Volume 100, Issue 3 , Pages 288-289, September 1997
Role of the allergist/immunologist as a subspecialist☆☆☆★
Article Outline
Abstract
J Allergy Clin Immunol 1997;100:288-9.
Abbreviations: ABAI: , American Board of Allergy and Immunology
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With the approach of the twenty-first century, the health care delivery system in the United States is in the midst of turbulent evolution. Even though it is impossible to predict with precision what model of health care delivery will predominate in future years, the purpose of this position paper is to preserve and to continue to promote high-quality outcome and value-driven care for the 35 million Americans with allergic and immunologic diseases. We wish to foster assurance of patient access to care and its oversight by allergy/immunology subspecialists, as well as by ensuring the availability of their expertise for the future. This position paper seeks to define the roles of the allergist/immunologist as a subspecialist.
The explosion of biomedical discovery in the latter half of the Twentieth Century has emphasized the benefit of technology and expertise of the specialist as a vehicle for improved care over that of the generalist in the delivery of specialized health service. Now, however, under various forms of managed care and integrated provider networks, the control of health care delivery has been redirected from the specialist to the generalist. In most managed care organizations, the “primary care provider” is responsible not only for preventive care and initial management of illness but also for initiation of subspecialty consultation and direction of subsequent care with or without additional subspecialist involvement.
Because many illnesses involve chronic disease processes, the American Medical Association has recognized a category of patient care as “principal care,”1 defined as ongoing, preventive, diagnostic, curative, counseling, or rehabilitative care provided by a physician, which is focused on a specific organ disease or disease condition. Principal care may be provided concurrently with or apart from primary care. The American Board of Internal Medicine also has recently advocated the use of the principal care model for those patients with complex and/or chronic disease for whom the subspecialist appropriately provides most of the patient's care.2 As the principal care provider, the subspecialist is expected to assume responsibility not only for subspecialty care but also for coordinating other medical services, as well as for providing communication to patients and their families. For example, the allergy/immunology subspecialist could function as the principal care provider for those patients with moderate to severe persistent asthma, chronic sinusitis, urticaria, immune deficiency diseases, and other immunologically mediated illnesses.
The certified subspecialist in allergy, asthma, and immunology is a physician who has fulfilled the requirements of and has been certified by the American Board of Internal Medicine and/or the American Board of Pediatrics, followed by an additional training period and certification by the American Board of Allergy and Immunology (ABAI), a conjoint board of the parent boards. Therefore by training, allergy/immunology subspecialist diplomates of the ABAI are also certified primary care providers.
According to the policy statement of the ABAI, the allergy/immunology subspecialist has detailed knowledge of the underlying pathophysiology and the methods of diagnosis, treatment, and prevention of allergic and immunologic diseases such as rhinitis, asthma, sinusitis, urticaria, angioedema, anaphylaxis, hypersensitivity pneumonitis, atopic and contact dermatitis, and allergic gastrointestinal disorders, as well as comparable clinical problems without an apparent allergic cause such as vasomotor rhinitis, otitis, nonallergic asthma, and idiopathic and/or hereditary forms of urticaria and/or angioedema. Expertise in the management of pulmonary complications of these diseases is a further prerequisite.3
In addition, ABAI-certified allergy/immunology subspecialists possess breadth and depth in the understanding of immunochemistry, immunobiology, and applied pharmacology plus experience in the application of this understanding to the diagnosis, management, and prevention of immunologic diseases such as primary or acquired defects of host resistance, primary or acquired immune deficiency diseases, bone marrow and solid organ transplantation, gene replacement therapy, adverse drug reactions, and other conditions associated with an abnormality of the immune system.3 Because allergy and clinical immunology is an evolving and expanding area of medicine, allergy/immunology subspecialists will vary in their individual expertise.
Subspecialists in allergy and immunology are needed not only as consultants and principal providers of patient care but also as knowledgeable and dedicated investigators who will contribute to advancing medical discovery and understanding of mechanisms of disease processes, as well as the clinical impact of this discovery and understanding. These subspecialty investigators may concentrate their research efforts either as clinical investigators, generating new data and translating new scientific evidence into clinical practice, or as basic scientists, discovering new concepts that improve the understanding of disease mechanisms.
It is imperative that the training programs for future subspecialty investigators in allergy and immunology be preserved, promoted, and protected so that there can be continued education and discovery leading to improved patient care, despite the economic constraints of the changing health care systems. As is currently the case in many training programs, these subspecialty investigators can also function as providers of clinical consultations and principal care. It is essential that future educators and scholars in allergy, asthma, and immunology develop from these career pathways.
Physician workforce assessments have not documented an excess of allergy/immunology subspecialists in contrast to many other medical subspecialists.4, 5, 6 Nevertheless, training programs in allergy and immunology are currently suffering and will continue to suffer from the present trend and determination of some to indiscriminately downsize subspecialty medicine. In order to continue to advance the discipline of this subspecialty, it is essential to continue to train adequate numbers of allergy/immunology subspecialists to prevent future shortages of clinician consultants, subspecialty principal care providers, clinical investigators, and basic scientists in the specialty of allergy and immunology.
References
- Definition of “Principal Care,” 1996 American Medical Association, House of Delegates Policy 160.943.
- . Future roles and training of internal medicine subspecialists. Ann Intern Med. 1996;124:686–697
- Policy statement. American Board of Allergy and Immunology; 1995;
- . Forecasting the effects of health reform on U.S. physician workforce requirements: evidence from HMO staffing patterns. JAMA. 1994;272:222–230
- Will the supply of allergists and immunologists in the United States meet future needs?. J Allergy Clin Immunol. 1994;93:803–810
- . Benchmarking the US physician workforce: an alternative to needs-based or demand-based planning. JAMA. 1996;276:1811–1819
☆ From the American Academy of Allergy, Asthma and Immunology.
☆☆ Reprint requests: AAAAI Executive Office, 611 E. Wells St., Milwaukee, WI 53202–3889.
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© 1997 Mosby, Inc. All rights reserved.
Volume 100, Issue 3 , Pages 288-289, September 1997
