The status of education in allergy and immunology in the United States of America in 1978

THE JOURNAL

OF

ALLERGY AND

AL

CLI VOLUME

Y

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62

Presidential

NUMBER

1

address

The status of education in allergy and immunology in the United States of America in 1978 Oscar L. Frick, M.D., Ph.D. San Francisco, Calif.

The Constitution of the American Academy of Allergy states in Article I, Section 2, that “The object of the Academy shall be the advancement of the knowledge and practice of allergy, by discussion at meetings, by fostering education of students and the public, by encouraging union and cooperation among those engaged in this field, and by promoting and stimulating research and study in Allergy.“’ In keeping with this philosophy, I would like to focus on the education of students and public-and by “students” I include all of us, as well as practicing physicians in general, as we continue to learn more about allergy. Allergy affects about one out of every seven Americans, or some 31 million people (Table I). Of these, 4%, or 8.6 million, have asthma, another 3%, or 5.4 million, have had asthma. In addition, 8%, or 17 million more, have hay fever, eczema, or other forms of allergy. The expenditures for this condition in its various manifestations, in terms of days of ill health, job and school efficiency, and economic costs of care now measure more than tens, even hundreds, of millions, as reported by Dr. Dorland Davis in 1972.’ How is the health establishment of this nation Presented at the Thirty-fourth Annual Meeting of the American Academy of Allergy, Feb. 28, 1978. Reprint requests to: Oscar L. Frick, M.D., Department of Pediatrics, 1404-A, HSW, University of California, San Francisco, San Francisco, Calif. 94143. 0091-6749/78/0162-0001$00.60/0

0 1978 The C. V. Mosby

educating its physicians to care for these particular millions of Americans? We recently completed a questionnaire survey* of 85 Allergy-Immunology Training Program Directors listed in the new American of Academy of Allergy Directory.’ From this, I shall report first on the undergraduate medical school and residency teaching programs in allergy and immunology; then, the current status of Fellowship training and Board certification; and, finally, the continuing education and recertification programs for physicians. In American medical schools, the student usually has one or two lectures on allergy in the Department of Microbiology, perhaps two more lectures in medicine or pediatrics, and he may observe the management of a few patients with acute attacks of asthma on his medical clerkship. A small percentage may even take an outpatient elective in an allergy clinic, if there is one in the school. My school, the University of California, San Francisco may be typical. In second-year microbiology, one lecture is given on immediate hypersensitivity by a basic immunologist; a second lecture is given on allergy in the “Introduction to Clinical Medicine” by a clinician. The third year has two more clinical lectures on allergy. In the second- and third-year clerkships, whether medical or pediatric, about half of the *Survey responses received between November, 1977, and February, 1978.

Co.

Vol. 62, No. 1, pp. l-6

2 Frick

TABLE I. Incidence and cost of allergic in the United States*

J. ALLERGY

diseases

Incidence 31 million allergic patients include: 8.6 million, asthma alone 5.4 million, asthma in past 17.0 million, hay fever, eczema

costs 85 5 7 27

million days, restricted activity million days lost from work million days lost from school million patient visits to physician 134 thousand hospitalizations ( 1968) $62 million estimated hospital costs (1968 rate of $55.80/D) $346 million estimated h:spital costs (1978 rate of $300/D)

TABLE Il. Ratios of allergy-immunology (A & I) specialists to allergic patients and numbers needed to achieve optimal care

Existing ratios (JCAI, 1976) 2,677 A & I specialists/213 million United Statespopulation 1 A & I specialist/80,000 population 1 A & I specialist/12,000 allergic patients Optimal specialist /patient ratios (Norman report, 1976) 1 A & I specialist/7,500 allergic patients If one-third need specialist consultation, 1 A & I specialist can handle 2,500 allergic patients.

Allergist-immunologist specialists needed 4,250 400 1,000

*Modified from Davis, D.: J. ALLERGY CLIN. IMMUNOL. 49~323, 1972.

students will follow the hospital admission of an asthmatic; on the ambulatory medicine clerkship, each student may see one asthmatic and possibly one other allergic problem. In the fourth year, 1 in 10 students will spend two weeks in electives in pediatric or adult allergy, or chest clinics; the remaining 90% of students have no exposure to allergic outpatients. This is insufficient exposure to so common a problem in any medical practice. This view is supported by the popularity among practitioners of continuing education courses in allergy. In our own survey of program directors, 68 responded that 1,650 students participated in allergy clinic each year, usually on electives, for an average of one week. According to the class sizes in those 68 schools, a rough estimate is that 20% of the students spend a week in allergy clinics. (1,650/8,160 = 20%; 68 schools x 120 medical students/class = 8,160). In medicine, pediatrics, and family medicine residencies, an annual average of two months is spent on an outpatient service, usually in an allergy or chest clinic, as a one- or two-week elective. In our survey of program directors, 50 responded that 704 residents participated in the allergy clinic each year, in institutions with about 1,800 medical and pediatric residents; therefore, about 40% saw allergy patients in clinic. Before I turn to Fellowship training in allergy and immunology, I would first like to review some figures on the need for allergists in America. In response to questions from the United States General Accounting Office, an ad hoc committee was formed in 1976, chaired by Dr. Philip Norman, representing all the

CLIN. IMMUNOL. JULY 1978

5,650 -2,677 2,973

Practicing allergists Teachers and researchers Clinical immunologists (immunodeficiency, cancer, autoimmunity) Total needed

JCAI survey-Current allergist-immunologists Current deficit

four national allergy societies and the American Board of Allergy and Immunology, A Conjoint Board of the American Board of Internal Medicine and the American Board of Pediatrics. Answers to its questionnaire came from many prominent practicing allergists, training program directors, and Joint Council of Allergy and Immunology (JCAI).3 In responding to a question about under- or oversupply of specialists in allergy and immunology, the overwhelming consensus was that there was a serious undersupply, and that the national needs could not be filled by existing training programs (Table II). Practicing allergists uniformly cannot meet the demand for their services and have difficulty in finding newly trained allergists to help with their burden. In 1976, the JCAI identified 2,677 allergists, about half certified in allergy and immunology, providing a ratio of 1 allergist to 80,000 population, or l/12,000 people with allergic problems. In response to the question of what is considered to be a reasonable number of specialists in allergy and immunology, the survey suggested l/50,000 population, or l/7,500 allergic patients, of whom one-third to one-half would require occasional specialist consultation. The respondents suggested that each specialist could manage 2,000 to 2,500 allergy patients. These figures suggest a need for 4,250 allergists to deliver care at present standards to the current population. Additionally, 400 academic teachers and researchers in allergy and immunology and 1,000 clinical immunologists in the broader areas of immunologic

patient care are needed in medical centers

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and community hospitals. Thus, about 5,640 physician specialists are required for proper care of patients, consultation, research, and teaching of allergy and immunology, or about 3,000 more allergy and immunology specialists than we now have in order to achieve an ideal ratio of allergists to allergic patients. We currently train about 120 allergist-immunologists each year (Fig. 1). The annual trainee graduates since 1972 and our current projections are shown in this block diagram. There is an annual attrition rate of about 80 active specialists per year. If the United States population were to remain stable, at these training figures it would take about 75 years to bring about this ideal specialist to patient ratio. This goal is hampered by other difficulties. The sharp reduction in supported research training for all specialties by the National Institutes of Health has cut back the number of academic teachers. Finding financial support for postdoctoral trainee stipends in today’s fiscal vacuum is our major problem in continuing to train specialists for the survival of our field. Our own survey just completed of allergy-immunology training programs shows that there are 214 full-time academicians, many of whom are involved primarily in research; this is an average of 2.5 academicians per program. These are supplemented by 100 part-time paid teachers and 277 clinical faculty who are largely unpaid. Therefore, the average training program would have 2 full-time academicians in teaching and research, aided in teaching by 5 parttime or volunteer clinical faculty. However, there is a wide variation in this pattern of programs, from several larger ones to many excellent programs consisting of one full-time and several clinical faculty-but the present retrenchment in research and training funding by the government threatens this whole teaching structure. Currently, in the training programs in allergy and immunology, there are 2.55 Fellows, 137 in the second year and I 18 in the first year; thus, there is already an 8% drop this year (Table III). Their parent specialty distribution is 78 in internal medicine, 148 pediatricians, and presumably 26 other or undesignated-or about 2 pediatricians for each internist. The medical school origins of current Fellows is 155 from United States schools and 5 1 foreign graduates, or 75% from American schools. In our survey form, these are separate questions, so that the numbers do not necessarily equal in all categories. The geographic distribution (Fig. 2) of current training programs shows the Northeast with 29 programs and 87 Fellows, the South with 18 programs and 38 Fellows, the Midwest with 19 programs and

Education

in allergy

and immunology

FIG. 1. Number of allergy-immunology pleted training versus natural attrition.

Fellows

3

com-

5 1 Fellows, and the West with 20 programs and 79 Fellows. Most of the Fellows tend to stay in their locale of training. From our survey, the number and activities of Fellows who completed two years of training in the past five years shows 623 graduates-with 266 internists and 357 pediatricians. The mean of 126 Fellows per year is about 6 more than Dr. Norman found in his survey last year, and not significantly different in these two independent surveys. An analysis of current activity of these last 5-year graduates (Fig. 3) shows that 381 (60%) are in private practice limited to allergy and immunology; 60 (10%) in specialty practice, with a major portion devoted to allergy and immunology; 150 (24%) are academicians in teaching and research; 24 (4%) are in the military or United States Public Health Service; and 12 (2%) are in administration or other activities. The current available funding and future funding of trainee stipends are listed in Table IV and Fig. 4. All program directors of Fellowship training describe the prospects for future funding as difficult, nonexistent, or disastrous. By 1979, government grants will drop by half, with the major slack taken up by patient costs through hospital residencies, but there will be an overall 18% drop, or 47 Fellowship positions in allergy and immunology. It thus becomes obvious that for allergy-immunology Fellowships to continue, new sources of funding are imperative for the survival of our specialty and our livelihood. One idea would be to strengthen the Allergy Foundation of America and the establishment of new chapters nationwide. Strong physician and lay support for help in the cure and treatment of asthma and allergic diseases will ensure more direct research training Fel-

4

Frick

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FIG. 2. Regional

distribution

of allergy-immunology

ASI Practice 61%

FIG. 3. Current

activity

of 1972-1977 A & I trainees.

lowship funds and, additionally, could exert pressure upon Congress for more such support. Furthermore, a strong Allergy Foundation would help to promote education of the public about allergies. Public pressure and the malpractice insurance crisis have brought to the fore the need for continuing education of all physicians, as well as Board certification

programs

(p) and number

of Fellows

CLIN. IMMUNOL. JULY 1978

(f) in 1978.

and recertification of specialists. Eleven states now require a certain number of Continuing Education, Category I, credits annually as a condition for medical relicensure. The American Medical Association Council on Medical Education is responding to public pressure by urging the specialty Boards to establish methods and examinations for recertification. A recent poll of the allergy section of the California Medical Association shows that 70% of California allergists recognize the need for recertification, although the mechanism for that recertification is a subject of much debate. Several allergists question the need for an examination; if such an examination becomes necessary, many feel that the scope of the questions would be irrelevant to their practice. I have written several letters this year emphasizing the need for knowledge of a basic core of immunology and pathophysiology, as well as allergy and clinical immunology, in order to apply new knowledge to the care of our patients. What may seem totally irrelevant today may be vitally important in practice tomorrow. For example, cyclic adenosine monophosphate was a laboratory curiosity in 1965, but today we all know that our most effective drugs in the management of asthmatic attacks work through this second messenger. In 1970, histocompatibility antigens were mostly the concern of the transplant

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Education

in allergy

and immunology

5

Prac Da \

Hasp 67%

1978

1979 proj.

FIG. 4. Percent distribution

TABLE III. Distribution

of Fellows

in allergy-immunology

Year of Fellows

First year

= 118

Secondyear = 137 Totals

TABLE IV. Current

of funding

Sources

Hospital residencies Government grants (Federal, state, local) Volunteer agencies Drug studies Private practice funds Trainee volunteer (non-paid)

programs

Parent Board

Origin

Internal medicine = 78 Pediatrics = 148

of Fellows

United States = 155 Foreign medical graduates= 51

226

2.55

available

of A & I trainees.

and projected

funding

Current

sources

Positions

206

sources of trainee

stipends

Future funding %

Positions

%

1977 Coth SurveySupport for Clinical Fellows, all specialties

133.5

51%

143

67%

52%

63.3 23.3 5.5 15 20.3 261

24% 9% 2% 6% 8%

30 23 3 6 -- 9 214

14% 11% 1% 3% 4% 100%

26% 7% 7% 8% 100%

100%

surgeon, but at this meeting, this Academy has established a Research Council Committee on Immunogenetics to study histocompatibility antigens in the genetics of allergy. Prostaglandins now receive greater attention in allergy, and there are many other examples of seemingly irrelevant basic science discoveries that will become vitally important clinically within a decade. Your Academy is responding to the educational needs of the membership, of medicine, and of the public in general. The Public Relations Committee, with the help of Mr. Ted Klein, has for ten years been publicizing new

advances in allergy and immunology, bringing them to the attention of science writers, government officials, and directly to the public. The Postgraduate Committee provided a superb program of new knowledge in its course in Phoenix in February. The Undergraduate and Graduate Education Committee selected 29 Fellows in training to receive travel grants to attend this meeting, and is developing sets of teaching slides to help lecturers in the many postgraduate courses offered in allergy and immunology around the nation. Under the auspices of members of the Commission

6

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Frick

of Allergy Society Presidents, the 1980 Self-Assessment Examination Committee has been formed and is starting the preparation of new examinations. The Joint Council of Allergy and Immunology is continuing to prepare position statements concerning the practice of allergy. The Directors of Allergy-Immunology Training Programs held their first meeting yesterday to discuss the teaching content of training programs and to explore the possibilities for Fellowship funding. We hope this will be an annual meeting. Finally, the Executive Committee of the American Academy of Allergy is exploring the establishment of an Education Council to coordinate all educational activities of the Academy, possibly with a professional Director of Education. This may entail eventual reorganization of the Academy structure to meet these educational needs. In summary, this brief survey shows us that: 1. There is insufficient undergraduate medical teaching in allergy. 2. Allergy-immunology specialists are in critical undersupply and, in order to achieve an optimal ratio of specialists to allergic patients, another 3,000 allergists are needed now. At the current net annual gain of about 40 trained specialists, it would take about 75 years to achieve this optimal ratio of l/7,500 patients. 3. Declining funds for training Clinical Fellows

Information

CLIN. IMMUNOL. JULY 1978

becomes a major threat to the maintenance of our specialty. 4. Strong lay support through the Allergy Foundation of America is vital to our patients and the future of the specialty. 5. The public is urging expansion of Continuing Education programs and Board certification and recertification. 6. “Fostering education of students and the public” is a primary function of the American Academy of Allergy. It has been a great pleasure and honor for me to have been able to serve this past year as your President. Thank you all. I am deeply grateful and give thanks for a job well done to the 85 Allergy-Immunology Training Program Directors who answered our survey questionnaire so promptly and completely. Their responses made this survey possible and meaningful. REFERENCES

I. The American Academy of Allergy-1977 Membership Directory, Executive Office, American Academy of Allergy, Milwaukee, Wis. 53202. 2. Davis, D.: NIAID initiatives in allergy research, J. ALLERGY CLIN. IMMUNOL. 49~323, 1972. 3. Norman, P. S.: Report: Physician manpower in allergy and immunology. J. ALLERGY CLIN. IMMUNOL. 62~61, 1978.

for authors

Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following statement, signed by each author: “The undersigned author(s) transfers all copyright ownership of the manuscript entitled (title of article) to The C. V. Mosby Company in the event the work is published. The author(s) warrants that the article is original, is not under consideration by another journal, and has not been previously published. ” Authors will be consulted, when possible, regarding republication of their material,