Dr Magdalena Dziadzio
Consultant Immunologist, Department of Specialist Allergy and Clinical Immunology
What made you decide to undertake the Clinical Immunology speciality training?
I became fascinated by immunology in the early nineties while training in internal medicine at the University of Ancona in Italy. At that time the differences between Th1 and Th2 cells were the “hot topic” and I found it intriguing how immune polarisation determines clinical conditions. Like many of us, I was “infected” by the contagious passion for immunology in the department. Professor Giovanni Danieli, Professor of Internal Medicine, inspired me and encouraged me to undertake a PhD in Immunological Sciences, in addition to my specialist training in internal medicine. A sound knowledge of internal medicine was a massive help to me once I decided to pursue my passion for immunology and started my second specialist training - clinical immunology. Immunology is a rapidly developing field hence it keeps me interested all the time. I have not stopped learning about the mechanisms underlying human disease.
What does the training involve?
Specialist training in immunology in the UK is very demanding, and requires much skill and commitment from those who embark on this path. It lasts five years on average. You may work in one immunology department or rotate between centres for those who train in London. Trainees attend outpatient immunodeficiency and allergy clinics, Day Wards and look after the inpatients, usually together with other clinical teams. Most jobs do not have on-call commitments, but this varies between the centres and also may change over time. Some centres are highly specialist in one area, for example, immunodeficiency. Others are well–rounded and look after patients with immunodeficiencies, allergic conditions and vasculitides. Trainees participate in the work of the diagnostic immunology laboratory. Laboratory work requires a mind-set quite different to clinical work.
In addition, one is required to pass the notoriously tough FRCPath immunology exam which comprises two parts and four components: written essays (part 1), laboratory practical, viva and casebook (part 2). If you are fortunate to have a recent PhD in immunology or a good number of first-author relevant papers in the field of immunology, you may apply to submit your thesis instead of the casebook. FRCPath exams are run twice a year.
Trainees prepare for their exams while developing their clinical skills. We learn to manage complex patients with primary and secondary immunodeficiencies. We also train in allergy and learn how to diagnose and treat conditions such as allergic asthma, hay fever, and food, venom or drug allergy. We deliver immunotherapy and some also deliver drug desensitisation. We are also required to be knowledgeable in the connective tissue diseases and vasculitides. We become familiar with the management of patients after solid organ or haematopoietic stem cell transplantation. We administer immunoglobulin replacement therapy (IVIG and ScIg), and biologic therapies, for example, omalizumab, infliximab or rituximab.
As clinical immunology is a pathology speciality in the UK, we receive thorough core laboratory training. We become competent in laboratory management and learn to maintain quality and to deliver reliable results. But numbers are not enough – we report the results with clinical interpretation to guide our colleagues from other specialities. To gain the full range of laboratory skills, it may be necessary to obtain experience in laboratories at other centres. Dr Joanna Sheldon, a Consultant Clinical Scientist at PRU, St. George’s Hospital, has helped many of us to prepare for the laboratory component of the FRCPath exam.
The immunology speciality is very small and there are approximately 30-40 trainees across 20 training centres. Therefore, to exchange ideas from individual centres and to meet with fellow trainees, we attend so-called “hitchhiker” training days. These topic-based training events are hosted four times a year, in turns, by different training centres. These give us an opportunity not only to learn but also to network, to get to know each other and to share experience and offer advice to defeat the much dreaded FRCPath examinations.
What sets the clinical immunology speciality apart?
Clinical immunology is a holistic speciality and a close link between clinical practice and research as well as basic science is essential. We are lucky to work often within multidisciplinary teams with other clinicians, clinical and biomedical scientists and academics. Immunology is not parochial; collaboration to determine genetic defects and their functional significance extends through the UK and into Europe (at the moment…and overshadowed by Brexit). The opportunity to provide a more individualised and less rushed clinical contact with our patients is a bonus.
A fundamental aspect of our speciality is that our knowledge base is growing exponentially. Trainees must keep up-to-date with new developments, in particular in the field of primary immunodeficiencies, where new gene defects resulting in PID are identified every month because of new technologies such as next generation sequencing! This gives us a unique opportunity to learn from our patients and the typical pattern of “bench to bed” is more personal: “bed to bench and then back to the bed”.
So I believe, together with my fellow trainees, that our chosen speciality, clinical immunology, is fun, satisfying and intellectually challenging.
What additional courses or training are available?
Many immunology trainees develop passion for research during training and they take time out of their training to obtain a PhD or MD degree. I took the excellent Medical Immunology MSc course at King’s College London to build up my scientific knowledge of the subject. ACP “hitchhiker” training days mentioned above focus on the immunology curriculum and FRCPath exams. Trainees are encouraged to attend UK NEQAS laboratory quality meetings and the BSACI allergy training days run 3-monthly by the allergy and immunology centres.
There are lots of local network meetings which trainees are encouraged to attend and present at. More formally, national scientific meetings such as the British Society of Immunology Congress, the British Society of Allergy and Clinical Immunology Conference and the UK Primary Immunodeficiency Network Meeting, and international immunology and allergy meetings organised by ESID, EAACI or AAACI, are all fantastic arenas to gain insight into the ever-changing would of clinical immunology. Remember, learning never ceases; if you are tired of immunology you are tired of life.
What are the most important skills and experiences that have got where you are today?
I think the most important and useful thing is to have vast clinical experience in many fields of medicine but in particular in internal medicine as this facilitates the management of complex immunology and allergy patients. A PhD in Immunology or equivalent is very helpful to understand basic immunology with the laboratory research experiments setting the background for the understanding of the NHS immunology laboratory and the interpretation of results. Good understanding of genetics has become a fundamental requirement in order to understand primary immunodeficiencies. I think that curiosity and passion for knowledge are also fundamental to keep up with the exponential research findings and clinical developments. Interpersonal and communication skills are also very important as nowadays we more and more work in the multidisciplinary teams of doctors, nurses, other health professionals and scientists. Immunology is not different from other medical specialities, hence high work ethics and respect for patients and colleagues is a must.
Any tips or advice you would give to someone thinking of going into this type of career?
Potential clinical immunology trainees should try to spend some time in the immunology departments to understand the type of clinical and laboratory aspects of our day to day work. Immunology centres in the UK have a very different profile so it may be a good idea to visit more than one. It would be useful to talk to the current trainees to get some insight into training and the FRCPath exams. The BSI and UKPIN websites may also be useful. Training in Immunology will require lots of exam-focused learning during training. Exam fees need to be kept in mind as this may be a problem for some. If you do not like the laboratory medicine, then this speciality is probably not for you.