Allergy and Immunology

Director: Stephen Peters, M.D. PhD

 

Overview:

Allergy and Immunology (AI) is an elective rotation for both Internal Medicine and Pediatric residents. During this month, each resident is exposed to a wide spectrum of allergic and immunological diseases in children and adults. The majority of patients are seen in the outpatient clinic. Residents also have the opportunity to participate in inpatient consults and follow up of patients admitted to the Day Hospital for infusion of Intravenous Immunoglobulin. 

 

Principle Teaching/Learning Activities:

 

• Allergy Outpatient Clinic (AOC): The resident will provide recommendations for the evaluation and management of patients with allergic diseases, after performing appropriate history, physical examination and discussing with supervising attending. They will learn indications, techniques and how to interpret: allergy skin percutaneous and intradermal testing, CAP-RAST, delayed type hypersensitivity testing, pulmonary function testing, and rhinoscopy. The resident may have exposure to allergy desensitization as well challenges performed in the outpatient clinic.
   
• Immunology Outpatient Clinic (IOC): The resident will provide recommendations for the evaluation and management of patients with primary immunodeficiencies, after performing appropriate history, physical examination and discussing with supervising attending. They will have exposure to the evolution of primary immunodeficiencies and learn to evaluate for associated infections, malignancies, and autoimmune diseases. Indications, techniques and interpretation of laboratory tests used to evaluate different aspects of the immune system will be discussed.
   
• Allergy and Immunology Inpatient Consults (AIIC): The resident is encouraged to accompany the allergy and immunology fellows during consults. They will examine, discuss recommendations, and actively participate in the evaluation and management of patients for whom consults where requested. They have the opportunity to perform evaluation of inpatient allergic conditions, desensitization procedures and also to participate in the follow-up and management of immunodeficient patients that are admitted to the Day Hospital to receive intravenous immunoglobulin infusions.
   
• AI Core Curriculum Lectures (CCL): Held on Tuesdays mornings, these sessions are designed to review the breadth of allergy and immunology clinical topics with fellows and residents. These interactive one hour lectures are given by both attendings and fellows as well as guest speakers experts in the field. Residents are encouraged to participate in the discussion.
   
• Board Review Session (BRS): Residents are encouraged to attend the fellow’s board review session, held on Wednesday morning from 9:30 to 10:30am. During these sessions, both clinical as well as basic allergy and immunology topics are reviewed. It will be a goal of this conference to demonstrate the clinical implications of the information being discussed.
   
• Journal Club (JC): Held once a month on Wednesday morning from 10:30 to 11:30am. The purpose of this conference is to review the current medical literature as it applies to allergy and immunology, and to learn the process of critical appraisal.  The articles will be selected with the following attributes in mind: new information of significant clinical or basic research relevance, pertinence to the care of our patients, and controversial topics with conclusions that need to be affirmed or discredited.  The types of studies presented should include those pertaining to etiology, diagnosis, treatment, harm, prognosis and cost analysis.  This conference will focus on original clinical or basic research, rather than review articles.
   
• AI Current Reviews (CR): Held once a month on Wednesday morning from 10:30 to 11:30am. The purpose of this conference is to review the current medical literature as it applies to allergy and immunology. This conference will focus on clinical or basic review articles rather than on original research.
   
• Monthly Consults Review (MCR): Held once a month on Wednesday morning from 10:30 to 11:30am. These sessions are designed to review the interesting consults from the prior month in greater details.
   
• Immunology Patients Review (IPR): Held once a month on Wednesday morning from 10:30 to 11:30am. A case-based conference which focuses on the evaluation and management of patients with immunological disorders, with an emphasis on the evidence which is available to guide our practice. During these informal sessions, the complicated cases will be discussed. The residents are encouraged to actively participate.
   
• Pulmonary Grand Rounds (PGR): Held on Wednesdays from 12:00 to 13:00. During these sessions the breadth of pulmonary topics is reviewed with both pulmonary and AI fellows, and residents. These interactive one hour lectures are given by the pulmonary attendings.
   
• Resident Lecture (RL): Resident will give a presentation to AI fellows and attendings on topic of personal interest. It is expected that resident perform an extensive review of the literature gaining significant fund of knowledge in this topic. Attending support is available.

 

Principle Educational Goals by Relevant Competency

 

In the tables below, the principle educational goals for the Allergy and Immunology Elective  Rotation are listed for each of the six ACGME competencies. The second column of the table indicates the most relevant principle teaching/learning activity for each goal, using the legend below.

 

* Legend for Learning Activities (See above for descriptions)

 

AOC	Allergy Outpatient Clinic
IOC	Immunology Outpatient Clinic
AIIC	Allergy and Immunology Inpatient Consults
CCL	AI Core Curriculum Lectures
BRS	Board Review Session
RL	Resident Lecture
JC	Journal Club
CR	AI Current Reviews
MCR	Monthly Consults Review
IPR	Immunology Patients Review
PGR	Pulmonary Grand Rounds

 

 

1)  Patient Care

 

Principle Educational Goals	Learning Activities*
Effectively obtain an accurate history in patients with symptoms of  allergic and immunologic diseases	AOC, IOC, AIIC
Effectively perform a complete physical examination in patients with allergic and immunologic diseases, with an emphasis on the facial and systemic stigmata of allergic  and immunologic diseases	AOC, IOC, AIIC
Appropriately select and interpret laboratory, imaging, and pathologic studies for the evaluation of allergic and immunologic diseases	AOC, IOC, AIIC, ICR, IPR
Learn the indications and contraindications for allergy skin test versus CAP-RAST, Pulmonary Function testing, Allergen Immunotherapy, IVIG  and other immunomodulators, Food and Drug challenges, Drug Desensitizations, and their associated therapeutic interventions	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL
Appropriately select medical and surgical management strategies for patients with allergic and immunologic diseases	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL

 

2)  Medical Knowledge

 

**Please see Appendix A for specific organ-based and symptom-based learning objectives**

 

Principle Educational Goals	Learning Activities*
Expand clinically applicable knowledge of the basic physiology of the immunologic mechanisms of both allergic and immunologic diseases as well as the cells involved	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL
Expand the ability to construct a clinically relevant differential diagnosis for patients presenting with symptoms of allergic and immunologic conditions	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL
Gain a basic understanding of the diagnostic modalities employed in the evaluation of allergic and immunologic diseases	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL
Gain a basic understanding of the pharmacologic agents used in the treatment of allergic and immunologic diseases, particularly new and emerging immunomodulatory drugs	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL
Gain an understanding of the evidence which guides the evaluation and management of patients with allergic and immunologic diseases	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL
Gain a working knowledge of current guidelines proposed for the evaluation, management, and prevention of allergic and immunologic diseases	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL

 

3) Practice-Based Learning and Improvement

 

Principle Educational Goals	Learning Activities*
Identify and acknowledge gaps in personal knowledge and skills in the care of patients with allergic and immunologic diseases	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL
Use the principles of evidence-based medicine to formulate  clinical questions which arise in the care of patients with allergic and immunologic diseases, search the medical literature, critically appraise such literature, and apply the information to specific patients	AOC, IOC, AIIC, JC, MCR, IPR, RL
Use evidence-based texts to guide the diagnosis and treatment of allergic and immunologic diseases	AOC, IOC, AIIC, MCR, IPR
Develop real-time strategies for filling knowledge gaps that will benefit patients with allergic and immunologic diseases	AOC, IOC, AIIC, ICR, IPR

 

4) Interpersonal Skills and Communication

 

Principle Educational Goals	Learning Activities*
Communicate effectively with patients and families	AOC, IOC, AIIC
Effectively educate and inform patients and families about diagnoses, prognosis and plans of care	AOC, IOC, AIIC
Present patient information concisely and clearly, verbally and in writing	AOC, IOC, AIIC
Communicate effectively with physician colleagues and members of other health care professions to assure timely, comprehensive patient care	AOC, IOC, AIIC
Gain skills in effective consultation, communicating in a supportive, helpful fashion with members of the primary team	AOC, IOC, AIIC
Gain an appreciation for the importance of a clearly defined question from the requesting team in effective consultation.	AOC, IOC, AIIC
Gain an enhanced understanding of the importance of true informed consent when considering invasive procedures	AOC, IOC, AIIC
Acknowledge and incorporate socio-behavioral dimensions of illness and care	AOC, IOC, AIIC

 

5) Professionalism

 

Principle Educational Goals	Learning Activities*
Behave professionally toward towards patients, families, colleagues, and all members of the health care team	AOC, IOC, AIIC
Consider patient autonomy, beneficence, and social justice as the guiding principles of dealing with ethical challenges	AOC, IOC, AIIC
Demonstrate humility, integrity, respect and responsibility in medical care	AOC, IOC, AIIC
Demonstrate respect and responsibility when attending the didactic sessions	AOC, IOC, AIIC, CCL, BRS, JC, CR, MCR, IPR, PGR, RL
Complete administrative tasks in a timely fashion	AOC, IOC, AIIC

 

 

6) Systems-Based Practice

 

Principle Educational Goals	Learning Activities*
Gain an enhanced understanding of the integral role of a consultant in the care of patients with allergic and immunologic diseases	AOC, IOC, AIIC, MCR, IPR
Collaborate with other members of the health care team to assure comprehensive patient care	AOC, IOC, AIIC, MCR, IPR
Learn to appropriately utilize diagnostic and therapeutic resources available within our institution and using outside laboratories in the care of patients with allergic and immunologic diseases to assure high quality patient care and optimum patient safety	AOC, IOC, AIIC, MCR, IPR
Gain an appreciation for the importance of effective collaboration with other disciplines such as otorrhinolaryngology, pulmonary, rheumatology, and dermatology among others	AOC, IOC, AIIC, MCR, IPR
Learn to appropriately refer patients with rare allergic and immunologic diseases to highly specialized centers	AOC, IOC, AIIC, MCR, IPR
Use evidence-based, cost-conscious strategies in the care of patients with allergic and immunologic diseases	AOC, IOC, AIIC, MCR, IPR

 

 

Recommended Resources

1. We recommend that each resident read through the syllabus provided during the month-long rotation.

2. We recommend that UpToDate be used as an evidence-based resource for practice-based learning to answer questions which come up during patient-care activities.

 

Evaluation Methods
 

Evaluations are based on personal observation by the Allergy and Immunology faculty of the resident’s performance in both the inpatient and outpatient clinical settings.  Medical knowledge is also assessed based on the resident’s performance and participation in the didactic sessions of the Allergy and Immunology Rotation. These factors serve as the basis for completing the standard Department of Medicine resident evaluation form. The completed evaluation is then sent to the medicine program director for review.

 

 

APPENDIX A

 

Specific Learning Objectives

 

1. Primary Immunodeficiencies:
1. When to consider further evaluation of patients with recurrent infections.
2. Be able to appropriately differentiate the several broad based primary immunodeficiencies
3. Evaluation and management of patients with primary immunodeficiencies
4. Appropriate follow up and surveillance of patients with primary immunodeficiencies
5. Symptoms and signs of ominous conditions associated with primary immunodeficiencies and appropriate screening strategies
    
2. Specific Organ Immunologic diseases, including autoimmune diseases:
1. Evaluation and management of the patient with immunologic conditions
2. Possible differential diagnosis
3. Cost-effective approaches for evaluation and treatment
4. Appropriate referral
    
3. Hypereosinophilic Syndromes:
1. Differential diagnosis of patients with hypereosinophilia
2. Effective use of the history, exam,  and laboratory in the evaluation and management of hypereosinophilia
3. Indications for endoscopic evaluation vs. noninvasive evaluation and empiric treatment
    
4. Anaphylaxis:
1. Symptoms and signs
2. Appropriate treatment and follow up including being able to describe or demonstrate the proper use of an Epi-pen, Ana-Kit or other device
3. Define anaphylaxis and differentiate from anaphylactoid reactions
4. Appropriate referral for further evaluation
    
5. Asthma:
1. Typical and atypical presentations
2. Differential diagnosis
3. Evaluation and management, including appropriate use of different pulmonary function tests
4. Appropriate asthma classification
5. Identification of complications such as allergic bronchopulmonary aspergillosis and concomitant COPD
6. Identification of occupational confounders
7. Explain environmental control measures
8. Demonstrate proficiency in the proper use of asthma medication
    
6. Rhinitis:
1. Typical and atypical presentations
2. Differential diagnosis
3. Evaluation and management
4. Appropriate differentiation of allergic and other non-allergic rhinitis, acute and chronic rhinitis
5. Explain environmental control measures
6. Demonstrate proficiency in the proper use of rhinitis medication
    
7. Sinusitis:
1. Typical and atypical presentations
2. Differential diagnosis
3. Evaluation and management
4. Recognition of importance of radiologic evaluation
5. Appropriate differentiation between acute and chronic and when referral for further evaluation is necessary
    
8. Immunologic based Dermatologic conditions:
1. Differentiation between Atopic dermatitis, Urticaria, Contact dermatitis and others
2. Recognition of typical and atypical presentations
3. Appropriate use of the history, physical exam, and laboratory on the evaluation of such conditions
4. Recognition of allergy role in such conditions
5. Appropriate management and surveillance
6. Recognition of socio-behavioral dimensions of illness and care
    
9. Drug Allergy:
1. Typical and atypical presentations
2. Differential diagnosis
3. Evaluation and management
4. Differentiation between allergic and other adverse reactions
5. Appropriate use of the history, physical exam to determine offending agent
6. Recognition of prognosis and importance of appropriate recommendation
    
10. Venom Allergy:
1. Typical and atypical presentations
2. Differential diagnosis
3. Differentiate the reactions that can occur after insect stings
4. Evaluation and management
5. Necessity of emergency treatment
6. Appropriate patient education, including identification of insect as well as their natural habitat, avoidance strategies
    
11. Food Allergy:
1. Typical and atypical presentations
2. Differential diagnosis
3. Evaluation and management, with particular emphasis on the role of skin testing versus CAP-RAST and oral food challenges
4. Necessity of emergency treatment
5. Appropriate patient education
    
12. Immunotherapy:
1. Recognition of Immunotherapy as a disease modifying therapy
2. Indications and contraindications of Immunotherapy
3. Appropriate evaluation prior to Immunotherapy
4. Recognition and appropriate treatment of adverse events
    
13. Other Immunomodulating agents:
1. Indications and contraindications of Immunomodulators
2. Appropriate evaluation prior to Immunomodulators use
3. Recognition and appropriate treatment of adverse events
4. Recognition of appropriate timing for discontinuation