Requirements for Physician Competencies in Allergy: Key Clinical ...

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Requirements for Physician Competencies in Allergy: Key Clinical ...

WAO POSITION PAPERRequirements for Physician Competencies in Allergy: KeyClinical Competencies Appropriate for the Care of PatientsWith Allergic or Immunologic DiseasesA Position Statement of the World Allergy OrganizationMichael A. Kaliner, Sergio Del Giacco, Carlos D. Crisci, Anthony J. Frew, Guanghui Liu, Jorge Maspero,Hee-Bom Moon, Takemasa Nakagawa, Paul C. Potter, Lanny J. Rosenwasser, Anand B. Singh,Erkka Valovirta, Paul Van Cauwenberge, John O. Warner, and WAO Specialty and Training Council(WAO Journal 2008;1:42Y46)Allergic diseases are quite prevalent worldwide, and theincidence of allergy is increasing everywhere. 1Y7 Becauseallergic and immunologic processes overlap all organ systems,allergy is not always taught in medical schools as a separatesubject. Indeed, lack of recognition of the specialty and of theneed to teach about allergic and immunologic diseases resultsin allergy not being included at all in some medical schoolcurricula. 8 With an estimated 22% of the global populationexperiencing allergic and immunologic diseases, it is timeto recognize and strengthen education in allergy andimmunology. 8The World Allergy Organization (WAO), an alliance of74 national and regional allergy societies, created thisconsensus document to establish educational guidelines forworldwide application to help identify and correct allergyeducation and training deficiencies and to define appropriatecompetencies. In creating this consensus, it is recognized thateach country has its own principles and goals in medicaleducation at the undergraduate and postgraduate levels. Thisdocument defines what WAO considers medical practitionersshould know to care appropriately for allergic patients.BACKGROUNDDiseases with an allergic etiology can affect many organsystems and occur in response to a wide variety ofenvironmental factors. Allergic diseases are among the mostcommon causes of chronic medical problems in both adultsand children and are associated with high morbidity. Theycarry a large socioeconomic burden 9Y12 and can result incatastrophic anaphylaxis or fatal asthma attacks. Systemichypersensitivity diseases include, among others, asthma,rhinoconjunctivitis, otitis, rhinosinusitis, urticaria, angioedema,eczema, food allergy, drug allergy, insect allergy,With special recognition of the contribution of Karen Henley, staff liaison toCouncil1 Some of these skills should be at least taught and understood but may not beperformed personally, in accordance with national guidelines andestablished practice parameters.Copyright * 2008 by World Allergy Organizationoccupational allergic diseases, and anaphylaxis. Conventionally,allergic diseases have been divided into those associatedwith immunoglobulin E (IgE)Ymediated hypersensitivity andthose involving other forms of hypersensitivity. 13 As a medicalspecialty based on immunology, the allergy specialty (in somecountries, called allergology) is concerned with preventionand diagnosis of the disease and management and rehabilitationof patients with allergic and related diseases.In some countries, the allergy specialty is combinedwith clinical immunology. Immune processes are fundamentalto host defense. Malfunction of the immune system causesinfections, reduces immune surveillance, leads to autoimmunephenomena, and impacts every organ system. Clinicalimmunology relates to immune system dysfunctions andimmunologically mediated diseases, which by definition alsoinclude allergic diseases. In some other countries, allergy ispositioned as a component of organ-specific specialties suchas dermatology, pulmonology, rheumatology, gastroenterology,and otorhinolaryngology; this positioning results in thespecialty of allergy not always being recognized separately,and there may be no defined standardization of specialtytraining requirements for allergy. The WAO, as a globalsociety, proposes that the best way to achieve a uniform qualitylevel of care for the many millions of patients with allergicdiseases is to define the key levels of competence required forboth primary care clinicians and specialists who see patientswho have allergic disorders.Given the very high prevalence of allergic diseases andthe different medical systems throughout the world, patientsmay be managed by primary care physicians, internists orpediatricians (who in this document are grouped and definedas first-level care), by organ-based specialists who receivesome specific training in allergy and/or immunology (definedin this document as second-level care), and/or by fully trainedspecialists in allergy (third-level care). The WAO believes thatan acceptable level of competence is required for allphysicians who see allergy patients but who are not allergyspecialists.A strong cooperative network with vertical links amongphysicians and other health care professionals at the first-levelof care, organ-based specialists, and allergists is necessary forthe optimal management of allergy patients. 14,15 Whichphysician sees which patient and to whom the patient is42 WAO Journal & Volume 1, Number 2, February 2008Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.


WAO Journal & Volume 1, Number 2, February 2008A Position Statement of the World Allergy Organizationreferred reflects both the availability of physicians specificallytrained in allergy and immunology and the levels ofcompetence of the referring physicians. It is essential forproper medical management that first- and second-levelphysicians are cognizant of the importance of an accuratediagnosis and the appropriate point at which to refer a patientto the next level of care.This document recommends the appropriate levels ofcompetence necessary to manage allergic patients at each ofthe 3 defined levels and clarifies the appropriate time point inthe disease for referral to an allergist. Once agreement uponthese recommendations is achieved, the WAO will develop amore specific core curriculum and appropriate educational andtraining programs for medical students, residents in training,general practitioners, pediatricians, internists, organ-basedspecialists, and allergy specialists.It is proposed that the levels of competence forknowledge and skills be divided as described in the followingparagraphs.First-Level CareThis level includes recommendations for the knowledgeand skills in allergy required for general practitioners,internists, and pediatricians. It also includes the knowledgeand skills recommended for family practitioners and specialistsin regions where organ-based specialists are not formallytrained in the allergic aspects of their specialty and wheretrained allergists are not available. These recommendationsalso will apply to nurse practitioners and physicians_ assistantsif they are part of the health care community.Knowledge at this level should include a background inimmunology obtained during medical training and shouldinclude an understanding of hypersensitivity mechanisms(Gell and Coombs I-IV); major mechanisms of host defense;the role of immunoglobulins in host defense; knowledge oflymphocyte function; the roles of leukocytes, especiallyeosinophils; and the functions of mast cells and basophils.Knowledge at the first level of care should include thefollowing areas:1. Adequate clinical knowledge about the main allergicdiseases, including rhinoconjunctivitis, rhinosinusitis,otitis, asthma, urticaria, angioedema, eczema, food allergy,insect allergy, anaphylaxis, drug allergy, and immunodeficiency,so that the diagnosis and treatment of both acuteand chronic diseases are possible. Where feasible, suchcare should be carried out in collaboration with or withaccess to an allergist or an allergy referral center.2. Adequate knowledge in the interpretation of the maindiagnostic allergy tests, skin prick tests, and serologicaltests for IgE and an understanding of pulmonary functiontest interpretation. Such training generally would notinclude competency in performing skin tests or the moresophisticated pulmonary function tests.3. Sufficient training to recognize patients with a level ofpersistence or severity, who experience exacerbations thatare life affecting or who have difficult-to-manage allergicor immunologic disease who should be referred to an allergyspecialist for evaluation and initiation of treatment beforethe disease advances to a severe or life-threatening stage.4. Immunotherapy (injective, sublingual) is performed byfirst-level physicians and other health care professionalsin some countries. The WAO suggests that this is onlyappropriate as follows:A. The immunotherapy has been prescribed by a specialist.B. The first-level physician and other professionals havehad adequate training in allergy and the recognitionand management of anaphylaxis to provide thisservice safely.C. The location where immunotherapy is performedfulfills all the conditions for patient safety. The sitewhere immunotherapy is performed should beequipped at a minimum with:a. oxygen and appropriate oxygen administrationapparatus (mask or nasal device) and a manual orautomatic respiration device;b. epinephrine to be administered intramuscularly orintravenously;c. antihistamines (both H1 and H2) for injection;d. corticosteroids;e. vasopressors;f. colloid plasma expanders;g. tourniquet to be placed above the site of injectionof the vaccine; andh. there must be good access to full resuscitationfacilities within the building or at a nearbyhospital resuscitation unit.It is recommended that immunotherapy be initiated by anallergist or in a referral center and that a suitably trained firstlevelphysician should provide maintenance treatment only.Second-Level CareRecommendations for key competencies at the secondlevel of care apply to organ-based physicians such as those indermatology, pulmonology, gastroenterology, otorhinolaryngology,and rheumatology, who see allergy patients or act asallergy specialists, receiving referrals of allergy patients fordiagnosis and management. In some health care systems,second-level care physicians receive training specifically inallergy. Knowledge at this level should include a fundamentalbackground in allergy and immunology, an understanding ofcommon allergic diseases, and the knowledge and skills toperform and interpret diagnostic tests to competently treatuncomplicated allergic diseases.In most countries, background training in allergy andimmunology is obtained through rotations in allergy andimmunology centers provided during residency in internalmedicine or pediatrics. Thereafter, during the 2 to 3 years oftraining in specialties such as dermatology, pulmonology,otorhinolaryngology, gastroenterology, or rheumatology, adequateopportunities for instruction in allergy and immunologyshould be required. Organ-based specialists at this level shouldbe required to have the knowledge base required of any firstlevelprimary care physician, plus additional knowledge ofhost defense and clinical immunology and some understandingof cytokines and chemokines, genetics and environmentalfactors, and allergens and their relationship to humandiseases. 16,17* 2008 World Allergy Organization 43Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.


Kaliner et al WAO Journal & Volume 1, Number 2, February 2008The recommendations for second-level organ-basedspecialists include the following:1. Broad clinical knowledge of major allergic and immunedeficiency diseases.2. Knowledge sufficient to diagnose and treat the commonuncomplicated cases of allergic disorders according tonational and international guidelines.3. Adequate skills to perform and interpret allergy skin testsand the ability to interpret the other tests useful for thediagnosis, treatment, and prevention of allergic diseases.4. Administration of various forms of immunotherapy (incollaboration with allergy specialists and referral centers)after adequate training, but only if such therapy isperformed in a setting where patient safety is ensured(see First-Level Care, 4.C.)Third-Level CareThird-level specialists are fully trained in allergy, havingspent 2 or 3 years in training beyond either internal medicine orpediatric training. Such specialists will be expected to have afull knowledge and complete set of skills relating to all allergicdiseases, and the competence to diagnose and treat in all areas.A core training needs to be acquired before the specifictraining in allergy. This training will be in internal medicinefor those intending to deal with adult allergy patients, and inpediatrics for those intending to deal with children. In certaincountries (the United States, for instance), training in allergyencompasses both pediatrics and internal medicine.KNOWLEDGE OBJECTIVES1. Immune mechanisms involved in the development ofimmunologically mediated diseases and, in particular,allergic sensitization and disease formation.2. Genetic and environmental factors, including infectiousdiseases, involved in the genesis of allergic diseases.3. Pathogenesis of rhinoconjunctivitis, otitis, rhinosinusitis,asthma, atopic dermatitis, urticaria, and angioedema;drug and food allergy; insect allergy and anaphylaxis;and the concept that many allergic diseases are systemicin etiology.4. Relationship between tissue inflammation and repair.5. Mechanisms of IgE-mediated immediate- and late-phaseallergic reactions.6. Mechanisms of non-IgEYmediated allergic reactions andother disorders in the differential diagnosis of allergicdisease. These diseases include, but are not limitedto, nonallergic rhinitis; drug-induced rhinitis; acuteand chronic rhinosinusitis; nonallergic asthma; cough;bronchitis; non-IgEYmediated anaphylaxis; idiopathicurticaria; eczema; otitis; conjunctivitis; eosinophilicesophagitis, gastroenteritis, and colitis; celiaclike syndromes;food-induced enteropathies leading to gastroesophagealreflux, esophagitis, gastritis, and gut motilitydisorders including constipation.7. National and global epidemiology of allergic diseases.8. Local airborne, contact, and occupational allergens.9. Classification and relative importance of all relevantallergens and their biologic characteristics, includingheat, digestive stability, and cross-reactivity; understandingof local pollen counts and the characteristicsof various aeroallergens and routes of allergen exposure.10. Therapy.A. Use and route of administration of antihistamines;mast cell stabilizers; bronchodilators; nasal, oral,topical, and inhaled glucocorticosteroids; decongestants;leukotriene modifiers; theophylline; adrenergicagonists; anticholinergics; mucolytics; antibiotics;adrenaline; and all other pharmacological and immunologicagents used to treat allergic and immunologicdiseases.B. Use of emollients, antibiotics, topical glucocorticosteroids,immune modulators, and all other agentsand techniques used to manage eczema and otherallergic skin disorders.C. Use of immune modulators, such as specific allergenimmunotherapy, monoclonal antibodies, includinganti-IgE, and immunoglobulin replacement used totreat allergic and immunologic disorders, andknowledge of immune modulators that are beingdeveloped for clinical use in allergic and immunologicdisorders.D. Methods and value of allergen-avoidance techniques.E. Avoidance diets and nutritional implications ofdietary modification.F. Knowledge of national and international guidelinesfor the management of allergic and immunologicdisorders in adults and children, with particularemphasis on safety and efficacy of all therapies.11. Investigation and management of adverse reactions todrugs and vaccines.12. Methods to measure cells and mediators in biologicfluids and tissues.13. Primary and secondary prevention of allergy, particularlyin children.14. Understanding of the social and psychological issuesassociated with allergic diseases.15. Diagnosis and management of occupational allergic diseases.16. Methods to monitor home or work environments forallergens associated with allergic diseases.17. Understanding of environmental factors such as pollutantsand occupational allergens and of viral respiratorytract infections that affect allergic sensitization anddisease development.18. Recognition/diagnosis and treatment or appropriate referralof patients with humoral and cellular immunodeficiencies,hereditary and acquired complement deficiencies,and phagocytic disorders, depending upon whether thespecialist is an allergist or allergist/clinical immunologist.SKILLS OBJECTIVES1. Clinical skills.A. Differential diagnosis, evaluation, and management orappropriate immunologic referral of the following:a. Eczemab. Rhinoconjunctivitisc. Conjunctivitisd. Rhinosinusitis44 * 2008 World Allergy OrganizationCopyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.


WAO Journal & Volume 1, Number 2, February 2008A Position Statement of the World Allergy Organizatione. Atopic dermatitisf. Asthma, cough, dyspnea, and recurrent wheezeg. Acute and chronic urticaria, including physicalurticariash. Angioedema, including hereditary angioedemai. Anaphylaxisj. Food allergy and intolerancek. Drug and vaccine allergies or intolerancel. Insect allergy/hypersensitivitym. Oral allergy syndromen. Latex allergyo. Occupational allergy, asthma, eczemap. Otitisq. Common variable immunoglobulin deficiencyand related immunodeficienciesr. Primary immunodeficienciess. Secondary immunodeficienciest. Complement deficienciesu. Abnormalities of phagocytic cells2. Management of patients with multiple or complexallergies.3. Management of patients with multiple food allergies,requiring avoidance diets.4. Provision of allergen avoidance advice.5. Safe supervision of food and drug challenges.6. Assessment of patients for immunotherapy. Properadministration of immunotherapy including immunotherapydose adjustment and management of complications.Supervision of immunotherapy protocols.Recognition and management of allergic reactionsassociated with immunotherapy.7. Recognition of indications for and the skills to perform,interpret, and understand the limitations of skin prick,intradermal, patch, and delayed-type skin tests, andspecific in vitro IgE antibody tests.8. Interpretation of natural allergen and environmentalexposures.9. Evaluation and differentiation of non-IgEYmediatedhypersensitivity reactions.10. Investigation and management of behavioral problemsrelated to allergic and immunologic diseases.11. Improvement of patient compliance with pharmacotherapyregimens through personalized disease managementplans.12. Knowledge of drug desensitization protocols.13. Management in the community of patients at risk ofanaphylactic reactions, incorporating an understandingof integrated care pathways.14. Diagnosis, treatment, and/or referral of primary andsecondary humoral and cellular immunodeficienciesSuch diseases include, but are not limited to Brutonagammaglobulinemia, severe combined immunodeficiency,thymic dysplasia, adenosine deaminase deficiency,Wiskott-Aldrich syndrome, ataxia telangiectasia,and various lymphocyte activation defects.15. Safe and effective administration of intravenous gammaglobulin.16. Recognition and management or appropriate referral ofhereditary and acquired complement deficiencies.17. Knowledgeaboutand treatment/referral of phagocyticcelldisorders, such as Chédiak-Higashi syndrome, chronicgranulomatous disease, leukocyte adhesion defects, anda variety of congenital and acquired neutropenias.TECHNICAL SKILLS AND KNOWLEDGEOBJECTIVES1. Performance and interpretation of skin prick, intradermal,patch tests, and delayed hypersensitivity tests.2. Performance of diagnostic testing for suspected drug,biologic, or vaccine allergy.3. Safe preparation and administration of immunotherapyvaccines.4. Performance of allergen provocation tests, such as nasal,conjunctival, bronchial, and oral challenges, and foodand medication challenges.5. Performance of patch testing for contact dermatitis.6. Performance or knowledge of rhinoscopy and laryngoscopy,nasal endoscopy, acoustic rhinometry, 1 andrhinomanometry. 17. Performance of basic lung function testing, includingspirometry and bronchial provocation tests (methacholineor histamine challenges, measurement of flowvolumeloops and pulse oximetry, and prebronchodilatorand postbronchodilator testing).8. Knowledge of how and when to measure exhaled nitricoxide, and how and when to perform whole-bodyplethysmography and impulse oscillometry. 19. Knowledge of how and when to use various tests tomeasure airway inflammation and/or constriction,including bronchodilator-induced bronchodilation,induced sputum, 1 and/or bronchial and bronchoalveolarlavage. 110. Assessment of environmental hazards in occupationalallergy and knowledge of live insect sting challenges.11. Management of exclusion diets and provocation diets.12. Knowledge of and ability to interpret measurements ofimmune function, including serum immunoglobulinlevels, IgG subclass levels, preimmunization and postimmunizationantibody titers, isohemagglutinin titers,and other ancillary tests for use in the differential diagnosisofcongenitaloracquiredhumoral immunodeficiency.13. Measurement and interpretation of laboratory tests todiagnose hereditary angioedema and complementdeficiencies.14. Measurement of phagocytic function.15. Interpretation of electrocardiograms, chest radiographs,computerized tomography scans and magnetic resonanceimages of the chest and sinuses, and interpretation of themain laboratory tests (blood, serum, microbiological,urine, and fecal tests).ATTITUDES1. Ability to work with colleagues in other disciplines.2. Appreciation of the scope and limitations of allergy testing.3. Appreciation of the limitations and problems created byso-called complementary medicine or alternative allergypractices.* 2008 World Allergy Organization 45Copyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.


Kaliner et al WAO Journal & Volume 1, Number 2, February 20084. Understanding of the role of patient support groups andability and willingness to work with patient supportorganizations.5. Appreciation of all the issues relating to patient confidentialityand the ethical standards expected of allphysicians.6. Understanding of research protocols, the ethics ofexperimental design, data analysis, biostatistics, goodclinical practice, and good laboratory practice, and awillingness to become involved in either clinical or basictranslational research.7. Knowledge of the country-specific legal framework forreporting of occupational diseases and assisting patients inobtaining compensation for occupational diseases.8. An ability to be a clinical decision maker, communicator,collaborator, manager, health care advocate, and scholar.REFERENCES1. Worldwide variation in prevalence of symptoms of asthma, allergicrhinoconjunctivitis and atopic eczema: ISAAC. The International Study ofAsthma and Allergies in Childhood (ISAAC) Steering Committee.Lancet. 1998;351:1225Y1232.2. Variations in the prevalence of respiratory symptoms, self reported asthmaattacks and use of asthma medication in the European CommunityRespiratory Health Survey (ECRHS). Eur Respir J. 1996;9:687Y695.3. Grundy J, Matthews S, Bateman B, Dean T, Arshad SH. Rising prevalenceof allergy to peanut in children: data from 2 sequential cohorts. J AllergyClin Immunol 2002;110:784Y789.4. Sheikh A, Alves B. Hospital admissions for anaphylaxis: time trend study.BMJ 2000;320:1441.5. Garabrant DH, Schweitzer S. Epidemiology of latex sensitisation andallergies in health care workers. J Allergy Clin Immunol 2002;110:S82YS95.6. Demoly P, Bousquet J. Epidemiology of drug allergy. Curr Opin AllergyClin Immunol 2001;1:305Y310.7. Bousquet J. Allergy as a global problem: think globally act globally.Allergy 2000;57:661Y662.8. Warner JO, Kaliner MA, Crisci CD, Del Giacco S, Frew AJ, et al. Allergypractice worldwide: a report by the World Allergy OrganizationSpecialty and Training Council. Allergy Clin Immunol IntYJ WorldAllergy Org 2006;18:4Y10.9. Weiss KB, Gurgen PJ, Hogson TA. An economic evaluation of asthma inthe United States. N Engl J Med 1992;326:862Y866.10. Grupp-Phelan J, Lozars P, Fishman P. Health care utilization and cost inchildren with asthma and selected co-morbidities. J Asthma2001;38:363Y373.11. van den Akker-van Marle ME, Bruil J, Deetmar SB. Evaluation of costdisease: assessing the burden to society of children with asthma inchildren in the European Union. Allergy 2005;60:140Y149.12. Weiss KB, Haus M, Iikura Y. The costs of allergy and asthma and thepotential benefit of prevention strategies. In: Johansson SGO, Karger HT,eds. Prevention of Allergy and Allergic Asthma, 2004.13. Johansson SGO, Bieber T, Dahl R, Friedmann PS, Lockey RF, et al.Revised nomenclature for allergy for global use: report of theNomenclature Review Committee of the World Allergy Organization,October 2003. J Allergy Clin Immunol 2004;113:832Y836.14. Allergy: The Unmet Need. A Blueprint for Better Patient Care. A Reportof the Royal College of Physicians Working Party on the Provisionof Allergy Services in the UK. London: Royal College of Physicians,2003.15. House of Commons Health Committee. The Provision of Allergy Services6th Report of Session 2003/2004. House of Commons London, UK:The Stationery Office Limited HC696-1.16. Malling HJ, Gayraud J, Papageorgiu P, Hornung B, Rosado-Pinto J, DelGiacco SG. Objectives of training and specialty training corecurriculum in allergology and clinical immunology. Allergy.2004;59:579Y588. European Union of Medical Specialists AllergyTraining Syllabus. Approved by UEMS Allergology and ClinicalImmunology Section and Board: 07.06.2003. Available at:www.worldallergy.org/allergy_certification/index.shtml.17. Shearer WT, Buckley RH, Engler RJ, Finn AF Jr, Freeman TM, et al.Practice parameters for the diagnosis and management ofimmunodeficiency. The CLI Committee of the AAAAI. Ann AllergyAsthma Immunol 1996;76:282Y294.46 * 2008 World Allergy OrganizationCopyright @ 2008 World Allergy Organization. Unauthorized reproduction of this article is prohibited.

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