Immunology and allergyBMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7099.S2a-7099 (Published 05 July 1997) Cite this as: BMJ 1997;315:S2a-7099
- 1Regional Department of Immunology, Royal Victoria Infirmary Newcastle-upon-Tyne,NE1 4LP,
- 2Department of Medicine, Southampton General Hospital, Tremona Road,Southampton, SO16 6YD
Training paths in the specialities have been reviewed and clarified. Gavin Spickett and Anthony Frew outline the prospects for physicians with an interest in allergy
Specialists in clinical immunology and clinical allergy work with a wide range of illnesses, from very common and relatively mild conditions such as hay fever, to rarer and serious conditions such as anaphylaxis, vasculitis, and primary immunodeficiency. In Britain the specialties are small, and these conditions have often been managed by general practitioners or organ based specialists such as chest physicians, dermatologists, or ear, nose, and throat specialists largely for historical reasons.
Many of these doctors are knowledgeable about allergic diseases, but others are not; the way patientsõ problems are handled may depend greatly on where they live and the interests of the doctor who is consulted. This variation, the rising prevalence of allergic conditions, and the advent of the Calman report all gave impetus to a fundamental re-examination of future training in immunology and allergy Until recently, immunology has really meant “immunopathology”, with posts being based in clinical immunology laboratories, the incumbent consultants predominantly laboratory oriented and trained under the auspices of the Royal College of Pathologists. Clinical work was limited. Allergy fared even less well, and most current practising “clinical allergists” in Britain were trained as organ based specialists (mainly in respiratory medicine) and developed their allergy interest in post. Academic posts have provided niches for clinical scientists with specific immunology or allergy interests who have often developed clinical services from their academic positions.
After much consultation, a joint committee of the Royal Colleges of Physicians and Pathologists has drawn up two training programmes, one in immunology, and one in allergy, both of which will lead to the certificate of completion of specialist training (CCST). Flexibility of the programme to meet the needs of trainees with differing skills and interests will be a key feature of these programmes. Training posts have been allocated to major regional centres where allergy trainees and immunology trainees will train together.
What do immunologists do?
Immunologists operate mainly from teaching hospitals or larger district general hospitals with sub regional status. The aim is that consultants should be working from centralised departments with more than one consultant. Work will involve the supervision of the diagnostic laboratory, the reporting of results, a substantial amount of direct liaison with clinicians for advice on further immunological investigation, and the review of complex patients. The demand for clinical immunological review is such that several outpatient clinics each week will be required, often involving joint clinics with paediatricians to investigate for immunodeficiency.
Other joint clinicsÑfor example, with rheumatologists or ophthalmologistsÑmay also develop. It is anticipated that the new Calman trainees, who will all have membership of the Royal College of Physicians (MRCP) or equivalent, and will receive significant clinical training, will increasingly participate in the care of in patients with immunological diseases and will undertake immunotherapies. The effect of the laboratory accreditation programme means that district general hospital laboratories offering laboratory immunology services will be required to have input of consultant immunologist sessions, and this will often develop into a full blown satellite service, with outreach clinics.
What do allergists do?
Allergists will also work mainly from regional centres, ideally in close collaboration with immunologists, who will be providing the necessary laboratory back up. Their time will be spent entirely on clinical work, with both inpatients and outpatients, dealing with all forms of allergic disease. Joint clinics with ear, nose, and throat, ophthalmology, dermatology and chest medicine, will usually form part of the workload. Outreach clinics in district general hospitals are also likely to be a feature. Typical patients will include those with multisystem allergy, particularly anaphylaxis, allergic asthma, rhinitis, food allergy, drug allergy, and cutaneous allergy. Allergists will be responsible for allergic immunotherapy (desensitisation), a field which is now growing once again, with improved therapies and a better understanding of the risks and benefits. It is not currently anticipated that allergy will be combined with general internal medicine and therefore acute medical takes will not form part of their duties. However a dual certification in allergy with relevant organ based specialities is planned. The first such dual training will be in allergy with respiratory medicine.
All entrants into the higher specialist training programmes, both for allergy and for immunology, are required to have completed general medical training as a senior house officer and to have passed the membership examination of the Royal College of Physicians, or to have experience and qualifications deemed to be equivalent. Potential trainees should speak informally about potential careers with several consultants before applying for posts as they will be able to give an up to date feel for the specialty, as well as advice on the pick of the jobs. The best place to start is with the immunologists or allergists in the closest regional centre; the Royal College of Pathologists also has a specialty adviser in every region.
Training in immunology
The model here has been the organisation of haematology services, where specialists are responsible for laboratory services but also provide important clinical services. The training must therefore provide both these elements. The first two years of the training programme focus on the core knowledge and skills. This entails learning the basic science that underpins immunology, obtaining laboratory skills in the diagnostic laboratory, and gathering experience in the clinics and on the wards of patients with immunological diseases. This period is likely to include rotations or attachments to other clinical departments such as rheumatology, dermatology, haematology, or infectious diseases, as well as to laboratoriesÑ for example, tissue typingÑto obtain the breadth of knowledge required. The joint committeeÑs curriculum outlines the areas of knowledge expected of trainees. At the end of this period the membership examination of the Royal College of Pathologists (MRCPath) Part I will be taken. This comprises two written papers, one in basic science and one in applied science, and a practical examination with a viva. Success in this leads on to the final three years, in which the knowledge gained will be consolidated through application in clinical and laboratory work, again with rotations and encouragement to develop special interests. After a further two years the final part of the MRCPath may be undertaken, which may be obtained by submission of a thesis, a collection of publications, a previously submitted MD or PhD thesis, or a case book, followed by a searching clinical viva.
Training in allergy
Trainees opting for the CCST in allergy will be expected to obtain the same core training, including basic science and laboratory immunology, although the elements of the core programme may be integrated over the five years rather than taken as a block at the beginning. These predominantly clinical trainees will not be expected to take the membership of the MRCPath Part I examination, although they will be eligible to do so when they have completed the core training programme if they wish. Success in the Part I is recognised by the award of the diploma of the Royal College of Pathologists (DipRCPath). The rest of the training will concentrate on clinical work and must include a period attached to both a respiratory medicine unit and a dermatology unit. Other attachments should include ear, nose and throat department, to learn about the assessment of the nasal airway. Programmes leading to dual certification in respiratory medicine and allergy will also be possible, and this will take six years, with a longer period in respiratory medicine.
Training for the “undecided”
It is recognised that entrants may be uncertain as to which of the two CCSTs they wish to opt for in the early stages of their career. Because the core training programme is common to both allergy and immunology, trainees may complete this in the first two years and decide at the end of this period without detriment or delay. Conversely, someone who opted initially for allergy, may switch to immunology provided that they complete the necessary outstanding elements of the core programme and the examinations: clearly their specialist area of interest for Part II of the MRCPath would be allergic disease. Those who want to hedge their bets may undertake dual certification in immunology and allergy, although this will obviously take longer.
The original Calman proposals excluded research, and it will be interesting to see whether consultant appointments begin to move away from those with the obligatory but poor MD. Both training programmes split at two years, which makes a natural break when trainees can take time out to do research and obtain a higher degree, although others may choose to do their research before entry to the specialist registrar grade. Either way, most academic centres have important research based immunology or allergy departments in which good quality research can be undertaken, the limiting factor being difficulty in obtaining suitable grant support.
Pay and prospects
Employment prospects for immunology trainees are currently good. Most trainees are appointed rapidly after completing their specialist training, although the situation has been confused recently by an increase in consultant mobility. There is scope for further expansion as many regional centres are still staffed by singlehanded consultants. The clinical pathology accreditation schemeÑs demands for increased consultant supervision of laboratories should fuel this expansion. Posts for consultant allergists are slightly less predictable. Most such posts have arisen in academic departments with major research interests in allergic disease. The noticeable increase in allergy referrals should make it much easier to make cases for new consultant posts, which will ideally be placed in regional or subregional centres with immunologists, and are likely to provide satellite clinical services to neighbouring district general hospitals. Many trainees may opt for dual certification in allergy with respiratory medicine and aim to develop their interest in allergic disease from within a respiratory post.
Pay conforms to norms for consultant appointments, but the latest figures show that a high proportion of immunologists obtain some form of merit award. The high level of merit awards in the specialty is a reflection of the hard work required from singlehanded consultants and the fact that, as a small speciality, everyone has to contribute to administration, committee work, college duties, and examinations. This means that if you are looking for a nice cushy number to see you through to retirement, youÑll have to look elsewhere. On the other hand if you want a busy, challenging job at the cutting edge of science and medicine, then immunology and allergy could be for you.