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We have a well organized, newly revamped, outpatient program rotation
delineated below. These rotations have served to train our Allergy
and Immunology Fellows, Pediatric Allergy Fellows, Residents from
HUP and affiliated institutions and medical students. In the following
pages we will describe our programs and the process by which we
introduce physicians and medical students to them. It has been our
experience that through a combination of conferences, clinical case
discussions, hands on interactions with patients and direct observation
of experienced subspecialists evaluating patients that physicians
gain a deeper appreciation of:
- The unique patient disorders seen in an A&I ambulatory care
setting.
- A deeper understanding of the pathophysiology of the common
disorders seen by Allergist (i.e. Rhinosinusitis, Asthma and Urticaria).
- The role of Allergy and Immunology in the evaluation and care
of these patients.
The Allergy and Immunology Programs are conducted from 9AM-1PM
in the Allergy and Immunology outpatient practice area Monday
through Friday. This area encompasses five exam rooms, one skin
test rooms, a procedure room and an allergen extract preparation
room. In addition there is an Asthma Program at Presbyterian
Medical Center (an affiliated institution, 6 blocks from HUP).
a. Organization of the OPD
The outpatient programs in the A&I Division are under the
overall direction of Paul C. Atkins, MD, Professor of Medicine
and Director of Outpatient Allergy Programs. Each clinic is
attended by one or more A&I Fellows, with participation
in some of the clinics by Pediatric (CHOP) A&I Fellows,
Otorhinolaryngology Resident and Internal Medicine house staff
and medical students on elective. Each clinic is under the direct
supervision of one of the full-time A&I faculty. Also participating
in each clinic are 1-2 nurses and 1-3 secretaries.
b. Schedule of HUP A&I Program
There are currently two HUP Programs, and two CHOP Programs
each week in which the HUP A&I Fellow participate. In addition,
there is an Asthma Program at Presbyterian Medical Center in
which the fellow participates.
1. General Allergy/Immunology Program: Monday,
Tuesday, Wednesday, and Friday AM weekly. These clinics are
organized for the care of patients with a wide variety of
allergic and other immunologic problems, including asthmatics
not seen in the Monday morning clinic. Patients are seen initially
by Fellows (as described above) and presented to Dr. Phillips,
Dr. Atkins, and Dr. Apter, who respectively serve as Attending
Physicians in these clinics.
2. Combined Sinusitis Clinic: 2nd Wednesday
of each month. This special program, organized in conjunction
with the Otorhinolaryngology (ORL) Department, is directed
towards care of patients with "difficult to manage"
chronic sinus diseases. All patients are seen initially by
A&I and ORL Fellows who then discuss the cases with Dr.
Kennedy (ORL) in a group setting. X-rays and CT scans are
reviewed. Rigid endoscopic rhinoscopy is performed with video
enhancement/recording so that all can see the structures visualized
in rhinoscopy. Allergy studies are scheduled when indicated
and results of operative approaches discussed. (Dr. Kennedy,
Chair of ORL, is an internationally known authority in the
diagnosis and treatment of sinus disease.)
3. Clinical Immunology Clinic: Thursday AM
weekly. The Fellow evaluates patients referred for a wide
variety of clinical presentations under the supervision of
Dr. Levinson. Here the Fellow has extensive exposure to patients
with suspected immunodeficiency disorders, collagen vascular
diseases, hyperosinophilic syndromes, vasculitides and immune
medicated neurologic disorders. For example, in the past ten
months, our fellow has evaluated and provided follow-up care
of patients with: x-linked agammaglobulinemia, common variable
hypogammaglobulemia, selective IgA deficiency, Churg–Strauss
vasculitis, immune mediated peripheral neuropathies, lung
transplant rejection, idiopathic hyperosinophilic syndrome,
systemic mastocytosis, C1-inhibitor deficiency, and IVIG hypersensitivity
syndromes to name a few. In addition, the fellow frequently
evaluates patients referred for recurrent infections, which
defy classification. Although a specific diagnosis is sometimes
not rendered, the fellow has the opportunity to exercise his/her
differential diagnostic skills.
4. Asthma Program: Thursday PM weekly, in conjunction
with our Pulmonologist colleagues in the Pulmonary, Allergy
and Critical Care Division. This is organized for care of
"difficult" asthma patients who have a history of
frequent admissions and Emergency Room visits for asthma care.
All patients are seen by Fellows and presented to and Pulmonology
Faculty. Spirometry is performed and there is intensive patient
education efforts by physicians and 2 pulmonary nurses specifically
assigned for this purpose. The latter includes follow-up calls
to increase patient compliance in a frequently non-compliant
population. Evidence of the success of this clinic approach
has been a significant reduction in hospitalization and ER
use by patients after their enrollment in this clinic.
5. Pediatric Allergy Clinic: Wednesday AM weekly. One of the HUP A&I Fellows participates in this clinic in the adjacent Children’s Hospital of Philadedelphia on a rotational basis. This clinic is directed towards care of patients with a variety of allergic and immunologic problems and is supervised by Drs. Spergel and Pawlowski. Following the extensive discussions about the outpatients by all in attendance, the HUP A&I Fellow joins the CHOP A&I staff on in-patient rounds when appropriate for educational purposes.
6. Pediatric Immunology Clinic: Thursday AM
weekly. This Clinic at CHOP is organized for the care of children
and young adults with diagnosed and suspected defects in host
defense mechanisms. It currently follows over 350 patients
with primary immunodeficiencies, making it one of the largest
immunodeficiency clinics in the world. Children's Hospital
is the national center for the study of chromosome 22q11.2
deletion syndrome or DiGeorge syndrome and is the site of
ongoing clinical research on this important immunodeficiency.
This research program allows visiting fellows to observe the
dynamic nature of the immunodeficiency and the complex interdisciplinary
care required for these patients. Other ongoing research in
the immunodeficiency clinic includes the characterization
of novel immunodeficiencies. Fellows are given sufficient
time in clinic to develop a mechanistic approach to patients
with unknown immunodeficiencies and to postulate specific
functional defects to account for the phenotypic presentation.
The presence of an on-site diagnostic laboratory capable of
performing sophisticated phenotypic and functional assays
facilitates this type of approach. One HUP A&I Fellow
participates in this clinic at a time with each Fellow having
at least 3 months experience. This Clinic is supervised by
Drs. Stephen Douglas and Kate Sullivan.
First Year
The Fellows attend 1/2 day clinics as noted in their schedule
of clinical responsibilities and spend 6 months on the in-patient
consultation service covering HUP, Presbyterian Hospital, and
the Veterans Administration Medical Center.
Second Year Fellow
This is primarily a research year but will include:
- A minimum of 8 months of a 1/2 day/week Pediatric
rotation - divided between Pediatric Allergy and Pediatric
Immunology at Children's Hospital of Philadelphia.
- Twelve months of 1/2 day/week out patient Allergy
Program -Friday or Tuesday AM, to provide continuity of care
and long-term observations of patients seen in the first year.
- Rotations through the Pulmonary Function laboratory
- Rhinoscopy training with Otorhinolaryngology
Third Year Fellow - (Optional year but highly recommended)
- exclusively a research year with options for 1/2 day rotation/week,
in any of our A&I Programs.
- Patients are examined initially by one of the Fellows
(sometimes by Internal Medicine house officers or medical students
on elective).
- All new patients are presented in detail to one of
the clinic faculty who then examines the patient, followed by
extensive discussion of differential diagnosis proposed approaches,
etc.
- All patients seen in follow-up are also discussed
in detail with the faculty member and examined by the faculty
member, including review of laboratory findings, x-rays (brought
to the clinic as indicated) Spirometry, etc.
- All records in a particular clinic session are reviewed
and a faculty note is written by the full-time A&I faculty
member assigned to supervise the clinic.
Each fellow is on-call on the average every third night and
every third weekend to "handle" emergency/urgent calls.
The fellow who takes call with an A&I Attending as backup
is the first member of the A&I team to be notified of problems
occurring after 5 p.m. or on weekends. The calls are typically
routed through the hospital operator who is aware of the on-call
schedule. The fellow is instructed to discuss all such calls
with the Attending of record during the early months of training.
As the fellow becomes more experienced and more comfortable,
routine calls are communicated to the appropriate Attending
during "normal" hours on the following day. In addition,
fellows append a note to the patient's chart detailing the substance
of the call and action taken.
This is described in the description of our clinics in #1.
To summarize, the fellow has direct exposure to Otorhinolaryngologists
and Pulmonologists in joint A&I/Specialty or Subspecialty
Clinics. In addition, fellows have the opportunity to take a
one month elective in a Dermatology Clinic, where they receive
formal training by Dermatology Attending Physicians and Fellows.
Their exposure with IVIG treated hypo-gammaglobulinamic patients
establishes a unique interaction/collaboration with Pathology/Lab
Medicine Fellows and Attending Physicians. Of note, interactions
with Pathologists, Radiologists and other subspecialty/Specialty
physicians are ensured by the routine practice of personally
reviewing all imaging studies and results of pathologic studies.
As is evidenced from the diverse array of A&I Programs,
our fellows are exposed to a broad spectrum of allergic and
immunologic disorders. In our General Allergy, Rhinosinusitis
and Urticaria programs the Fellows are exposed to a broad spectrum
of allergic and immunologic disorders. Workups to rule out anaphylaxis,
mast cell disorders and unusual drug reactions are not infrequently
encountered. These diseases encompass 60% of all patients in
our programs. The Asthma program, in collaboration with our
Pulmonary colleagues provides exposure to the diagnosis and
treatment of severe, chronic asthma (30% of patients in this
program are found to have a primary disorder other than asthma
accounting for their symptoms). The Adult Immunology Program,
supervised by Dr. Levinson, exposes the fellows to the diagnosis
and treatment of adult immunodeficiency disorders, collagen
vascular diseases, vasculitis and immune hypersensitivity disorders
(10%). In addition, fellows evaluate patients (with A&I
Attending backup) who encounter reactions while receiving intravenous
immunoglobulin in the Apharesis Unit which is directed and staffed
by the Department of Pathology and Laboratory Medicine. Finally,
with the admixture of the programs at Children's Hospital of
Philadelphia, the fellows see children with both allergic and
immunodeficient disorders.
Continuity of care by individual Fellows is assured by assignment
of patients to them for the duration of their fellowship when
possible. The Fellow is thus considered by the patients as "their
physician" and receives all communications/telephone calls
from the patient in case problems arise between clinic sessions.
An A&I faculty member is always available for consultation
about problems that may arise from such telephone calls. Evidence
of the success of this approach is that few of the patients
followed regularly in our clinics ever require hospitalization.
Follow-up of in-patients: In-patients seen in consultation
by the A&I in-patient team are frequently followed in our
clinic after discharge as the primary responsibility of the
Fellow who had previously evaluated the patient in the hospital.
The same approach is used for patients seen in consultation
in the ER. If such in-patients are readmitted in the future,
the Fellow has immediate access to information about the previous
A&I consultation since copies of the previous consultative
reports are kept on file in our clinic.
All fellows learn how to perform the following procedures.
- Diagnostic allergy skin testing (prick and intradermal) approximately 15/week.
- Skin testing for penicillin/cephalosporin sensitivity - 2-3/week.
- Physical agent challenges for diagnosis of physical
Urticaria, occasional, as indicated.
- Spirometry and peak flow assessment 20-30 week.
- Food/drug/latex challenge - occasional, as indicated.
- Inhalational challenge - occasional, as indicated
- Methacholine
- Antigen
- Diagnostic flexible rhinopharyngoscopy - 3-6/months.
- Allergy injection treatment - preparation of extracts, administration of injections (including emergency treatment of any systemic reaction).
- Punch skin biopsy (for diagnosis of skin conditions) - occasional, as indicated.
All Fellows are thoroughly instructed in all these techniques by faculty and nursing staff. They then carry out all the pulmonary function rhinopharyngoscopy and inhalational/ingestant/injection challenges on patients seen by them in the clinic under the supervision of the Attending physician. In addition, fellows skin test a sufficient number of their patients to achieve considerable competence in the techniques and interpretation. Also, fellows administer allergy injection treatment in the Wednesday noon injection hour under the supervision of faculty and our 2 highly experienced nurses.
Participation by HUP A&I Fellows in clinical research in
the OPD has been a longstanding practice. In such projects,
the Fellow is involved in study design, data acquisition and
analysis, and writing of abstracts and manuscripts. Almost every
study has resulted in presentation at national meetings and
publications.
Recent examples of such activities include:
- Clinical characterization of patients with urticaria with correlation to evaluated in to serum histamine-releasing activity.
- Clinical evaluation of a new anti-asthma medication.
- Investigation of the effects of a unique anti-histamine on immediate and late phase allergic reactions. Such studies involved not only effects of the medication on skin test reactivity, but also elucidation of mechanisms underlying the drug actions.
- Description of patients with selective antibody deficiency.
- Assessment of adherence to steroid inhaler treatment in patients with asthma.
Each Fellow is typically scheduled to see one new and 3-4 follow-up patients in Adult Clinic. In addition, there are a small number of unscheduled patients who are established patients in our clinic being seen earlier than their scheduled appointment because of acute problems. This latter arrangement plus the contacts of Fellows with patients on the telephone frequently reduces the need for ER visits by our patients. From 1-2 new patients and 1-2 follow-up patients are seen in the CHOP teaching clinics.
Overall
Philosophy of the Fellowship Program
Outpatient
Training
Inpatient Training
Core
Curriculum
Application
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