THE WAY I SEE IT
Clinical immunology: more than just immunoglobulins?
Authors: Kyla Thomas
Publication date: 11 Aug 2007
Kyla Thomas describes her foundation year placement
There is an ever expanding patient base and increasing variety as new diseases are discovered. Immunological treatments are increasingly used in new ways to benefit patients
“Immuno-what? Immuno-holiday,” guffawed my gastroenterology consultant when I told him that my next foundation year 1 (F1) job would be immunology. The other F1 doctors smirked: “What will you learn by the end of that? The difference between IgG and IgM?” At least the specialist registrar was a little bit nicer. “Don't worry about the opinions of the rest of the surgical team,” he said. “It should provide plenty of intellectual stimulation. With your academic background you will probably enjoy it.”
A little known specialty
Exposure to clinical immunology at all grades remains limited. Basic immunology was a minor part of my two year basic sciences course at the University of the West Indies. The clinical immunology placement was sandwiched into four weeks of my third year. The situation is similar for many UK graduates. I had decided to apply for the four month F1 rotation in clinical immunology to compensate for this lack of exposure. In addition, the introduction of the Modernising Medical Careers programme meant that I had just two years to experience as many different specialties as I could before applying for run-through specialist training positions. By the end of the placement I was definitely an immunology convert. I would like to shed some light on this fascinating but relatively unknown specialty.
What is clinical immunology?
The clinical practice of immunology, as defined by the World Health Organization, encompasses clinical and laboratory activities dealing with the study, diagnosis, and management of patients with diseases resulting from disordered immunological mechanisms, and conditions in which immunological manipulations form an important part of treatment. Clinical immunology also offers an opportunity to combine laboratory based research with general medicine and rare medical conditions such as primary immunodeficiencies, severe allergies, vasculitis, anaphylaxis, and autoimmune rheumatic diseases. The immunology curriculum is ideally suited to both medical and scientific trainees, with or without postgraduate training, who are considering a career in clinical immunology or another medical specialty which has specific immunology content, such as haematology, rheumatology, neurology, nephrology, and dermatology. Several universities, including the University of Oxford, offer MSc programmes in immunology, with opportunities for progression to PhD or MD programmes. Post-foundation year experience in general medicine or paediatrics and membership of the Royal College of Physicians are required to enter immunology specialist training. The immunology exam for membership of the Royal College of Pathologists is then taken during the five year training period.
Immunology as an F1 placement
The immunology department at the John Radcliffe Hospital in Oxford has a mixture of clinical and laboratory staff: four consultants; two specialist registrars, one of which is in flexible training; three nurse specialists; several biomedical and clinical scientists; and two F1 doctors, one of which is in the academic rotation. There is no banding in immunology, but the overall experience definitely outweighs the reduction in pay.
Benefits of immunology
Helen Chapel, reader in clinical immunology and co-author of a popular immunology textbook, Essentials of Clinical Immunology , chose the field because of her fascination with the application of science to clinical problems. She says: “Unlike other specialties, immunology gives you the chance to combine laboratory and clinical fields, providing a chance to improve insight into problems in immunologically mediated diseases. There is an ever expanding patient base and increasing variety as new diseases are discovered. Immunological treatments—for example, monoclonal antibodies and immunoglobulins—are increasingly used in new ways to benefit patients.”
Siraj Misbah, consultant immunologist and co-author of the same textbook, says: “Immunology challenges you to keep abreast of the science. The mix of complex conditions, excellent work-life balance, and the intellectual buzz of occasionally being able to solve diagnostic conundrums are definite advantages.”
Jennifer Lortan, consultant and lecturer in immunology, initially planned to do nephrology and wanted to learn immunology in relation to renal disease and transplantation. She switched allegiance after completing an MSc in immunology and says: “Often posts are based in teaching hospitals with good opportunities for involvement in training medical students and research. Because it is a small specialty, you get to know more of your colleagues nationally.”
Downsides of immunology
The biggest disadvantage of immunology is the negative perception of the specialty by medical colleagues, which is usually the result of ignorance. Siraj Misbah continues: “The biggest issue is the question of `what do immunologists actually do?' It is sometimes seen as a mechanism based specialty and, as an emerging specialty, doesn't feature in national health priorities. Immunology is everywhere but is seen as `nowhere' due to lack of a specific procedure that `belongs' to the specialty.” Dilani Arnold, specialist registrar, is concerned about the limited number of available consultant posts. Hopefully, further cuts to the NHS budget won't make immunology a disappearing specialty.
The clinical practice of immunology, as defined by the World Health Organization, encompasses clinical and laboratory activities dealing with the study, diagnosis, and management of patients with diseases resulting from disordered immunological mechanisms
My experience of immunology
After completing the placement, I am more confident with the clinical presentation and management of patients with primary immune deficiency, systemic autoimmune disease, vasculitis, and severe allergy. I learnt a lot about immunoglobulin therapy, treatment of infections in patients with immune deficiency, appropriate use of laboratory procedures such as serum electrophoresis and immunofluorescence, importance of relevant autoantibody requests, and interpretation of imaging and laboratory tests. I developed appropriate skills for pursuit of a clinical academic career, such as assessment of scientific papers, mechanisms for publication of scientific papers, and how to obtain informed consent for clinical trials. There were numerous opportunities for direct observation of procedures (DOPS), audits, and case based discussions. More importantly, the consultants, specialist registrars, and nurses were always enthusiastic about filling out those all important assessment forms.
Was it worth it?
Overall, I was pleased with my placement. I felt a valued member of the team and enjoyed the complexity of medical conditions seen in the clinics and the relationships I developed with many of the patients. The willingness of each member of staff to engage in open discussion between clinical cases, in the laboratory, and at tutorials was extremely refreshing. I would advise anyone to apply for an immunology placement. Trust me; it is much more than immunoglobulins.
Kyla Thomas F1 doctor John Radcliffe Hospital, Oxford firstname.lastname@example.org