Penn offers a well-organized and newly revamped outpatient program rotation delineated below. These rotations have served to train allergy and immunology fellows, pediatric allergy fellows, residents from HUP and affiliated institutions, and medical students
Through a combination of conferences, clinical case discussions, hands-on interactions with patients, and direct observation of experienced subspecialists evaluating patients, fellows gain a deeper appreciation of:
- The unique patient disorders seen in an allergy and immunology ambulatory care setting.
- 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.
- Organization and Assignment of Resident Outpatient Activities
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 Penn Presbyterian Medical Center (an affiliated institution, 6 blocks from HUP).
- 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.
- 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.
- 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.
- 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.)
- 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.
- 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.
- 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.
- 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.
- Description of the Clinical Responsibilities of the Fellows
- First Year Fellow
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.
- Responsibility in Outpatient Care/Faculty Supervision
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.
- Emergency Service/On-Call System
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.
- Collaboration/Consultation with other Specialties and Subspecialties
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.
- Diversity of Out-Patient Populations
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
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.
- Resident's Participation in Outpatient Procedures
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
- 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 in Clinical Research Program
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.
- Patient load responsibilities
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.