and immunology and to examine the future of this specialty, it is useful to review the current ABAI definition of an allergist/immunologist: “A certified specialist in allergy and immunology is a physician who has fulfilled the requirements and received certificationas a Diplomate of the American Board of Internal Medicine and/or the American Board of Pediatrics followed by additional certificationby the American Board of Allergy and Immunology, a conjoint Board of Internal Medicine and the American Board of Pediatrics.”
The American Board of Allergy and Immunology, which certifies competence in this discipline, is sponsored by the American Academy of Allergy, Asthma and Immunology, the American Academy of PediatricsSection on Allergy and Immunology, the American College of Allergy, Asthma and Immunology, the American Medical Association-Section Counsel of Allergy and Immunology, and the Clinical Immunology Society. These organizations nominate individuals for possible membership in the Board of Directors of the American Board of Allergy and Immunology.
From the Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases; and the Allergy and Immunology Training Program, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland PRIMARY CARE VOLUME 25 *NUMBER 4 * DECEMBER 1998
885
886
METCALFE
TRAINING IN ALLERGY AND IMMUNOLOGY
The training requirements in allergy and immunology are quite specific and are set forth by the Residency Review Committee in Allergy and Immunology as governed by the Accreditation Council for Graduate Medical Education. Allergy and immunology training requires 12 months of clinical experience, 6 months of education or research, and 6 months of re~earch.~,~ Specialists in allergy and immunology must be able to manage patients with allergic diseases of the respiratory tract, including allergic rhinitis, sinusitis, and asthma, and their complications. They must be able to evaluate and treat atopic skin diseases, including acute and chronic urticaria, and allergic and contact dermatitis. They further are expected to understand and manage gastrointestinal disorders caused by immune responses to foods. These include immediate hypersensitivity reactions to foods and food additives, and food protein-induced enterocolitic syndromes of newborns and infants. Specialists in this discipline also learn how to diagnose and treat hypersensitivity pneumonitis and other disorders that may be caused by an adverse reaction to environmental insults, including those occupationally acquired. Similarly, allergy and immunology specialists must be able to take care of comparable clinical problems to the above, including vasomotor rhinitis and hereditary angioedema. Allergic and Immunologic Disorders Allergic diseases allergic rhinitis urticaria anaphylaxis hypersensitivity pneumonitis atopic and contact dermatitis allergic gastrointestinal disorders comparable clinical problems (vasomotor rhinitis, hereditary angioedema) Clinical immunology inborn and acquired defects of host resistance autoimmune diseases bone marrow and solid organ transplantation gene replacement therapy adverse drug reactions other conditions associated with an abnormality of the immune system The allergist/immunologist is a specialist in the problems of clinical immunology also. This includes skill in the diagnosis and treatment of inborn and acquired defects of host resistance, autoimmune diseases,bone marrow and solid organ transplantation questions, gene replacement therapy, the diagnosis and treatment of adverse drug reactions, and other allied conditions associated with an abnormality of the immune system. As with allergic diseases cared for by the allergist/immunologist, these
FUTURE ROLE OF THE ALLERGIST-IMMUNOLOGIST
887
disorders of clinical immunology encompass both problems in pediatric and adult medicine for which the allergist/immunologist is cross-trained. Accompanying the need to diagnose and manage disorders of allergy and immunology, the allergist/immunologist must master a number of procedural skills that are not taught routinely in pediatric and internal medicine training programs. Skills include the application of immediate hypersensitivity skin testing to aeroallergens, foods, antibiotics, vaccines, and insects. If appropriate, specific allergen immunotherapy may be ordered and is a skill learned during allergy and immunology training. In some cases, drug desensitization may be indicated and is performed by the specialist in allergy and immunology. The allergist /immunologist must also be able to perform routine pulmonary function studies, including methacholine and allergen challenge, in the evaluation and diagnosis of pulmonary diseases. Other skills acquired by the allergist /immunologist include patch testing, rhinoscopy, oral food challenge, and immunomodulatory therapy. Procedural Skills immediate hypersensitivity skin testing: aeroallergen, food, antibiotic, vaccine, insect delayed hypersensitivity skin testing specific allergen immunotherapy: aeroallergen, insect drug desensitization pulmonary function testing; challenge intravenous immunoglobulin therapy patch testing rhinoscopy immunomodulatory therapy oral food challenge Accompanying the need to acquire specific procedural skills is a need to understand, perform, and supervise specific clinical laboratory tests. Clinical and Laboratory Test Proficiency serum immunoglobulin determination functional antibody measurement lymphocyte subset analysis using monoclonal antibodies and flow cytometry lymphocyte proliferation assays chemotaxis assays molecular diagnostic techniques: RT-PCR, Northern blotting, Western blotting, sequencing knowledge of misuse of standard tests and of controversial tests These include the determination of serum immunoglobulin levels, functional antibody measurements, and complement component and function assays. The practitioner in allergy and immunology is trained in flow cytometry and lymphocyte subset analysis using monoclonal antibodies. Additionally, standard lymphocyte proliferation assays used in
888
METCALFE
the evaluation of a number of disorders must be mastered, as must chemotaxis assays and molecular diagnostic techniques. Molecular diagnostic techniques include RT-PCR, Northern blotting, Western blotting, and sequencing. As in other areas of medicine, the practitioners of allergy and immunology must also understand the misuse of standard tests and their proper application, and the controversial tests in the discipline. The evolution of medical care delivery has made it imperative that all physicians, including those specializing in allergy and immunology, understand clinical principles and analytic methods. Thus, as part of all training, the allergist/immunologist learns to understand those procedures that protect human subjects. Interpretation of the evaluation of safety, toxicity, efficacy and outcomes of drug treatments are reviewed. The principles and methods of epidemiologic studies must be mastered. FUTURE OF ALLERGY AND IMMUNOLOGY The future of allergy and immunology, in large part, rests on research conducted within allergy and immunology training programs, as well as research into the diagnosis and treatment of immunologic disorders at universities, foundations, pharmaceutical companies, and government institutions. Within allergy and immunology training programs, the clinical research focuses on clinical trials; the diagnosis of allergic and immunologic disorders, the natural history of disease; and the application of advances in molecular biology, cellular biology, and pharmacology to the understanding of human diseases. It is quite clear that basic and clinical research on immunologic disorders is increasing the diagnostic and therapeutic options available in the treatment of a number of disorders. These include diseases classically considered within the expertise of the specialists in allergy and immunology, such as asthma. Here, for instance, leukotriene-modifying drugs have led to new and novel approaches in the treatment of asthma. Similarly, current advances in induction of tolerance offer promise in desensitization to allergic disorders and in the management of other clinical conditions, such as those caused by reactions against self and those related to the rejection of transplants. Although some advances are incorporated into the medical expertise of other disciplines, there is sufficient complexity and evolution in the understanding of the basis of immunologic disorders and their treatment that specialists with expertise are clearly required. Allergy and immunology career advantages thus include expertise in the management of allergic and immunologic disorders and in the treatment of individuals of all ages. Research and evolution in the clinical science of immunology will, in part, take place within the specialty of allergy and immunology and will offer the promise of an expansion of allergy and immunology into the management of a number of additional clinical situations. Similarly, allergy and immunology offers cost-effective management to major disorders including asthma. Currently, manpower needs to fill the positions of allergists retiring
889
FUTURE ROLE OF THE ALLERGIST-IMMUNOLOGIST
from practice cannot be met. There is also a documented academic undersupply of the allergist /immunologist, and there are multiple opportunities within the pharmaceutical industry and within government regulatory b ~ d i e sThus, . ~ the average number of jobs (4.5) available to 1995/96 graduates was the same as during 1985/86. Also, in an HMO-capitated, managed-care format, allergy and immunology is distinct in that more positions are required to serve the needs of the HMO population than are generally available to serve a similar number in the United States population (Table 1).4,5 CONCLUSION
The specialty of allergy and immunology is a challenging, interesting and evolving discipline. It offers significant career opportunities in practice, academics, regulatory agencies, and pharmaceutical companies to those who train within the discipline. There is substantial satisfaction in improving the lives of patients of all ages who have allergic and immunologic disorders. In the final analysis, the patient care options presented by the allergist/immunologist offer the best reason for electing to train in Table 1. WORKFORCE REQUIREMENTS: HMO SETTING COMPARED WITH UNITED STATES SUPPLY OF THAT SPECIALTY+ Multiple of United States Supply Required in HMO Setting Medical, Surgical or Hospital-Based Specialty Allergy/lmmunology Dermatology Rheumatology 0toIaryngoIogy Radiology Gastroenterology Pathology Emergency Medicine Urology Hematology/Oncology Anesthesiology Ophthalmology OWGYN Orthopedic Surgery Neurology General Surgery CardioIogy Pulmonary Plastic Surgery Neurosurgery Psychiatry
Goodman et al
Weiner
Multiplet
Rank
Multiplet
Rank
1.5X 1.4X 1.2x 1.2x 1.ox 1.ox 1.ox 1.ox 0.9 x 0.9 x 0.9 x
1 2 3 4 5 6 7 8 9 10 11 12
1.2x 0.9 x 0.6 x 1.ox 0.8 X 0.7 X 0.6 X 1.ox 0.9 x 1.ox 0.6 X 0.6 X 0.9 x 0.7 X 0.5 X 0.5 X 0.5 X 0.7 X 0.2 x 0.5 X 0.4 X
5 12 2 8 11 15 3 7 4 13 14 6 9 18 16 17 10 21 19 20
0.8 X 0.8 X 0.7~ 0.6 X 0.5 X 0.5 X 0.4 X 0.4 X 0.3 X 0.2 x
13 14 15 16 17 18 19 20 21
1
'Rank is based on most-needed in an HMO setting: 1 = most needed.
tfrorn Metcalfe DD,Anderson J: The future of the subspecialty of allergy and immunology. J Allergy Clin lmmunol 100:441, 1997; with permission.
890
METCALFE
allergy and immunology. Here, the future offers an expanding scope of practice and the ability to successfully treat individuals with a wide diversity of allergic and immunologic diseases. References 1. Goodman DC, Fisher ES, Bubolz TA, et al: Benchmarking the US physician workforce.
JAMA 276:1811,1996 2. Huston DP: Core curriculum outline. J Allergy Clin Immunol90:992, 1992 3. Metcalfe DD, Anderson J: The future of the subspecialty of allergy and immunology. J Allergy Clii Immunol 100:441, 1997 4. Shearer WT, Adelman DC,Huston DP, et a1 Core content outline for clinical and laboratory immunology. J Allergy Clin Immunol, 94993,1994 5. Schearer WT, Blaiss MS, Diaz JD, et a 1 Training program directors committee position statement on health care reform. J Allergy Clin Immunol98:719, 1996 6. Weiner JP: Forecasting the effects of health care reform on US physician workforce requirement. JAMA 272222,1994
Address reprint requests to Dean D. Metcalfe, MD NIH/NIAID/LAD Building 10, Room llC205 10 Center Drive MSC 1881 Bethesda, MD 20892-1881 e-mail: [email protected]