As the Allergist World Rotates

By Dr. Paul Ehrlich

The new issue of the Annals of Allergy, Asthma and Clinical Immunology (published by the American College of Allergy, Asthma and Immunology [ACAAI] as distinct from the Journal of Allergy and Clinical Immunology published by the American Academy of Allergy, Asthma and Immunology [AAAAI]) has an article called “The value of an allergy and clinical immunology rotation at an academic tertiary medical center”. I salute the authors, Cindy Bauer, MD et al for this first-ever study of its kind, although the news is mixed. The authors say that rotations are not mandatory for medical students in most institutions, and that such rotations are not very extensive. “At the Medical College of Wisconsin (MCW), first- and second-year students receive minimal clinical AI education (2 hours on hypersensitivity disorders; 1 hour on immunodeficiencies) with moderate basic science instruction (9 hours of immunology; 6 hours of pharmacology of AI medications; and a 3-hour pulmonary function laboratory). Students and residents can rotate for varying durations in the combined pediatric/adult AI Clinic.” Among those who did these rotations at all institutions, “59% spent 1 to 5 days in AI, whereas the rest rotated 6 to 30 days. More rotations were elective (69%) (31% mandated/assigned as part of a curriculum).”

The students found the rotations very rewarding. Most thought they would be useful for their careers, and a third of those who completed rotations would consider fellowships. But the facts on the ground are not at all encouraging–the AAAAI website shows just 75 allergy fellowship programs serving MDs from the 141 medical schools in the country and DOs from 29 schools of osteopathy. California has 10 training programs, but just three serve ten other states in the west including Hawaii. And since the list was compiled, at least one program, at Long Island College Hospital in Brooklyn (founded by none other than Dr. Larry Chiaramonte) has now been absorbed by Downstate, which is part of the state university system, a few miles away. As we said in our book, the rate of replacement of the current generation of clinical allergists is falling short.

I know how this works. At NYU, there is no allergy department. I take as many residents as I can in my office, although I prefer not to have more than a dozen a year. (When the hospital was closed after Hurricane Sandy, however, a total of 22 residents worked with me over the months of rehab.) Most of them echo the findings of the study—they feel their rotations have been very valuable, and ten of them have chosen to go into allergy as a career over the past several years. Dr. Maureen Egan’s recent Q&A with us represents the best expression of the rewards of an allergy rotation.

Still, the feel-good implications of this story can’t be very heartening to anyone worried about the immune systems of the next generation. People ask us all the time, if allergies are increasing, shouldn’t more and more medical students go into it? Well, yes, but demand doesn’t drive supply in the short term. Medicine isn’t Walmart (and you’d better hope it doesn’t become that). Specialty practice remains a handmade product. If medicine is a healing art, technique is passed from one generation to the next by young artists apprenticing with older ones. And the quality of new practitioners will be determined in great part by those with whom they apprenticed. I know that young allergists from Mount Sinai will be experts on food allergies because that’s a big part of what they do. I can’t say the same for every program in the country.