CCI - Training requirements

Training requirements for the speciality of Allergy and Clinical Immunology within General Internal Medicine

Training requirements for the speciality of Allergy and Clinical Immunology

within General Internal Medicine

1. Definition of the specialty
Clinical Immunology is that section of general internal medicine which specializes in disorders resulting from defects or abnormal functioning of the immune system. Specific disorders are: immune deficiencies, autoimmune diseases and vasculitides, and diseases related to hypersensitivity reactions. This last category has traditionally come under the sub-specialty of allergy. Transplantation Immunology is also classified under Clinical Immunology. The specialty is also concerned with correct treatment indication and with the interpretation of immunology laboratory results for diagnosis and follow-up, and responsible application of immune-modulating therapies. Given the broadness of the specialty there is a varying amount of overlap with other specialties within general internal medicine, and also with other specialties, in particular Rheumatology, Dermatology, Ear, Nose, Throat (ENT) and Pulmonary Diseases. For professional and organizational reasons it is desirable that the relationship between Clinical Immunology and Allergy should be as clear as possible. The training programme for the specialty of Allergy and Clinical Immunology includes a common component and two specializing streams, subsequently referred to as Clinical Immunology and Allergy respectively. In order to make the sub-specialties recognizable to patients and other medical disciplines, these two specialist physicians with sub-specialties are referred to as ‘physician specializing in clinical immunology, with a demonstrable interest in allergy' and ‘physician specializing in allergy, with a demonstrable interest in clinical immunology' respectively.


2. Description of the tasks of a physician specializing in Allergy and Clinical Immunology
A physician specializing in Allergy and Clinical Immunology has in-depth knowledge of the structure and function of the normal immune system and the pathophysiology of diseases caused by disorders of this system. He or she also has knowledge of allergic reactions in various organ systems and the specific problems that accompany them, and knowledge of allergy-related aerobiology. He or she has specific expertise relating to immunology laboratory diagnosis, the techniques used in this context and the interpretation of results in relation to clinical questions. He or she also has knowledge regarding the execution and interpretation of allergy provocation tests. He or she has expertise relating to the treatment of the immunologically mediated disorders described above and has understanding of and experience with immunomodulatory therapies. He or she is a partner in discussions with other specialties which frequently require expertise relating to Clinical Immunology and Allergy, such as Rheumatology, Neurology, Pulmonary Diseases, Cardiology, ENT, Ophthalmology and Dermatology.

3. Training programme
3 a. Previous training
The trainee must have completed at least four years of the training programme for physicians, including the compulsory internships in consultative work, outpatients' clinic, pulmonary diseases and intensive care. The ‘free year' in the internist's training programme may not be included.

3 b. Compulsory internships
The programme must include the following components:
- A four-month laboratory internship at a medical immunology laboratory and functional laboratory for allergies to become familiar with laboratory techniques and laboratory diagnosis for disorders relating to Allergy and Clinical Immunology and with monitoring immunomodulatory therapies.
- A four-month internship involving in-patient and outpatient work relating to Clinical Immunology. Specifically this will entail the diagnosis and treatment of immunologically mediated disorders such as immune deficiencies, autoimmune diseases and vasculitides. During this period the trainee will be responsible for the daily care of the in-patients. In addition, during the entire period he or she will carry out outpatient and consulting work relating to Cinical Immunology for other specialties as well as internal medicine. There should also be an opportunity at this stage for the trainee to be present during case discussions at a transplantation ward.
- A four-month internship involving in-patient and outpatient work relating to allergy medicine. During this period the trainee will gain experience in the diagnosis and treatment of patients with allergic disorders. If a training institute is unable to provide an internship, another accredited training programme in Allergy and Clinical Immunology may provide the internship or in consultation with the Board of the Division an allergy specialist or clinical immunologist not designated as a trainer may be asked to provide an internship as a temporary solution.


For the remainder of the programme the two specialties follow separate paths:

- The trainee ‘physician specializing in Clinical Immunology with a demonstrable interest in allergy' goes on to work in clinical immunology on hospital wards and at outpatient clinics for 12 months. During this period the trainee will follow an internship on a rheumatology ward - if he or she has not already done so - in order to gain optimal training in the diagnosis of joint disorders. The trainee must also be provided with an opportunity to do an internship of about four months on a transplantation ward.
- The trainee ‘physician specializing in allergy with a demonstrable interest in clinical immunology' goes on to do a 12-month internship on hospital wards and at outpatient clinics, during which he or she gains experience in the diagnosis and treatment of patients with allergy disorders. During this period he or she does a two-month internship on a dermatology ward accredited by the Medical Specialists Registration Board (MSRC)( and a two-month internship on an MSRC-accredited ENT ward. During the entire outpatient period of the training programme the trainee will also maintain intensive contact with the functional examination department.

During the entire period the trainee internist must participate in multi-disciplinary case discussions and discussions about laboratory diagnostics and must also be actively involved in discussions of literature.

3c. Short courses
During the programme all trainees will receive theoretical training organized not only through the normal routes (academic associations) but also through national courses in each of the specialties, for example an annual course which alternately examines all aspects of Allergy and Clinical Immunology.

3d. Scientific research
The training programme must include patient-based and possibly also fundamental immunological research. During his or her training, the trainee specialist must publish an article relating to allergy or clinical immunology in a national or international journal and must present a paper to an academic society. At least twice during the training period he or she must participate actively in a national and an international course or conference. Preferably the components of the training programme should be completed during one consecutive period. Programme components may be split or combined, provided the duration and relative difficulty match the criteria set out above. If the trainee in question is doing a PhD in clinical immunology or allergy, the programme components may be spread over a longer period, but about 50% of the trainee's time must be spent on the training programme.

4. Training department and staff
4a. Training department
The training department must have outpatient facilities for patients with immunologically mediated disorders at its disposal. The department must also have access to inpatient facilities for these patients. The department must have access to a medical immunology laboratory, or to laboratories where immunological diagnostics are conducted, and to a functional examination laboratory for allergy diagnostics. Arrangements must be made with these laboratories for a training programme for the trainee allergy specialist or clinical immunologist. The department must have a library at its disposal with a number of standard works and academic journals relating to allergy and clinical immunology. Literature discussions must take place at least once a month. The hospital where the training department is based must have accreditation for training in general internal medicine for at least four years.

4b. Staff
The training department must be headed by a physician specializing in Allergy and Clinical Immunology. At least one other physician specializing in Allergy and Clinical Immunology must be present. Training in one of the specific sub-specialties will be in the hands of a trainer who has had training in this sub-specialty (specifically, allergy training will be provided by an allergy specialist and training in Clinical Immunology by a clinical immunologist). A physician specializing in clinical immunology will be responsible for the clinical immunology internship in the allergy sub-specialty. A physician specializing in allergy will be responsible for the allergy internship in the clinical immunology sub-specialty. The staff members of the department must publish in scientific journals and regularly attend conferences and meetings relating to clinical immunology and allergy. If a training institute is unable to arrange an internship, an allergy specialist or clinical immunologist from elsewhere who has not been designated as a trainer may provide the internship as a temporary solution. However, Division Management must approve this arrangement. See also 3b.

5. Recognition of the programme
A department may be recognized as a training department for the specialty within internal medicine of Allergy and Clinical Immunology if it meets the requirements set out in 4a and 4b. It is possible for a department to be recognized for one of the two sub-specialties.

A department must apply to the Board of the Dutch Society of Physicians for recognition, and recognition is granted by the Concilium Medicinae Internae, on the recommendation of the Division of Allergy and Clinical Immunology within Internal Medicine. Six months before the visitation of the Internal Medicine programme, the training programme for the specialty will undergo visitation by two members of the Department of Allergy and Clinical Immunology. If neither of the assessors is a member of the Concilium, a member of the Concilium will be added to the visitation committee. If possible a trainee in the specialty will also participate in the visitation. The Department of Allergy and Clinical Immunology consists of the academic trainers in Allergy and Clinical Immunology trainers plus two peripheral physicians specializing in Allergy and Clinical Immunology.

6. Registration, certificates
A physician who has completed a training programme meeting the training requirements for the specialty of Allergy and Clinical Immunology set out in 3a-3c above may register as a ‘physician specializing in Allergy and Clinical Immunology within internal medicine' (‘internist met het aandachtsgebied Allergologie en Klinische Immunologie binnen de Inwendige geneeskunde'). Recognition is granted by the Division of Allergy and Clinical Immunology, on the recommendation of the allergy and clinical immunology trainer. The physician's name will be entered in a register kept by the Dutch Society of Physicians. As proof of his or her registration, the allergy specialist-clinical immunologist is given a certificate. In view of the fact that the Central Board has granted title protection to the title of ‘Physician specializing in Allergy', this protection remains in full force for a specialist with the sub-specialty of Allergy. Registration is renewed every five years by the Department of Allergy and Clinical Immunology provided the conditions set out in 4.7 have been satisfied. For members of the Netherlands Society of Physicians registration and re-registration are free of charge; for non-members there are charges.

7. Refresher courses
A physician specializing in Allergy and Clinical Immunology will remain registered if the following requirements are met:

1. the specialist works at a centre with sufficient outpatient and inpatient facilities for the
diagnosis and treatment of allergic disorders and disorders relating to clinical immunology, while participating actively for at least 12 hours a week in relevant patient care.
2. the specialist has access to a centre with a laboratory which actively follows developments in
medical immunology and participates in national consultation and quality assurance
programmes regarding laboratory research in medical immunology.
3. the specialist must prove to have participated in sufficient refresher activities relating to
Allergy and Clinical Immunology. Apart from postacademic training this may include attending reference meetings at university training clinics or participating again for a few days at a university training clinic.

 

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