Division of Pulmonary, Allergy and Critical Care

Penn offers a well-organized and newly revamped outpatient program rotation.

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

Fellows work in the first class, newly built Allergy and Immunology Clinic from 8 am to 3 pm Monday through Friday (clinics start at 9:40 am on Fridays). This area encompasses eight exam rooms, two skin test rooms, a procedure room and an allergen extract preparation room.

Organization of the Outpatient Program

The outpatient programs in the A&I Division are under the overall direction of Michael S. Phillips, 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, Internal Medicine resident 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 two to three nurses, two medical assistants and two secretaries.

Schedule of A&I Program

  • Allergy/Immunology Program:
    (Monday through Friday)
    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, collagen vascular diseases, hypereosinophilic syndromes, vasculitides, and immune mediated neurologic disorders. In addition, the resident frequently evaluates patients referred for recurrent infections, which defy classification. Although a specific diagnosis is sometimes not rendered, the resident has the opportunity to exercise his/her differential diagnostic skills. Patients are seen initially by residents and presented to Drs. Phillips, Takach, Fadugba, Apter or Feldman, who serve as attending physicians in these clinics. In the course of care for these patients, residents are asked to write prescriptions for immunotherapy in relevant patients. Residents have each been given a time slot during which allergy procedures can be performed: injections can be given and skin tests performed under the supervision of the nurses. Spirometry is performed on patients with asthma and residents have the opportunity to perform this test.
  • Pediatric Allergy Clinic:
    (Monday mornings weekly for six months)
    A&I residents participate in this clinic in the nearby Children’s Hospital of Philadelphia (CHOP) 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. Corry, Spergel, Brown-Whitehorn, Heimall, and Reddy. Following the extensive discussions about the outpatients by all in attendance, our A&I resident joins the CHOP A&I staff on inpatient rounds when appropriate for educational purposes.
  • Combined Sinusitis Clinic:
    (Second Monday 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 residents 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 is an internationally known authority in the diagnosis and treatment of sinus disease.)
  • Pediatric Immunology Clinic:
    (Thursday mornings weekly for six months)
    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 program allows visiting residents 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 6 month experience in this clinic. This clinic is supervised by Dr. Kathleen Sullivan, Dr. Jennifer Heimall and Dr. Soma Jyonouchi.

Description of the Clinical Responsibilities of the Fellows

First Year Fellow

The A&I residents attend clinics as noted in their schedule of clinical responsibilities and spend 10 months on the inpatient consultation service covering the Hospital of The University of Pennsylvania and Penn Presbyterian Medical Center. The A&I residents will also spend one month of the inpatient consultation service at CHOP on the pediatric service.

Second Year Fellow

The focus of the year depends upon whether the fellow chooses a research or a clinical focus but will include:

  • At least one weekly A&I outpatient clinic (two half days); two full days if the focus is clinical
  • Rhinoscopy training with otorhinolaryngology
  • One month orienting the incoming first-year fellow/s on the consultation service, which typically involves rounding on one to three patients/day
  • Electives if desired in dermatology, rheumatology or ENT
  • One to two additional months on the consultation service, usually rounding on one to three patients/day. This includes one month covering the consultation service while the first year fellow has an inpatient month at CHOP.
  • Consult service during the first year fellow’s vacation time and when the first year fellow is away at the ACAAI meeting
  • Participating in the on-call service in rotation with the other fellow(s)

Third Year Fellow

The third year is exclusively focused on research with weekly half day clinics. This is an optional year that is highly recommended, if the focus is academic.

Responsibility in Outpatient Care/Faculty Supervision

Patients are examined initially by one of the Fellows.

All new and follow-up patients are presented in detail to one of the clinic faculty. Relevant data such as laboratory findings, spirometry and imaging are reviewed.

This is followed by discussion of the differential diagnosis, assessment and proposed management, and examination and discussion with the patient.

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 resident is on-call on the average every second week and every second weekend to "handle" emergency/urgent calls. The resident who takes call with an A&I attending is the first member of the A&I team to be notified of problems occurring after 5 pm or on weekends. The calls are typically routed through the hospital operator who is aware of the on-call schedule. The resident is instructed to discuss all such calls with the attending of  record during the early months of training. Residents must write a note of any patient calls in EPIC, copying involved attendings, detailing the substance of the call and action taken. As the resident becomes more experienced and more comfortable, routine calls are communicated to the appropriate attending during "normal" hours on the following day or through the electronic health record system, "PennChart".

Collaboration/Consultation with other Specialties and Subspecialties

The fellow has direct exposure to Otorhinolaryngologists, Rheumatologists and Pulmonologists through Subspecialty Clinics, interactions through patient care, as well as joint conferences with rheumatologists. 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 hypogammaglobulinamic 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

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.

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 is responsible for following the patient’s labs and seeing them in follow up visits. An A&I faculty member is always available for consultation about problems that may arise regarding the patient.

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.

Resident’s Participation in Out-Patient Procedures

All fellows learn how to perform the following procedures:

  • Diagnostic allergy skin testing (prick and intradermal)
  • Skin testing for adverse drug reactions where published protocols exist, e.g. influenza vaccine, local anesthetics; desensitization where risk of anaphylaxis exists and no validated skin test procedures exist
  • Physical agent challenges for diagnosis of physical urticarial
  • Spirometry and peak flow assessment
  • Food/drug/latex challenge - occasional, as indicated
  • Inhalational (e.g. methacholine) challenge - occasional, as indicated
  • 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 in Clinical Research Program

Participation by HUP A&I Fellows in clinical research  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:

  • Retrospective study of clinical outcomes in hematologic malignancy patients with beta-lactam allergy label
  • Association of reported penicillin allergy and diagnosis of chronic idiopathic urticaria
  • 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
  • Occurrence of PML in CVID
  • Association of monoclonal gammopathy of undetermined significance with humoral immune deficiency

Participation in Quality Improvement Projects

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 2nd year. 

Patient Load Responsibilities

Fellows are expected to evaluate both new and follow-up patients in clinic. Initially, patient evaluations will take longer, but as fellows become more experienced and efficient, their patient load will increase accordingly, in preparation for practicing independently. Whenever possible, fellows evaluate the same patients on their return to clinic. Whenever possible, residents will examine new patients.

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