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Training outside the thymus - journey to clinical immunology

Dr Magdalena DziadzioOn 28 June I completed my specialist training in immunology and was signed off as competent by a panel of senior colleagues. What a strange feeling: a shake of hands, smiles in the room, congratulations, and off I went. It was over! It is still difficult to believe I am a clinical immunologist now, after a long and challenging journey, which felt like a 3000m steeplechase – you have to jump over hurdles, you inevitably end up in the water, you sweat, you may fall, you get tired but, you eventually get there, after 7 and a half laps.

What’s involved?

Specialist training in immunology in the UK is very demanding; it requires much skill and commitment from those who embark on this path. One is required to pass the notoriously tough FRCPath exam, which comprises two parts and four components, with written essays, laboratory practical, viva and a casebook. If you are fortunate to have a recent PhD in immunology you may apply to submit your thesis instead of the casebook. Additionally, I took the excellent Medical Immunology MSc course at King’s College London to build up my scientific knowledge of the subject.

Trainees prepare for their exams while developing their clinical skills looking after patients with primary and secondary immunodeficiencies and allergic diseases. We learn to deliver immunotherapy, test for drug allergy, and perform desensitisation and food and drug challenges, on top of caring for patients receiving immunoglobulin replacement therapy. We are also required to be knowledgeable in the fields of connective tissue diseases, vasculitis, and solid organ and bone marrow transplantation. Training in administering biological therapies, for example, omalizumab, infliximab or rituximab is also required.

As clinical immunology is a pathology specialty 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 gain experience in other centres. Dr Joanna Sheldon, a Consultant Clinical Scientist at PRU, St George’s Hospital, helped many of us prepare for the laboratory component of the FRCPath exam.

Multidisciplinary speciality

Clinical immunology is a multifaceted specialty and we often work in teams with other clinicians, clinical and biomedical scientists, and academics. In fact, another 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 genes responsible for PID seem to be identified every month. PID 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’. It’s worth noting that immunology is not parochial; collaboration to determine genetic defects and their functional significance extends through the UK and into Europe. Trainees at the Royal Free benefited from having an opportunity to directly learn from Professor Bodo Grimbacher, a renowned scientist and clinician from the Centre for Chronic Immunodeficiency, Freiburg.

Some of our patients with an umbrella diagnosis of antibody deficiency are now characterised with genetic mutations accounting for their disease. So, learning from our patients we can recognise what phenotype is associated with a gene defect, unlike in the past when we had to rely on animal models to predict what would happen in humans. Many immunology trainees develop passion for research during training and they take time out of their training to obtain a PhD or MD degree.

The immunology speciality is very small and there are about 20 training centres in the UK with approximately 30–40 trainees. Therefore, to exchange ideas and to get to know fellow trainees, we attend ‘hitchhiker’ training days. These topic-based training events give us an opportunity not only to learn but also to network, and to share advice to defeat the much dreaded FRCPath examinations.

Why clinical immunology?

So, you may ask, who wants to embark on the very difficult and very demanding training in clinical immunology, knowing that other medical specialties are more straightforward with much easier exit exams and more jobs waiting?

I became fascinated by immunology in the early nineties while training in internal medicine at the University of Ancona, 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 inspired me and encouraged 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.

I have shared insights from my fellow trainees in this article. I think we all agree that clinical immunology is a holistic speciality and a close link between clinical practice and research and basic science is essential. The opportunity to provide a more individualised and less rushed clinical contact with our patients is a bonus.

I hope that this article will inspire medical students and junior doctors to embark on this fascinating, tortuous, trek through clinical immunology training. I have met many extraordinary people who have chosen this specialty and I was privileged to train with them. I am certainly very grateful to Dr Ronnie Chee, my Educational Supervisor, for his guidance and support throughout my training. I am looking forward to my next challenge as Consultant Immunologist and Allergist at UCLH, where I will complement a multidisciplinary team of specialists.

Dr Magdalena Dziadzio
Consultant in Immunology and Allergy at UCLH
Previously Specialist Registrar in Immunology at the Royal Free Hospital

Other trainees' experiences

I became an immunologist because this speciality married my interests of clinical care and biological sciences. The rewards and challenges go hand-in-hand in clinical immunology and, being a diverse speciality, it requires an in-depth specialist knowledge of allergy, autoimmunity, immunodeficiency and laboratory medicine; good clinical, laboratory and time management; and all the clinical skills of medicine. There are all the research and academic opportunities and the need to 'keep up to date' in such a developing field. These factors keep it interesting but are also very demanding. I enjoy meeting other immunologists who are a bunch of chatty nerds

Dr Tanya Coulter (Dublin)

I wanted to pursue a medical career with a strong scientific basis, and with the potential for research. Immunology and allergy seemed to be the most dynamic and interesting of the areas. I enjoy the fact that I can engage with one patient for a longer period of time; I appreciate a holistic approach towards patients as the immunological disorders tend to present as multisystem disease; I also value the fact that a career in clinical immunology facilitates a good work–life balance.

Dr Nada-Lee Al-Muhandis (Hull)

Immunology impacts on every part of the human body, and that this makes clinical immunology the only truly ‘multi-organ specialty’. I like the challenge of being in a young evolving specialty where much is still to be found out; with small patient groups we have to be more flexible as there will never be the numbers to conduct robust clinical studies, unlike in other diseases.

Dr Arthur Price (Leicester)

 I was fortunate during my foundation years to have a placement in immunology and rheumatology at Manchester Royal Infirmary Hospital. I was inspired by Dr Matthew Helbert, consultant immunologist, my mentor, to look into a career in immunology. I value the chance of combining clinical, academic and laboratory fields and working in a rapidly advancing specialty with cutting-edge science. I enjoy working as part of a multidisciplinary team, providing integrated care for patients. I feel that working within a small speciality enables me to get to know my colleagues both on a national and international level.

Dr Shuayb Elkhalifa (Manchester)

I specialised in clinical immunology in Slovakia, and am currently working as an SpR at the Royal Free Hospital in London. Having had the opportunity to practice immunology and allergy, I’ve always felt more attracted by immunology, as being an incredibly fast-advancing interdisciplinary field. In my opinion, the complexity, broad spectrum and constant development makes clinical immunology a great multidisciplinary tool, continuously enriching medical knowledge, giving possibilities and hope to treat or even cure what has not been possible so far. I am fascinated by what our understanding of the immune system has already taught us, and what new diagnostic treatment options it can offer in the near future.

Dr Jaroslava Orosova (London)