Beyond the textbook: the challenges of learning (and teaching) basic immunology in allergy-immunology training programs

For incoming allergy-immunology fellows, learning basic immunology is daunting due to the complexity of the topic and limited exposure during undergraduate medical education. Allergy-immunology exposure is also limited during primary residency training, especially for trainees from programs without an allergy-immunology training program.¹ A lack of educational infrastructure for immunology in graduate medical education (GME) results in self-directed learning and inconsistent knowledge in spite of the broad framework provided by certification boards. A standardized basic immunology curriculum does not currently exist.

The pace of immunology advancements, therapeutics and knowledge generation further compounds these challenges. In 1950, medical knowledge was estimated to double in 50 years. In 1980 the doubling rate was 7 years, and in 2020 medical knowledge is projected to double every 73 days.² An average of 46 new biologic and small molecule therapies have been approved annually by the FDA’s Center for Drug Evaluation and Research.³ The rapid pace of drug and disease discovery, including newly described inborn errors of immunity, makes staying current increasingly difficult.⁴ Furthermore, a new era of secondary immune dysregulation syndromes has emerged with the use of novel therapeutics. This expansive subject matter is daunting for educators and learners alike. As such, it is increasingly unrealistic to expect incoming trainees to master immunology using only a textbook, especially as the textbooks often do not contain recently discovered new information. Given the importance of a robust understanding of basic immunology for Allergy and Immunology (A/I) specialists, a better approach is needed.

At the meeting of the A/I Program Directors (PD) Assembly in Atlanta, Georgia in January 2024, the topic of teaching basic immunology was presented and discussed. The session covered adult learning strategies and best-practices in immunology education, innovative teaching approaches for engagement, and unmet needs for the specialty.

A survey was taken of the attendees which generated several important observations. There were 59 respondents from the 88 training programs in the United States. Most respondents were PDs (60.7%), while others served as associate program director (APD) or other clinical teaching faculty. Most participants in the session were in the 36–45 age range (51.1%), followed by 46–55 (29.8%). Accordingly, a significant proportion (44.8%) had been in the role of teaching faculty or PD/APD for <=3 years, followed by 19.4% having 4–6 years of experience, 26.8% with 7–12 years of experience, and only 9% of PDs having greater than 12 years of experience. Although there is a range of experience across programs, it is noteworthy that >60% of PD/APDs have 6 or fewer years experience as educators.

Most programs reported matriculating 1–2 clinical fellows per year (71.7%). In-person lectures were common (62.5%), with 23.2% utilizing predominantly virtual or hybrid formats. PDs or core faculty teach immunology in most programs (47%), with 41% of programs utilizing other basic or translational research faculty in immunology. Just 5% reported fellow-only led sessions. A significant number of programs reported using a flipped classroom approach, employing asynchronous pre-reading followed by in class discussion or problem-based formats, either frequently (36%) or almost all the time (36%). Respondents universally indicated that the need to develop a universal/core immunology video series as urgent and important.

Improving the pedagogical approach to immunology education requires knowledge of adult learning theory concepts. Diverse instructional practices and examples of how to apply learning concepts to curriculum development were discussed. Strategies employed at training programs included integration of gaming elements (e.g., Kahoot!, Jeopardy, card games, polling) to foster competition or collaborative learning. Some educators developed brief reviews designed for easy learner engagement, while others utilized 2D or 3D printed models to allow learners to physically interact with models to demonstrate knowledge, for example changing cell surface receptors on a T cell to show the various subsets and their development.

One of the core tenets of adult learning theory is making new information relevant to the learner. For example, using genetic variants to describe downstream clinical effects can help learners apply the knowledge in a clinical context. Additionally, applying evidence-based teaching approaches as outlined in Table 1 to immunology instruction can improve understanding and retention of these challenging concepts. As substantial differences in exposure to core clinical content (e.g., for rare conditions) exist across programs, innovative teaching approaches are needed to enhance retention of concepts that cannot be learned at the bedside, or where exposure to rare cases might vary even between individual trainees in a program. While teaching and learning immunology has become increasingly complex, technological advancements and the ability to collaborate across programs in web-based content creation has continued to grow.

Table 1.

Summary of learning concepts applied to immunology education

Learning Concept	Definition	Example
Retrieval Practice	Asking learners to recall/report/demonstrate material learned in a prior session.	Instead of “recapping” key aspects of the previous lecture on antigen presentation, ask learners to describe two important learning points from the prior lecture.
Spaced Learning	Shorter learning segments spaced over a longer interval. Spacing of information improves retention in contrast to cramming.	Cover primary IEI and secondary immunodeficiencies (including the role of immunosuppressive medications), over the course of several weeks or months.
Interleaving	Multiple different concepts are reviewed/learned intermixed instead of in a block.	Discuss B cell development, receptors and function during discussions of antibody development, VJ rearrangement and receptor signaling.
Elaboration	Encouraging learners to explain and describe ideas in detail.	Learners are asked to explain the differences between Type 1 and Type 2 responses.
Dual Coding	Combining verbal information with visual elements for better understanding.	Use diagrams and charts alongside explanations of T cell signaling to enhance comprehension.
Concrete Examples	Providing specific instances or cases to illustrate abstract concepts.	In an immunology lecture, use applied examples such as specific diseases or vaccine development to illustrate principles.
Metacognition	Encouraging learners to reflect on and monitor their own thinking processes.	Prompt learners to reflect on their thought processes, identifying strategies that help comprehension.
Flipped Classroom	Moving from lecture-based knowledge transfer to higher order discussions or interactive sessions during classroom time.	Providing pre-reading on complement pathways followed by case-based problem solving of complement disorders in groups during learning sessions.

Educating the next generation of allergists-immunologists is one of the most important obligations for individual PDs and teaching faculty. Yet, keeping core faculty abreast of changes in clinical immunology poses significant challenges. Pairing basic immunology researchers with contemporary knowledge of immune mechanisms and research techniques with an experienced clinician-educator to bridge basic concepts to clinical disease states may solidify understanding, for e.g. in the context of genotype and phenotype correlations. This “bench to bedside” approach can be incorporated into a flipped classroom in case based approaches that may enhance retention. Interdisciplinary education from adjacent specialties, such as hematology-oncology specialists working with CAR-T cell therapies, can provide valuable context for emerging immunologic and therapeutic developments. In many cases, allergist-immunologists play an important role in contextualizing immune mechanisms, understanding off-target effects of prescribed therapies, and exploring potential treatment options or monitoring based on disease mechanisms.

In response to the need for a comprehensive curriculum, as outlined in the recent survey of PDs/APDs, a majority of whom are early faculty, the AAAAI Program Directors Executive Committee is actively pursuing development of a series of immunology concept videos that would provide a framework of core immunologic concepts as trainees start fellowship. Ensuring trainees have the capability to meet the increasing demand for applied immunologic knowledge is an essential priority. Incorporating adult learning theory strategies should be routinely used in teaching immunology and teaching faculty unfamiliar with these concepts would benefit from further training in their utilization.