An allergist is a physician who has successfully completed both a specialized training period in allergy and immunology and a training period in either internal medicine, or a sub-specialty of internal medicine such as dermatology, pneumology, or otorhinolaryngology, and/or pediatrics. Subject to national training requirements, allergists are also partially or fully trained as clinical immunologists, because of the immune basis of the diseases that they diagnose and treat. In most countries, the approved period of specialty training in allergy and immunology will be two to three years of specific, intense training. Depending on national accreditation systems, completion of this training will be recognized by a Certificate of Specialized Training in Allergy, in Allergy and Immunology, or in Allergy and Clinical Immunology, awarded by a governing board. In some countries this will follow successful completion of a certification test, and in other countries by competencies being signed-off by a training supervisor.
Fully trained allergists make an important contribution to designing local care systems and delivering the necessary care for patients with allergic diseases. Allergists act as advocates for patients, and support and argue the case for better education of the primary and secondary care physicians and other health care professionals who also care for allergic patients. Allergists should be available to provide care for the more complicated problems that are beyond the purview of well-trained primary and secondary care physicians and other health care professionals. The main defining characteristics of an allergist are the appreciation of the importance of external triggers in causing disease, and the knowledge of how to identify and manage these diseases, together with ex-pertise in appropriate drug and immunological therapies. This approach to diagnosis and therapy is a core value of the allergy specialist, and contrasts the allergist with many of the organ-based specialists whose patient bases may overlap with the specialty.
The unique training requirements for an allergist are detailed in "Requirements for Physician Training in Allergy: Key Clinical Competencies Appropriate for the Care of Patients with Allergic or Immunologic Diseases: A Provisional Position Statement of the World Allergy Organization."[1] In that document, the levels of allergy training required of first-, second-, and third-level physicians are documented, differentiating the training and knowledge base of an allergy specialist from that of primary care physicians and organbased specialists. The American Academy of Allergy, Asthma and Immunology has also published guidelines: "Consultation and Referral Guidelines Citing the Evidence: How the Allergist/Immunologist Can Help."[2] The European Union of Medical Specialists Allergy Training Syllabus [3,4] is available online at the World Allergy Organization Web site:http://www.worldallergy.org/allergy_certification/index.shtml.
Defining the allergist
The allergist is a physician who has a broad range of highly specialized clinical and diagnostic skills and a strong knowledge base covering:
Disease manifestations, including those for every allergic, immunologic and overlapping disease, and the cellular basis of immune and allergic reactions;
Rhino-conjunctivitis
Sinusitis
Otitis
Asthma
Cough
Bronchitis
Hypersensitivity pneumonitis
Alveolitis
Atopic dermatitis/eczema
Contact dermatitis
Urticaria and angioedema
Drug allergy
Food allergy
Latex Allergy
Insect Allergy and Stinging-insect hypersensitivity
Gastrointestinal reactions resulting from allergy
Anaphylactic shock
Immunodeficiencies
Occupational allergic diseases
Risk factors for progression of allergic diseases--the "allergic march"
Other specific organ reactions resulting from allergy
Conditions that may mimic or overlap with allergic disease;
The epidemiology and genetics of allergic diseases and auto-immune diseases, and a specialist knowledge of regional and local allergens, including aero allergens, drugs, venoms, occupational allergens, and food allergens;
The effector cells involved in allergic disease (stem cells, lymphocytes, mast cells, basophils, eosinophils, neutrophils, monocytes, macrophages, dendritic cells);
The molecules involved in the immunological response (both innate and acquired), including chemical mediators; immunoglobulins; antibodies; complement; cytokines, including interleukins; chemokines and their receptors; and human leukocyte antigen/major histocompatibility complex (HLA/MHC) antigens;
The main hypersensitivity reactions;
Cell-to-cell interactions;
The scientific in vitro laboratory diagnostic tests for allergy andtheir selection and interpretation, including radio-allergosorbent tests (CAP-RAST®); enzyme_linked immunosorbent assays (ELISAs); Western blotting; tests for inflammatory markers (eosinophil cationic protein [ECP] and tryptase); cellular antigen stimulation tests (CAST®), and histamine release assays.
The allergist is especially competent in performing/interpreting the following:
Allergic history and physical examination
Skin testing
Ordering and interpreting allergy- and immunology-related laboratory tests
Evaluation of total IgE and allergen specific IgE measurements
Provocation testing for allergic and immunologic disease
Analysis and advice regarding local environmental/airborne allergens and irritants
Analysis and advice regarding ingested allergens/irritants
Conducting and/or evaluating tests of pulmonary function and tests of inflammatory markers
Conducting and/or evaluating tests of nasal function; this may include examination of nose and throat via fiberoptic rhinoscopy and nasal endoscopy
Specific allergen and venom immunotherapy
Pharmacotherapy of allergic disorders and related diseases
Where necessary, investigating alternative diagnoses
Environmental modification strategies to reduce allergen exposure
Immunomodulatory therapy
Drug desensitization
Evaluation and treatment of allergic and immunologic competence
Primary, secondary and tertiary prevention of allergic disease
Education for patients, caregivers and primary care physicians
Appendix
All societies that have commented and approved
American Academy of Allergy, Asthma and Immunology
American College of Allergy, Asthma and Immunology
Argentine Association of Allergy and Immunology
Australasian Society of Clinical Immunology and Allergy
Bangladesh Society of Allergy and Immunology
Brazilian Society of Allergy and Immunopathology
Chilean Society of Allergy and Immunology
Colombian Allergy, Asthma, and Immunology Association
Danish Society for Allergology
Egyptian Society of Allergy and Clinical Immunology
French Society of Allergology and Clinical Immunology
German Society for Allergology and Clinical Immunology
Hungarian Society of Allergology and Clinical Immunology
Italian Society for Allergology and Clinical Immunology
Japanese Society of Allergology
Malaysian Society of Allergy and Immunology
Mexican College of Allergy, Asthma and Clinical Immunology
Mongolian Society of Allergology
Netherlands Society of Allergology
Paraguayan Society of Immunology and Allergy
Romanian Society of Allergology and Clinical Immunology
Russian Association of Allergology and Clinical Immunology
Allergy Society of South Africa
Singapore Society of Immunology, Allergy & Rheumatology
Swiss Society of Allergology and Immunology
Allergy and Immunology Society of Thailand
Turkish National Society of Allergy and Clinical Immunology
Venezuelan Society of Allergy and Immunology
Vietnam Association of Allergy, Asthma and Clinical Immunology
Zimbabwe Allergy Society
The Asia Pacific Association of Allergology and Clinical Immunology
Czech Society of Allergology and Clinical Immunology
References
- Kaliner MA, Del Giacco S, Crisci CD, Frew AJ, Liv G, Maspero J, Moon HB. Requirements for physician training in allergy: key clinical competencies appropriate for the care of patients with allergic or immunologic diseases--a provisional position statement of the World Allergy Organization. Allergy Clin Immunol Int J World Allergy Org. 2006;1:92–97. doi: 10.1027/0838-1925.18.3.92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- American Academy of Allergy, Asthma and Immunology. Consultation and referral guidelines citing the evidence: how the allergist/immunologist can help. J Allergy Clin Immunol. 2006;1(suppl):S495–S523. doi: 10.1016/j.jaci.2005.10.047. [DOI] [PubMed] [Google Scholar]
- Malling HJ, Gayraud J, Papageorgiu-Saxoni P, Hornung B, Rosado-Pinto J, Del Giacco SG. et al. Objectives of training and specialty training core curriculum in allergology and clinical immunology. Allergy. 2004;1:579–588. doi: 10.1111/j.1398-9995.2004.00467.x. [DOI] [PubMed] [Google Scholar]
- European Union of Medical Specialists Allergy Training Syllabus. Allergology and Clinical Immunology Section and Board: 07.06.2003. http://www.worldallergy.org/allergy_certification/index.shtml