Introduction

General Competencies

Direct Patient Care Activities

Research and Scholarly Activities

Other Educational Activities

Evaluation of A&I Resident Progress

Program Objectives and Quality Assurance

Introduction
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This document and the July, 2003 ACGME Program Requirements for Residency Education in Allergy and Immunology comprise the goals and objectives for the University of Washington Residency Training Program in Allergy and Immunology (A&I).  Since A&I residents entering the training program will have had differing experiences during their medical training, the needs of each individual will necessarily be different.  Each resident will be assigned an advisor from the participating faculty.  A proposed schedule will be submitted prospectively by the advisor for approval by the A&I Training Program Committee.  This will allow the Committee to ensure that the resident's program is properly balanced, that the resident has the variety of experience required and will have made optimal use of the facilities offered by the academic environment.  Our goal is to prepare specialists who provide expert medical care for patients with allergic and immunologic disorders and who can serve as consultants, educators, and physician scientists in asthma, allergic disorders, immunologic disorders, and immunodeficiency diseases.  The primary patient base of the trainees' clinical and educational activities is as follows:  anaphylaxis, asthma, atopic dermatitis, contact dermatitis, drug allergy, food allergy, immunodeficiency, rhinitis, sinusitis, stinging insect hypersensitivity, urticaria and angioedema.  Resident experience with patients having the following disorders is strongly encouraged: autoimmune disease, bronchopulmonary aspergillosis, eosinophilic disorders, hypersensitivity pneumonitis, mastocytosis, ocular allergies, occupational lung disease, and vasculitis.  These goals can be achieved by patient contact, lectures, and/or reading.  

The resident will develop skills in skin testing, pulmonary function testing, immunotherapy, and other A&I procedures as described in the Program Requirements for Residency in Allergy and Immunology . The knowledge base presented to residents will include the etiology, immunopathogenesis, differential diagnosis, therapy, and complications of those A&I diseases listed above.  The following knowledge areas are included in the educational program:  1) Knowledge of aerobiology; cellular and molecular immunobiology; humoral and cellular immunology; pulmonary physiology; mechanisms of inflammation; pharmacology and pharmacokinetics, drug metabolism, drug side effects, and drug interactions; the scientific basis of the methodology, indications, and interpretation of laboratory tests and imaging procedures used in the diagnosis and follow up of patients with asthma, allergic, and immunologic and other diseases; preparation and standardization of allergen extracts; means to measure indoor allergens and institution of environmental control measures in the home and other sites; transplantation medicine and tumor immunology; reproductive immunology; the costs of therapy and diagnostic testing; and the psychological effects of chronic illness.  2) Knowledge of applied immunology, to include the principles and techniques of clinical immunology laboratory procedures such as tests for humoral immunity, cellular immunity, neutrophil function, cytokines, immune complexes, cryoprecipitable proteins, total serum complement activity and individual complement components, and histocompatibility, as well as procedures for the preparation and use of monoclonal antibodies.  3) Knowledge of the etiology, immunopathogenesis, differential diagnosis, therapy, and complications of those diseases referenced in ACGME Program Requirements.  4) Knowledge of controversial or unproven drug or therapeutic techniques in allergy, asthma, allergic disorders, immunologic disorders, and immunodeficiency diseases.  The manner used for achieving skills in these areas will be determined by A&I Training Program Committees based on the patient and teaching resources available to the University of Washington program.  The following are the general, allergy and immunology-specific, and professional competencies to be attained by our trainees:  

General competencies
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Residents must demonstrate the following general competencies to begin the independent practice of this specialty:

1. Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
2. Medical knowledge about established and evolving biomedical, clinical, and cognate (epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.
3. Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal, and assimilation of scientific evidence, and improvements in patient care.
4. Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals.
5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, and adherence to ethical principles, and sensitivity to a diverse patient populations.
6. Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of healthy care and the ability to effectively call on system resources to provide care that is of optimal value to the patient.

2.                  Allergy and immunology-specific competencies

Residents must be able to expertly and appropriately demonstrate the following allergy and immunology specific competencies to begin the independent practice of this specialty:

1. Conduct a comprehensive and detailed medical interview with children and adults who present with suspected allergic and/or immunologic disorders.
2. Perform a physical examination appropriate to the specialty.
3. Select, perform, and interpret diagnostic tests or studies.
4. Assess the risks and benefits of therapies for allergic and immunologic disorders (e.g., drug therapy, allergen immunotherapy, immunomodulatory therapy).
5. Counsel and educate patients about diagnosis, prognosis, and treatment.
6. Consult with and educate other physicians and health care providers.
7. Apply basic and clinical science to the clinical care of patients.
8. Coordinate the care of patients, including the use of consultations.
9. Analyze medical and other scientific literature
10. Design, conduct, write, and present research in either laboratory-based or clinical investigation in allergy and/or immunology.

3.                  Personal and professional competencies

Residents should demonstrate the following personal and professional characteristics:

1. Caring, altruistic, and compassionate behavior.
2. Honesty, integrity, and professionalism in relating to patients and other healthcare providers.
3. Acceptance of the need for a lifelong pursuit of excellence, self-directed learning and continuing education.

Ethical management of real and perceived conflicts of interest.

Direct Patient Care Activities
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The trainee must spend 50% of time in clinical education as direct patient contact in both the outpatient and inpatient settings, clinical care conferences, and record reviews.  Clinical training is divided between adult and pediatric allergy/immunology and related subspecialty fields.  Adult allergy/immunology clinics are held at the University of Washington Medical Center (UWMC), Harborview Medical Center (HMC), Fred Hutchinson Cancer Research Center (FHCRC), Northwest Asthma and Allergy Center (NAAC), Virginia Mason Medical Center (VMMC), Madigan Army Medical Center (MAMC), and Pacific Medical Center and Clinics (PMCC).  Pediatric allergy/immunology clinics are held at Children's Hospital and Regional Medical Center (CHRMC), NAAC, MAMC, and PMCC.  Trainees must spend 20% of the direct patient care activity time commitment in cross-training in both pediatric and adult allergy/immunology patients with a combination of ambulatory and inpatient experience.  Whenever possible, longitudinal follow-up of patients will occur.  During clinical rotations (including cross-training rotations), trainees are required to do inpatient consultations.  Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences.  Duty hours do not include reading and preparation time spent away from the duty site.  Duty hours are limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.  Residents are provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call.  One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.  A 10-hour time period is provided between all daily duty periods, and after in-house call.  The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period.  In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution.  In-house call will occur no more frequently than every third night, averaged over a four-week period.  Continuous on-site duty, including in-house call, will not exceed 24 consecutive hours.  Residents may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care.  No new patients will be accepted after 24 hours of continuous duty.  A new patient is defined as any patient for whom the resident has not previously provided care.  At-home call (pager call) is defined as call taken from outside the assigned institution with regard to at-home call.  1) The frequency of at-home call will not be so frequent as to preclude rest and reasonable personal time for each resident.  Residents taking at-home call will be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period; 2) When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit; and 3) The program director and the faculty will monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.  Residents must have personal responsibility for continuing patient care and must recognize that their obligation to patients is not automatically discharged at any given hour of the day or on any particular day of the week.  Depending on the trainee's prior medical or pediatric training, clinical electives are available at UWMC, HMC, FHCRC, and CHRMC in dermatology, gastroenterology/hepatology, hematology/oncology, transplantation immunology, HIV/infectious diseases, otolaryngology, occupational medicine/environmental medicine, pulmonary and critical care medicine with pulmonary function laboratory, rheumatology and vocal cord dysfunction.  Written documentation of each resident's ambulatory and inpatient clinical experience must be maintained by the fellow and the training program.  For ABAI certification, the resident must maintain a log book of procedures performed as outlined by the ABAI (attachment).

Research and Scholarly Activities
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The trainee must spend 25% of time in research and scholarly activities.  The research program involves the resident's direct participation in designing, conducting, and evaluating experiments and in preparing for presentation and publication, a basic or clinical research project.  Specific guidelines are described in the UW A&I Training Program Research Training Guidelines and as follows:  

1. Residents must be able to conduct a comprehensive literature search.

2. Residents must have the opportunity to design, write, review, or edit research protocols or plans.

3. Residents must demonstrate a working knowledge of research design, statistics, clinical trials, epidemiology, and laboratory research.

4. Residents must be able to apply the principles of data collection, data analysis and data interpretation.

5. Residents must conduct the research activity under proper supervision.

6. Residents must be able to communicate research findings orally and in writing.

7. Presentations at national meetings and publication in peer-reviewed journals are strongly encouraged.

Residents will be provided with a structured research experience sufficient to result in an understanding of the basic principles of study design, performance, analysis, and reporting such that:

The resident is expected to attend the A&I Journal Club sessions on Tuesday mornings at UWMC for all years of training, scheduled didactic/interactive sessions on A&I topics with A&I faculty, and other required conferences/seminars [e.g., UW Department of Immunology seminar series, Puget Sound Allergy Society, Northwest Allergy Forum, and American Academy of Allergy, Asthma, and Immunology (AAAAI) meetings].  It is expected that the trainee present their research findings at the annual meeting of the AAAAI or another major society if appropriate (e.g., American Association of Immunologists, American Thoracic Society/American Lung Association).  Significant progress toward publication of at least 1 paper in a refereed journal is also required.

Other Educational Activities
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The trainee must spend 25% of time in other educational activities as described in the Program Requirements for Residency Education in Allergy and Immunology.  The trainee may attend other pertinent conferences/seminars (e.g., UW Pulmonary Research Conferences, UWMC Medical Grand Rounds, CHRMC Pediatric Grand Rounds, and UW Department of Microbiology and Pathobiology seminar series).  The resident will take one or both of the following immunology courses:  a) Human Biology 523 (Introduction to Immunology) for those residents without a firm foundation in immunology and b) Immunology 532 (Advanced Immunology).  The trainee must complete the UWMC Clinical Immunology Laboratory rotation to acquire knowledge of principles, techniques and interpretation of clinical immunology laboratory procedures as outlined in the Program Requirements for Residency Education in Allergy and Immunology.  During the training period, the A&I resident is expected to read the following journals as a requirement:  The Journal of Allergy and Clinical Immunology, Journal of Immunology, and American Journal of Respiratory and Critical Care Medicine.  In addition, the resident should be familiar with pertinent A&I papers published in other journals such as The New England Journal of Medicine, Journal of Clinical Investigation, Nature, and Science.  The resident will also have access to Allergy Principles and Practice (Middleton et. al.), Immunological Diseases (Samter et. al.), Essential Immunology (Roitt), Allergy, Asthma, and Immunology from Infancy to Adulthood (Bierman, et al.), Fundamental Immunology (Paul), Immunologic Disorders in Infants and Children (Stiehm), and Allergy (Kaplan) for specialized sections.

Evaluation of A&I Resident Progress
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The resident's progress toward competence in A&I will be reviewed at six-month intervals by the UW A&I Fellowship Training Program and Advisory Committees.  The program director will discuss this evaluation with the resident and a written evaluation will be provided to the resident.  A final written evaluation will be provided for each resident who completes the program that includes a review of the resident’s performance during the final period of education and verifies that the resident has demonstrated sufficient professional ability to practice competently and independently.  The final evaluation will be a part of the resident’s permanent record maintained by the institution.  The residents will review the teaching of the program's faculty also at six-month intervals and complete an evaluation of the educational effectiveness of the program at the end of their two-year training period. 

Program Objectives and Quality Assurance
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Overall objectives for this residency include but are not limited to development and/or enhancement of a number of long term, critical skills: Communication, organizational, leadership, time management, prioritization, teaching, presentation, practice management/development, team building, evaluation, role modeling, stress management, business, literature evaluation, and database organization/management. 

We would like this residency to prepare our residents to be successful for careers in both academia as well as private practice depending on their priorities.  We would like this residency to provide our residents with realistic financial, professional, and personal expectations and to impart a clear understanding of health care reform, managed care, and practice organization.