The A&I fellow is responsible for first evaluation of all admissions to the A/I service and all consultations and is supervised closely by the A&I faculty member inpatient attending on service that month. The fellow evaluates all patients admitted from our outpatient clinics, private patients of the faculty and individuals referred to A&I for admission. Inpatients are seen principally at the Hospital of the University of Pennsylvania and occasionally at Presbyterian Medical Center, and the Philadelphia Veterans Administration Medical Center. In addition, inpatients at CHOP are evaluated as detailed elsewhere.
When a patient is admitted to the A&I service, the fellow sees the patient initially, then presents the case to the faculty member who also examines the patient. The A&I fellow write a complete note which includes the history, physical examination, differential diagnosis, and suggested approaches for diagnosis and treatment. The patient is examined by the faculty member and the A&I fellow's note reviewed. After any appropriate changes are made, the A&I fellow's note is placed on the chart with the attending's note. Copies are made and kept in the A&I module for future reference to the patient. In occasional situations when an immediate consultative response is needed, the A&I fellow may discuss the case on the telephone with the A&I Attending and subsequently put a preliminary A&I note in the chart. This note is followed by a full report after the patient is seen with the A&I Attending, within 12-24 hours of notification of the case. Consultations are handled in the same way.
When the A&I service is the primary service, the A&I fellow liaisons directly with house officers as well as consulting services. Teaching other housestaff and medical students is an integral part of our inpatient activities. Thus, after plans are recommended and discussed in detail with the house staff teams, these teams have primary responsibility for requesting studies and writing orders concerning inpatients. For inpatients on our service, the A&I team makes the definitive decision in the unusual instance where there are differences concerning diagnostic or therapeutic approaches. The A&I fellow examines the patient daily, more frequently if required. He/She is responsible for reviewing current and old charts and collecting necessary information. The A&I fellow reports his/her findings and assessment at least daily to the Attending and the clinical issues are discussed. They examine the patient daily if the patient is on the A&I service, and as necessary for consultations. For patients on consultation the fellow likewise has first responsibility to communicate with house officers, the primary service, and other consulting services. He/She and the A&I Attending examine the patient in follow-up as necessary. If medical fellows or house officers are rotating on the A/I service, our fellow will provide the preliminary supervision of their activities that will then be additionally supervised by the attending.
There is a close working relationship between the A&I staff and the staff of the Intensive Care Units. On average there is at least one A&I consultation/week in the MICU. Consultations are handled in the same way as floor consultations except they are generally followed more closely as the patients are sicker.
We collaborate closely with many services, particularly general medicine, pulmonary, dermatology, rheumatology, and otorhinolaryngology. Reviewing shared cases broadens A&I fellow's approach to differential diagnosis and patient management.
A& I fellows evaluate a variety of inpatients at the Hospital of the University of Pennsylvania. The patients are 19 years and older, males and females, and include a wide range of racial/ethnic backgrounds. The fellow is exposed to patients that represent the spectrum of allergic/hypersensitivity/immunodeficiency disorders. For example, in the last year, approximately 40% of the patients seen had asthma, 30% had atopic disorders and 30% had immunologic disorders. In the last year, the A&I fellow admitted or performed consultations on patients with adverse drug reactions, angioedema, idiopathic anaphylaxis, exercise-induced anaphylaxis, asthma, chronic cough, allergic rhinitis, food allergy, latex allergy, cold urticaria, hypersensitivity pneumonitis, x-linked agammaglobulinemia, common variable immunodeficiency, other forms of immunodeficiency excluding AIDS, transverse myelitis attributed to systemic lupus erythematosis, cryoglobulinemia, vasculitis, serum sickness and hypereosinophilic syndrome, to name a few. The A&I fellow also routinely supervises penicillin skin testing and antibiotic desensitizations. The fellow is also exposed to a wide variety of clinical pathology by virtue of the fact that the fellow performs consultation on patients from a variety of services including general medicine, dermatology, pulmonary, gastroenterology, infectious diseases, other medical specialties, neurology, and surgical specialties. Thus, the range of clinical problems is wide.
Rounds are made each day formally with A&I attendings and on an ad hoc basis as needed. In some instances the A&I Attending and fellow are invited to lead General Medicine Attending Rounds when more formal didactic input regarding A&I issues are sought. Additionally, several of the weekly A&I conferences each year are devoted to case presentations. Additionally, we have formal case-presentation conferences monthly with Pulmonary Medicine with Rheumatology. The A&I weekly conference frequently invites presentations from otorhinolaryngology and dermatology. The monthly A&I journal club sometimes encompasses inpatient clinical issues like immunodeficiency. Medical Grand Rounds, held weekly, also sometimes cover topics relevant to A&I and related services.
Our fellow on rotation on the CHOP Allergy and Immunology Clinics participate in In-patient consultation rounds in CHOP which immediately follows those clinics. Here, the fellow gains valuable experience in learning about evaluation and treatment of complex pediatric A&I problems
Patients discharged from the hospital, needing A&I follow-up are assigned to the A&I fellow's clinic (supervised by rotating attendings) unless already a private patient of an A&I attending. In that situation, the patient is seen on a clinic day when both can be present. This arrangement provides the fellow with ample opportunity to follow-up patients to ascertain the impact of inpatient interventions on the course of the patient's disease. The A&I fellow also has the opportunity to interact with discharged patients through the on-call program.
The fellow sees outpatients for a half-day daily during the first year and during those days also performs the inpatient duties, rotating with other fellows. When on-service, the fellow sees on average 2-3 hospitalized patient per day.
Other Teaching Activities:
Pulmonary Function Lab – In addition to doing and interpreting their own spirometry, A&I fellows spend one week observing other techniques (e.g. lung volume, diffusion, plesythmography studies) in the hospital pulmonary function lab.
Allergy and Immunology Techniques – fellows get "hands-on" experience doing skin testing, challenge techniques, immunotherapy and (where desired) immunoassays as part of our clinical activities.