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A & I Fellowship - Clinical Rotations

The required and elective clinical rotations are performed at the following components of the University of Washington Allergy and Immunology (A&I) training program:

University Rotations

University of Washington Medical Center (UWMC), Seattle, WA

UWMC is a 450-bed teaching and research hospital offering comprehensive care including complete medical, surgical, ob-gyn, and psychiatric services and is rated as one of the top-10 hospitals in the U.S. Adult Asthma and Allergy clinics are located at UWMC. Patients are referred from the UW Medicine sites and from community practitioners from the Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) region. UWMC offers A&I fellows a wide mix of inpatient and ambulatory patients referred from primary care to specialized tertiary care, plus opportunities for research. Fellows gain exposure to the most severe/complex cases of asthma and other allergic disorders. Elective rotations are available in related specialties and training in clinical immunology laboratory methods is provided.

Seattle Children's Hospital (SCH), Seattle, WA

The SCH Immunology Clinic, a national referral center for pediatric and adult patients with primary immunodeficiency disorders (PIDD), is the primary site for training A&I fellows in the evaluation and treatment of patients with PIDD including use of IVIG, immunomodulators, and bone marrow transplantation for severe combined immune deficiencies (SCID) or SCID-like disorders. SCH subspecialty clinics provide exposure to both rare and common pediatric immune-mediated and allergic diseases not available at any other location in the region. SCH also provides an inpatient environment where fellows directly participate in the management of pediatric A&I patients including children with severe asthma.

Harborview Medical Center (HMC), Seattle, WA

HMC is a King County-owned medical facility operated by UW. This major UW facility has unique features, including a regional trauma center and an ethnically and socially diverse population. Of note, the Occupational Medicine and Environmental Health elective at HMC is centered around regularly scheduled diagnostic and surveillance outpatient clinics and an environmental challenge chamber is available for occupational agent provocation testing. Residents rotating through the HMC Dermatology Clinic gain experience in patch testing in the evaluation of contact dermatitis. Elective rotations in other related specialties are available including Pulmonary Medicine with Pulmonary Function Laboratory and Rheumatology.

Military Medicine Rotations

Madigan Army Medical Center (MAMC), Tacoma, WA

MAMC has a beneficiary population exceeding 350,000 within a six-state region and ~120,000 soldiers, family members, and retirees in its 40-mile catchment area. MAMC (350 physician staff) averages 821,000 outpatient visits per day with 126 inpatients per day. The MAMC A&I clinics are staffed by 2 ABAI-certified A&I attending physicians and both pediatric and adult patients are seen. As part of he allergy and immunology clinics, is the vaccination clinic where routine and biodefense (e.g., smallpox and anthrax) vaccines are administered. Since MAMC A&I clinics treat patients from outside the Pacific Northwest, skin testing includes a wider geographic range of aeroallergens and desensitization strategies (e.g. fire ant immunotherapy) than at other UW A&I teaching sites.

Community Medicine Rotations

Northwest Asthma and Allergy Center (NAAC), Seattle, WA

NAAC is a multi-center, private A&I practice in Seattle with satellite clinics throughout Puget Sound and has 12 ABAI-certified A&I specialists who are clinical faculty at the UW School of Medicine and its affiliated hospitals. There are annually ~70,000 patient visits in the Puget Sound NAAC clinics with ~50% of the patients pediatric. NAAC clinic assignments provide the A&I residents with experience with protocol-driven diagnostic and therapeutic approaches to an efficient, patient-oriented clinical practice. NAAC also provides experience in diagnosis and management of vocal cord dysfunction including performance of rhinolaryngoscopy, methacholine challenge, and free running exercise challenge. Exposure is provided to the conduct of clinical research trials in asthma and allergy.

Virginia Mason Medical Center (VMMC), Seattle, WA

VMMC is a large private, non-profit organization based in Seattle with over 390 physicians offering both primary and specialized care, a regional network of neighborhood clinics, and 336 bed hospital. The VMMC clinic is staffed by 3 ABAI-certified A&I attending physicians who see both adult and pediatric patients. The A&I service is integrated with the Rheumatology service such that A&I residents also gain exposure to the diagnosis and management of patients with rheumatologic disorders. VMMC provides an important teaching venue for patient oriented clinical practice including training in appropriate coding, documentation, and billing. Opportunities for research are with the Division of Basic Immunologic Research in the Division of Clinical Immunology at VMMC.

Allergy, Asthma, and Immunology Center of Alaska (AAICA)

Allergy, Asthma, and Immunology Center of Alaska (AAICA) is a multi-center, private A&I practice in Anchorage with satellite clinics throughout Alaska and has 5 ABAI-certified A&I specialists, a physician assistant, a speech pathologist, and a diet therapist. AAICA Director Jeffrey G. Demain, MD is UW Clinical Associate Professor of Pediatrics (WWAMI Program) and is also an Adjunct Professor at the University of Alaska. There are annually >5200 patient visits in the Anchorage clinic location with ~35% of the patients pediatric. AAICA clinic assignments will provide the A&I residents with experience with protocol-driven diagnostic and therapeutic approaches to an efficient, patient-oriented clinical practice encompassing allergy, asthma, and immunology problems, including: allergic rhinitis, asthma, food allergy, immunodeficiencies (chronic infections), bee/wasp/yellow jacket/ant venom allergy, latex allergy, reactions to medications (e.g. penicillin, local anesthetics), reactions to immunizations, urticaria and angioedema, allergic fungal sinusitis, as well as other allergy-related problems. AAICA provides experience in diagnosis and management of vocal cord dysfunction with a certified speech-language pathology practitioner. The rotation will provide UW AI trainees experience in meeting Healthcare Disparities since AAICA has a large Alaska Native patient population that it serves.

 

Overall goals and objectives of clinical rotations for years 1 and 2 of training are as follows:

University Allergy Clinics

Goals: In-depth analysis of a smaller number of patients with more complicated problems; exposure to unique problems that would not necessarily be seen in a community practice; exposure to patients with more severe problems who have failed therapy in a community practice.
Objectives: learn advanced techniques for diagnosis and management of more complicated patients and problems; learn appropriate use of other university subspecialists and coordination of care; become familiar with translational care, bringing the bench science to the bedside; learn how to interact with referring physicians. Since internal medicine, pediatric, and family medicine residents and medical students rotate through these clinics, the A&I fellows have the opportunity to do teaching.

University Immunology Clinics

Goals: in-depth exposure to a wide variety of patients with suspected and proven immunodeficiency disorders.
Objectives: learn the indications for evaluation for immunodeficiency, the appropriate initial and secondary laboratory evaluations; learn specific physical exam for signs of immunodeficiency or specific immunodeficiency disorders; learn the appropriate use of IVIG, bone marrow transplant and potentially gene therapy; learn appropriate F/U for immunodeficient patients; perform inpatient and outpatient consults on patients with suspected or known immunodeficiencies; complications of immunodeficiency therapy.

University Subspecialty Rheumatology, Dermatology, Pulmonology Rotations

Goals: Exposure to a wide variety of patients with a broad spectrum of disorders that could present to the allergy office.
Objectives: learn an approach to the evaluation of problems that are not typical allergy problems, including appropriate laboratory evaluation and referral; learn specialty physical examinations; learn appropriate use of laboratory tests that are not common in an allergy practice; learn what patients should be referred and who can be cared for in an allergy practice.

University Otolaryngology Clinics

Goals: exposure to a different viewpoint on the management of patients with allergic or infectious problems that can be managed in the allergy office.
Objectives: learn subspecialty surgery exams; learn appropriate indications for surgery; become familiar and observe specific surgical procedures for problems that are commonly seen in an allergy office.

University Pulmonary Function Laboratory

Goals: familiarity with the use and performance of a variety of pulmonary function techniques.
Objectives: learn the appropriate tests to order for a given disorder or differential diagnosis; learn what tests are useful in distinguishing disease states; learn to interpret results of such tests.

University Laboratory Immunology

Goals: exposure and hands-on experience with a wide variety of clinical laboratory immunology procedures.
Objectives: learn the principles behind various tests; clinical indication for certain tests; techniques used to perform tests; limitations and problems with certain tests; interpretation of results.

Military Allergy Clinics

Combines some of the goals and objectives of community practices and university clinics with the additional experience of global health issues, international environments and exposures, bioterrorism issues and vaccination practice and adverse effects. In particular, MAMC treats soldiers and their families who have lived throughout the world due to assignments across the U.S., Asia, Middle East, Europe and other regions. This gives the residents exposure to patients who present with unusual infectious process and immune dysregulation. Highly mobile population of military patients typically have exposures to greater variety and different regional aeroallergens than is seen just in the Northwest. Residents are taught regional differences in the U.S. and how to write allergen immunotherapy to patients based on different geographic locations such as for fire ant hypersensitivity that is not seen frequently in the general Northwest population. Due to high risk of biologic weapons, army soldiers deploying receive smallpox and anthrax vaccinations. Residents are exposed to management of adverse effects with these and other vaccines. Residents have exposure to travel medicine and assessing for travel immunizations.

Community Allergy Practices

Goals: exposure to a large number of patients with a wide variety of allergy problems. Experience a variety of practice styles and practice models. Development of the skills necessary for the community practice of allergy, including business models.
Objectives: learn the keys to specialty history taking and physical examination; develop differential diagnoses for a specific clinical problem; become familiar with community and referral sources; learn appropriate tests including skin testing; develop management plans for a variety of problems; learn the prescription and preparation of immunotherapy sets, advancement protocols and maintenance doses, adjustment of dosing; become familiar with the principles of clinical research and design of protocols for research concepts.

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