Careers in allergy medicine
Authors: Yasmin Akram
Publication date: 28 Jul 2007
Yasmin Akram finds out what being an allergist is all about
“It's a big problem, and it's not going away,” says Chris Corrigan, professor of asthma, allergy and respiratory science at King's College London.
Prevalence and prevention
Allergy medicine is a relatively new but rapidly advancing specialty. Many unanswered questions allow the field to retain its academic roots, so allergy medicine is likely to interest individuals who wish to have an academic component in their career.
Allergic disease varies from mild to life threatening. In the past two decades there has been a doubling in prevalence of common allergic disorders such as asthma, eczema, and rhinitis in addition to a rapid rise in serious allergic disease. There is now one child in every year of every class who has peanut allergy. There is set to be an expansion of allergy services with increasing numbers of people wanting immunotherapy, accurate allergy diagnoses, and management.
Allergy medicine and immunology are now separate specialties; a stand alone allergy curriculum was established seven years ago by the Joint Committee on Higher Medical Training, and now the Postgraduate Medical and Education Training Board. Allergists do mostly clinical work whereas immunology training is more laboratory focused. It is a very patient orientated specialty, mostly outpatient based. Dr Sophie Farooque, specialist registrar in allergy medicine at Guy's Hospital, London, was the first ever allergy trainee in London (box 1). She explains, “It's a wonderful mixture of the clinical and the academic and you get a chance to build your career the way you want to.”
Examine, explore, and inquire
Posts exist for clinical training, and an interest in research is not compulsory, but an understanding of its principles and a desire to follow updates is essential. For interested individuals there is potential as a trainee to spend dedicated time apart for research. You can also apply for a clinical research training fellowship—for example, through the new Medical Research Council's Centre for Allergic Mechanisms in Asthma, which embraces Imperial and King's colleges, London and also asthma UK.
The natural history of many allergies and the immunological mechanisms that lead to the production of allergic IgE antibodies when they contact the mouth, nose, or lung are massive research areas. Professor Corrigan says, “The million dollar question in allergy is why certain people make IgE antibodies to certain substances, such as foods or to grass pollen and never develop any clinical symptoms, whilst others develop fully fledged ones.”
Box 1 | A typical week for an allergist
Sophie Farooque describes her working hours as a 9 to 5 with no on calls. In a week you would typically have these clinics:
General allergy, where you see patients with a mixture of all kinds of conditions
Immunotherapy, where you desensitise patients with severe grass or tree pollen allergy, or those with anaphylactic reactions to bee and wasp stings, with a series of injections
Drug allergy clinic
Challenge clinic. Sophie describes challenge clinics as the clinic “where you really earn your money as an allergist because you are giving people challenges to which they may respond severely, this being the only way in some cases to make an accurate diagnosis”
Food allergy clinic
Specialist clinic is one of your attachments—for example, dermatology, paediatrics.
Sophie continues, “Allergy is such a small community that everyone knows each other and it is really friendly, so if there is a particular clinic somewhere that you want to go to, it's very easy to contact your colleagues and arrange an attachment in another hospital if you feel it would be of benefit.
“Allergy trainees are treated as a precious resource and valued. As an allergy specialist registrar, I found for the first time in my career, no conflict between service commitments and training. I was encouraged to attend meetings, write review articles and case reports, and apply to read for a PhD or an MD.
“Most diagnoses are made from the history, and the consultation really has two parts; you see the patient initially and decide if they need skin testing or not. If they do they will go through the tests, and come back at a later date so you can go through the results. Typical consultations take between 20 to 30 minutes.”
The pathogenesis of asthma is studied in a large number of centres, in particular at Guy's Hospital where they focus on steroid resistant and aspirin sensitive asthma. Other centres have done work on food allergy, especially peanut, and evaluating immunotherapy and on how desensitisation works. Epidemiology is also an area with a wealth of population research to be done.
The best of both worlds
Chris Corrigan splits his time half and half between seeing patients and doing clinical research into the inflammatory processes going on in asthma and allergic rhinitis, how they damage the airway and cause clinical symptoms, and mechanisms of resistance to standard drugs, particularly steroid treatment. He describes his work as being “the best of both worlds: my patients keep me in touch with real life, and the research work keeps me up to date with the fascinating world of academia.”
A foundation to build upon
The training is largely outpatient based. The course is normally five years. The first two years are spent building a foundation in allergy medicine, so there is a lot of general and food allergy, as well as basic immunology, because a large proportion of allergy relates to the immune system.
In the third, fourth, and fifth years you rotate into more specialist areas. So in addition to allergy the trainee is attached to various others specialties to learn about allergy in that field, so they will spend time in dermatology clinics, learning how to treat eczema, urticaria, and contact dermatitis and how to differentiate them from other skin diseases; time in ear, nose, and throat clinics identifying nasal allergic complications, such as rhinosinusitis, and their management; in respiratory medicine, where they will learn how to manage asthma and allergen avoidance; in immunology laboratories to familiarise themselves with laboratory diagnostic tests; and in paediatrics, learning how to manage paediatric allergy, food avoidance, special diets, and liaison with schools (box 2). The trainee will spend approximately three to six months in each of these specialties. Drug allergy runs throughout the course, as it is one of the most demanding areas of allergy medicine.
The public eye
In addition there is training in the fringe practices of allergy medicine that aren't scientifically validated. Professor Corrigan explains that this is “so at least they are authoritative on that subject since unproven allergy tests and unproven diagnoses are very much in the public eye.”
At Guy's Hospital all the facilities are in one place so trainees only have to move to local hospitals if at all; the same is true of Cambridge, Leicester, and Southampton. It is possible, however, that some centres in the future may be based around two or more hospitals that are a distance apart.
Box 2 | Pros and cons of allergy medicine
You are in a position to provide vital help and advice to a wide range of patients of all ages, including those with life threatening conditions.
It's a strictly outpatient 9 to 5 specialty, with no on call
You can mix clinical and academic work to suit you
You can work closely with other medical and surgical specialties—for example, ear, nose, and throat; dermatology; and paediatrics, with the potential for joint clinics
It's family friendly because it allows you to share training, thus work part time.
Career structure isn't as developed as it is in other specialties
Element of uncertainty about employment in the future
Lower pay banding than other specialties, because there is no on call
“Bright young trainees”
There are limited training posts at the moment, because there are limited centres with enough allergy experts to provide the training, but this is set to increase. Professor Corrigan reassures me that, “Hesitation on the part of bright young trainees who are interested in a semi-academic career is not necessary because the specialty is set to expand in the very near future.” In support of this claim, allergy medicine has been prioritised as a research growth area by the Department of Health, and following deliberations from Modernising Medical Careers, four new academic fellowships in allergy medicine have been awarded. The British Society of Allergy and Clinical Immunology (BSACI) can give interested individuals an idea of whether any new posts are being developed and candidates should be on the lookout for posts being advertised in BMJ Careers.
Yasmin Akram medical student St George's, University of London firstname.lastname@example.org