Clinical immunology encompasses the diagnosis and management of diseases with a major immunological component. In the UK, the practice of immunology is similar to haematology in that practitioners take responsibility for both the clinical management of patients and the running of the diagnostic laboratory. This represents a shift from the old order where immunologists would either work in the laboratory or on the wards, and has come about from the changing aspirations of trainees and the increasing demands for clinical services.
Consultant-lead Immunology services are located in Teaching Hospitals, Universities and a few of the larger District General Hospitals. It is likely that Immunology will remain concentrated in these larger centres, which will have at least two Consultants, to ensure continuity of senior cover and avoid the major difficulties of single-handed practice.
Allergy is now recognised as a separate training programme and will usually be taken with another medical speciality such as respiratory medicine, dermatology or gastroenterology, leading to a dual CCST. Allergists are likely to be appointed in the same centres as Immunologists and will work closely with them.
Entry to both programmes will take place after a minimum of two years of training in medicine at SHO level, culminating in the completion of the MRCP examination. Changes to general medical training to be implemented shortly will mean an additional post-MRCP year being spent in general medicine. Trainees will then enrol for Higher Specialist Training by obtaining a career registrar post. These posts will be attached to the major regional centres. For those uncertain about committing themselves to an SpR post, some centres are setting up temporary SHO posts in immunology to allow potential recruits to test the water. An alternative is to look out for locum posts, to ask whether a centre would be prepared to make a locum rather than a substantive appointment.
The first two years of HST will be devoted to a common core programme, which involve a modular approach. In the first year there will be emphasis on basic science, while in the second year the emphasis will be on clinical and laboratory work. Trainees will have a very significant component of clinical work involving both inpatient and outpatient work. This will involve attachments to other related disciplines, including renal medicine, haematology, rheumatology etc. Allergy Trainees and Immunology trainees will undertake the same core training, although there will be flexibility to allow the clinical aspects of training to be geared to previous experience and career goals. Both the types of trainees will have experience in the diagnostic laboratory, but only immunology trainees will be expected to have hands-on experience of diagnostic tests. For those committed to Allergy alone or dual certification in Allergy plus another discipline, the option of spreading the core training over the full training period will be permitted.
There will be nominated training supervisors who will assume responsibility for monitoring the progress of trainees through the programme, in conjunction with the Postgraduate Dean. Exit from the core programme will be by successful acquisition of the MRCPath Part I examination for Immunology trainees. This will be optional for Allergy trainees, who, if successful, will be entitled to the DipRCPath, without further examination. Exit from the core training programme for Allergy trainees will otherwise be by satisfactory appraisal and review of the training log which all trainees will keep. There is a mandatory annual appraisal system [RITA], at which the training log and progress will be reviewed.
The final three years of training will encompass further clinical training, with the option to develop a special interest. One year of research can be counted towards the requirement. Trainees will be expected to undertake suitable management training during this phase. Immunology trainees will be eligible to complete the final part of the MRCPath after a further two years. This can be by submission of a thesis, a collection of papers or a series of cases. Allergy trainees will undertake further relevant clinical training including any additional training to allow dual accreditation with another speciality. At the end of four years there will be a penultimate year appraisal [RITA] with an external assessor, who will go through the training and identify any gaps requiring attention in the final year. At the end of five years trainees who successfully complete the programme will be eligible for a CCST in the appropriate speciality and for inclusion in the Specialist Register of the GMC.
The training is supervised by the JCHMT, which is responsible for the approval of training programmes and the inspection of training centres. A detailed programme is available from the JCHMT, which gives the expected components and skills required. It is expected that trainees will obtain a copy of this document prior to embarking on higher specialist training.
Changes are underway in the format of the assessment process towards a competency based system, as used in other medical specialities: this will be incorporated in the trainees log and assessed at the annual appraisal
Within HST there will be limited scope for research, and it is anticipated that some trainees will either take time out of HST or complete a research degree prior to embarking on HST. However only one year of research will be counted against the training requirements for the CCST. The preferred degree is a PhD and there are opportunities in most academic departments associated with Training Centres. For those trainees with less of a research bias, MSc by thesis or by taught course in an Immunological field may be an acceptable alternative.
All trainees will be working in major centres and will be expected to be involved in teaching junior medical staff, medical students and paramedical personnel.
Trainees will be expected to undertake training in management. The ACP runs an excellent course specifically designed for registrars and newly appointed consultants, which incorporates aspects of laboratory management. Many hospitals and Postgraduate Institutes also organise managements training courses, but these may not be focussed on laboratory management. In some regions attendance on these local courses is a mandatory part of training.
Attendance at the meetings of the relevant professional societies is expected. These would include the academic meetings of the British Society for Immunology [BSI], the British Society of Allergy & Clinical Immunology [BSACI], the ACP and the Royal Colleges of Physicians and Pathologists and the Royal Society for Medicine. Unaffiliated meetings are also organised by individual centres.
A programme of training days, 4-6 per annum, are organised by the ACP. These rotate through all the major centres. There is an annual registration fee, payable to the ACP. Trainees will be expected to participate in these training days.
Membership of the BSI and/or BSACI should be viewed as mandatory. Trainee membership of the ACP and RCPath is also highly beneficial. The Clinical Immunology Society in America provides very favourable rates for trainees, an excellent journal and an annual meeting. The UK Primary Immunodeficiency Network is an informal organisation of immunologists, scientists and nurses interested in primary immunodeficiency diseases. It organises an biennial meeting.
Trainees are expected to keep up to date with general medical journals, BMJ, Lancet and NEJM. Specialist review journals are Trends in Immunology, Current Opinion in Immunology, Annual Reviews of Immunology and Immunological Reviews. Regular attention to these will ensure that most topics that appear in the MRCPath Part I written papers are covered. Primary journals of major interest include Clinical & Experimental Allergy, Clinical & Experimental Immunology, European Journal of Immunology, Journal of Experimental Medicine, Journal of Allergy & Clinical Immunology, Journal of Immunology. Additional papers of interest appear in Nature and Science, as well as other discipline specific journals. Trainees should ensure that they are conversant with techniques for computer-based literature searching.
The following books provide much of the relevant background.
Janeway & Travers: Immunobiology: the immune system in health and disease
Stites Terr & Parslow: Immunology
Holgate & Church: Allergy
Rich: Clinical Immunology: principles & practice
Samter: Immunological diseases
Middleton: Textbook of Allergic Disease
Paul: Fundamental Immunology
Gooi & Chapel: Clinical Immunology: a practical approach
Rose & Friedman: Manual of Clinical immunology
Mygind et al: Essential Allergy
Male et al: Advanced Immunology
Spickett: Handbook of Clinical Immunology
Training supervisors will develop and monitor specific targets with trainees. The RCPath Training Logbook in Immunology provides a detailed framework for setting and monitoring objectives. The following areas comprise the main learning objectives.
The RCPath has Regional Specialist Advisers in Immunology who will be happy to see and advise potential and existing trainees.
http://www.acaai.org/index.shtml [American College of Allergy, Asthma & Immunology]
http://www.aaaai.org/ [American Academy of Allergy, Asthma & Immunology Online]
http://www.clinimmsoc.org/ [Clinical Immunology Society]
http://www.pia.org.uk/ [PiA Primary Immunodeficiency Association]
http://www.eaaci.org/ [European Academy for Allergology & Clinical Immunology]
http://immunology.org/ [The British Society for Immunology]
http://www.worldallergy.org/ [International Academy for Allergology & Clinical Immunology]
http://www.rcpath.org/ [Royal College of Pathologists]
Produced by:
Dr.Gavin Spickett
Consultant Immunologist
Royal Victoria Infirmary
Newcastle upon Tyne NE1 4LP
Email: gavin.spickett@nuth.northy.nhs.uk
9 March 2002