Training overview and core curriculum

• Adult allergyiImmunology clinic:
  Fellows work in the first class, recently built Allergy and Immunology Clinic Monday through Friday (with 1-1.5 protected administrative half-days weekly).  This clinic encompasses eight exam rooms, two skin test rooms, a procedure room and an allergen extract preparation room. 
  

  These clinics are organized for the care of patients with a wide variety of allergic and other immunologic problems including asthma, allergic and non-allergic rhinitis, ocular allergies sinusitis and nasal polyposis, urticaria, atopic dermatitis, angioedema including idiopathic and hereditary angioedema, anaphylaxis, food allergy, drug allergy, and hymenoptera sensitivity. Many patients are evaluated with autoimmune and immunologic problems. These include immunodeficiency disorders, autoimmune conditions, hypereosinophilic syndromes, and undefined immune dysregulation disorders.  Although a specific diagnosis is sometimes not rendered, the fellow has the opportunity to exercise his/her differential diagnostic skills.

• Pediatric allergy clinic:
  A&I residents participate in this clinic in the nearby Children’s Hospital of Philadelphia (CHOP) on weekly basis. This clinic is directed towards care of patients with a variety of allergic and immunologic problems under supervision of nationally renowned experts in food allergy, eosinophilic esophagitis and other allergic conditions. A&I fellows also have the unique experience of 1-month intensive inpatient rotation on the CHOP inpatient service, where they care for patients with complex and rare immunologic disorders.

• A/I continuity clinic:
  Each fellow has a fellows’ "continuity” half-day clinic per week where patients “belong” to the fellow, with an attending precepting. This system promotes continuity of patient care, independence and ownership, which prepares fellows well for independent practice.

• Pediatric allergy clinics:
  This Clinic at CHOP is organized for the care of children and young adults with diagnosed and suspected defects in host defense mechanisms. The CHOP immunology program is one of the largest immunodeficiency clinics in the world. This program allows visiting trainees 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. Residents 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. Each A&I resident has at least a six month experience in this clinic. 

• Pediatric immunology clinic:
  This Clinic at CHOP is organized for the care of children and young adults with diagnosed and suspected defects in host defense mechanisms. The CHOP immunology program is one of the largest immunodeficiency clinics in the world. This program allows visiting trainees 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. Residents 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. Each A&I resident has at least a six month experience in this clinic. 

• ENT clinic:
  This program, organized in conjunction with the otorhinolaryngology department, is directed towards care of patients with "difficult to manage" chronic sinus diseases and aspirin-exacerbated respiratory disease (AERD). Our fellows learn from a leading Allergist expert in aspirin desensitization and otorhinolaryngologists. They learn practical aspects and challenges of aspirin desensitization, interpreting sinus images, and performing rhinoscopy.

The residents see patients of various ages, males and females, and include a wide range of racial/ethnic and socioeconomic backgrounds.

They are exposed to a broad spectrum of allergic and immunologic disorders include:

• allergic and non-allergic rhinitis
• ocular allergies
• sinusitis
• nasal polyposis
• asthma
• atopic dermatitis

• contact dermatitis
• urticaria
• idiopathic, hereditary, and acquired angioedema
• anaphylaxis
• food and stinging insect allergy
• adverse drug reactions including drug allergy

Immunology problems include the diagnosis and treatment of:

• primary immunodeficiency disorders
• collagen vascular diseases
• vasculitis
• immune hypersensitivity disorders

• systemic mastocytosis
• mast cell activation disorder
• hypereosinophilic syndromes, etc.

Finally, with the admixture of the programs at Children's Hospital of Philadelphia, the residents see children with both allergic and immunodeficiency disorders.

Patients are also diverse in their backgrounds, experiences and beliefs. The resident under supervision of the attending will take these factors into account in communicating with the patient to satisfactorily address their concerns and medical questions.

All fellows learn how to perform the following procedures:

• Diagnostic allergy skin testing (prick and intradermal)
• Skin testing for adverse drug reactions - e.g. influenza vaccine, local anesthetics; desensitization where risk of anaphylaxis exists and no validated skin test procedures exist
• Spirometry, peak flow assessment and full pulmonary function testing (including plethysmography)
• Inhalational (e.g. methacholine) challenge
• Food/drug/latex challenges, as indicated
• Delayed hypersensitivity (patch) testing; in dermatology clinic
• Diagnostic flexible and rigid rhinopharyngolaryngoscopy; in ENT clinic
• Allergy injection treatment - preparation of extracts, administration of injections (including emergency treatment of any systemic reaction)

All Fellows are thoroughly instructed in all these techniques by faculty and nursing staff.

Participation by A&I Fellows in research is a core part of training at Penn. In research projects, the Fellow is instructed in, and leads study design, data acquisition and analysis, and writing of abstracts and manuscripts. Fellows are encouraged and expected to present their work at national meetings, and to submit manuscripts for peer-reviewed publication

Recent examples of such activities include:

• Asthma inhaler devices and techniques
• Asthma control in the inner city setting
• Eosinophilic esophagitis presentation in adults
• Retrospective study of clinical outcomes in hematologic malignancy patients with beta-lactam allergy label
• Association of reported penicillin allergy and diagnosis of chronic idiopathic urticarial
• Description of patients with specific antibody deficiency
• A quantitative and qualitative assessment of adherence to steroid inhaler treatment in patients with asthma
• An evaluation of the internet as a source of information about steroids for asthma patients
• Laboratory approach to the patient with hypogammaglobulinemia
• Association of monoclonal gammopathy of undetermined significance with humoral immune deficiency

All fellows are expected to participate in a quality improvement (QI) project, as required by the ACGME. There is a formal workshop series designed to guide both fellows and their faculty mentor in planning and doing QI work in their division.  Attendees present their quality problem or topic to be addressed and will be guided through the appropriate use of QI methods and tools. The process and outcome of the QI project will be presented at a Friday conference in the second year.