Medical Specialties - Immunology (24 May 2023)

SPEAKER_00 0:00

If you enjoy listening to career conversations, why not become a member of the Royal College of Physicians of Edinburgh? Our membership provides you with access to the RCPE educational portal, the live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website. I'm Dr. Marilena Giunudi and I am on the TMC, and today I'm delighted to be joined by Dr. Sammy Amit, who is an immunology trainee based in Leeds. Sammy, welcome and thank you so much for joining us today. Not a problem. So can you please start by telling us why did you choose to go into immunology?

SPEAKER_01 1:08

So it's not a specialty many people initially go into thinking they're definitely going to do this from the start of medical school because we don't get much exposure to the specialty as a whole throughout our undergraduate learning and even our foundation training. I actually did a rotation on rheumatology, and I found myself being more interested in those patients that were on immunosuppressants and biologic medications, and then ended up attending some immunology clinics and realized that actually I was quite interested in that field. I did a clinical fellowship here in the specialty and then applied for it.

SPEAKER_00 1:47

And do you know, obviously, you mentioned that it's actually very difficult to get exposure to the specialty. I'm not aware, but are you aware of any rotations in F1, F2 where you can get placements in immunology, or is it something that you have to specifically look for more as an out-of-programme experience?

SPEAKER_01 2:04

So during core medical training, there is a number of clinics that we have to attend, and we do get that kind of freedom to choose what we want to attend. And I think the good thing about Leeds when I was uh medical training in Leeds is they do slot you into a variety of clinics, and I was put into an immunology clinic for exposure, which was lucky for me. Outside of that, it would be contacting the department or one of the departments local to you, and I'm sure the team would be happy to have either medical students there or other trainees for experience. And just going back to your question about rotations, currently where I work, there isn't any trainees that are specifically rotated to immunology, and I assume that's just because it's on a registrar level, it tends to be a nine to five specialty, and they may not be able to get the training curriculum, they need to hit all the pointers in their training done during the rotation in immunology. So no, we don't have any ones specifically rotating to us. But we've had discussions because we think it would be quite interesting maybe to get a co-medical trainee with us for a few months.

SPEAKER_00 3:10

And what does a typical day in the life of an immunology trainee look like?

SPEAKER_01 3:16

Well, I'm an allergy and immunology trainee, and we tend to have a number of different clinics. So we'll have a clinic in the week or a couple of clinics in the week dedicated to allergy patients. This could be patients with chronic allergic conditions or new patients that need skin testing either to food or drugs. Then we have an immunology clinic, and so these are patients that are born with immunodeficiencies or are suspected to have a primary immunodeficiency later in life or a secondary immunodeficiency, maybe refer to when they're a bit older and they need investigation or follow-up. And then we also have an auto-inflammatory clinic, so patients needing follow-up or a possible new diagnosis in periodic fevers, and we work closely with have a rheumatology colleagues for that clinic as well. So it's a really good mix of patients and conditions.

SPEAKER_00 4:02

And it's all outpatient-based. You don't have any inpatients.

SPEAKER_01 4:06

Yes, I forgot to mention that. So yeah, it's all an outpatient-based specialty. We provide input for inpatient care depending on where the questions come from. Occasionally we can go and review inpatients in person, but generally it tends to be advice over the phone. And the outpatient clinics are seeing patients face to face and a mixture of going to the lab because immunology has a significant overlap with laboratory medicine. So we do the same exams as the clinical scientists, so we need a good amount of exposure to the lab as well. So, like, for example, a session in an afternoon in the lab for me would either be looking through the results that have come through, like the immunoglobulins and validating them before they go out, making sure there's nothing that I'm concerned about, troubleshooting any machines or not personally, but identifying if they're the problem or something that isn't quite right on a lab level as well. And we also do things like drug challenges or food challenges. So bringing patients in one afternoon a week, so I'll either give them a medication that hopefully they're not allergic to and we just want to prove, or something as simple as peanuts just to make sure there's no other allergen that we're missing for patients. So yeah, a really good mix of different things.

SPEAKER_00 5:16

And you mentioned that obviously you'd had that time in the specialty before applying. If people such as yourself, if people haven't been as lucky as you to be able to have that exposure, given the fact that it's so different to what were taught in whether you did core medical training or whether you're a newer trainee and you're doing IMT, does the training pathway facilitate you, you know, being taught what you mean? So as you mentioned, the lab skills and yeah, all the you know, outpatient clinic-based skills and and the really nitty-gritty of immunology analogy medicine, which I imagine we don't even cover 5% of an MRCP.

SPEAKER_01 5:56

The learning that you have to do outside of just you know seeing the patients or being around the lab, it's it's quite big. I'm always joking and saying, Oh, it's like doing a whole degree in itself. But actually, if you enjoy that and you enjoy the specialty, you will probably actually enjoy the learning as well. On a cellular level, there's a lot of detail. Does it prepare you? You learn the core principles and the kind of the main learn basic immunology throughout medicine. And I think the important thing is that even though you might not have the whole immunobiology knowledge, you have a lot of clinical experience, and that's why we have to do core medical training before we go into it, because our in order to care for these patients who are quite complex and have numerous other specialties involved in their care as well, and being able to identify any issues or complications. So, from a kind of clinical point of view, I think up to the point of going into the training, yes, we need that knowledge, that's really important. There is a lot of reading that you have to do outside.

SPEAKER_00 6:50

But when you're on the training program, do you have allocated training days, teaching days, you know, to go over the lab skills, or is it something that you really have to do in your own time?

SPEAKER_01 7:00

So I don't know if other trainees are as lucky as this in other specialties, but we are given dedicated uh self-independent learning time in the week, which may be an afternoon, it may even be a whole day. We have regular teaching. Our teaching is national because there isn't many others, but with things going more virtually, it is much easier to attend these. And yeah, I would say that probably compared to some of my colleagues in other specialties, making sure the trainees are learning is definitely prioritized in this field. And I think it's that understanding that actually doctors will go into the field having only the kind of basic knowledge of immunology, and there is quite a lot to learn.

SPEAKER_00 7:38

And do you mind if we just talk through the application process as it was when you applied? Now, I know that things change year on year, and what I would say to anybody listening is make sure you look at the GRC TV website, and I'll make sure that you know a link to that is in the footnotes of this episode, but I still think it would be very beneficial for us to hear what the process was like for you as a trainee applying.

SPEAKER_01 8:03

I feel like it was a while ago because I've had a maternity leave in between as well. But as far as I remember, you apply online like you would for any of the other specialties. The interviews they may not be local to you because the interviews tend to be national. So I went to London for my interview. There was stations where they assessed general competencies, communication skills, and your achievements on an academic research level, and then a station where it was more clinical. For example, I remember mine was anaphylaxis, and I think it was to an insect bite. But again, I think the panel mostly appreciate that not everyone has exposure to the specialty necessarily before, well, not a huge amount of exposure prior to applying. And even with a clinical scenario, I think the most important thing they want to see is kind of people who are safe and sensible.

SPEAKER_00 8:52

Yeah, and I think that's really important to highlight to anybody listening that when you become a registrar, when you're applying to become a registrar, you feel that you're expected to have all the knowledge, whereas in actual fact, you just need to be safe. And the whole point of going onto a training program is so that you can acquire the knowledge for that specialty.

SPEAKER_01 9:10

Yeah. You know, they want to see your A to E assessment, they want to see that you're involving seniors appropriately, and I think anything else, any extra knowledge beyond that, it's a bonus. And I don't think I had I did do a clinical fellowship, but I actually applied quite early into that year because of how long the process took. So I did I didn't have a huge amount of knowledge and it was still I felt like it was a very kind of fair interview.

SPEAKER_00 9:33

And you mentioned that it's a nine to five specialty. Do you have any on calls during your typical working week?

SPEAKER_01 9:40

Yeah, so I say it's a nine to five specialty. We do need to offer an on-call. It's just that on a registrar level, it's that support on call is done between nine to five and when you become a consultant, then you join an on-call rotor, but you tend to be called quite infrequently. So out of hours on an evening or overnight, it's quite rare to be called in. So I feel like it's a huge plus because you get to have what you would like in a medical specialty without maybe heavy on-call rotor.

SPEAKER_00 10:04

And what advice would you give to people who are interested in in applying to immunology or who just want to learn a bit more about the specialties?

SPEAKER_01 10:11

So I think it's important to know whether you're going to enjoy it or not. It's important to attend probably a few clinics, maybe a mix of clinics, because you may go to allergy clinic and you might find that actually you are not finding it as interesting as an immunology clinic. And I think that's fair. I mean, as you get more senior in your training, you can, I think, drift towards more kind of one side than the other and see more patients under one specialty kind of subspecialise. So I think it's important to know that you enjoy it. So attend clinics. Do ask, like you did, the day-to-day experience for a registrar or a consultant is. And I guess that don't be so overwhelmed and daunted by all the conditions that you don't recognise. You are given time to learn and train. And look what skills do you think somebody needs to be an immunologist? So I was thinking about this actually, because I was thinking I would probably put so it's not very practical. You don't need dexterity and things like that. So it's not very practical in that sense. However, there's a lot of MDT working, so you need good communication, you need to be enjoying working in a team. A lot is discussed in regards to patient care and management, and that's because our patients are very complex with rare conditions. And and I think you have to be okay with not having clear guidance all the time. You know, we're involved in a lot of research, experimental drugs. And if you enjoy having complex patients and having to brainstorm and think about what do we do next, what can we try next? And if you're good at that, then yeah, that's that's a skill. So thinking out outside the box. And I think with our patients, they're very different. Like I said, some of the allergy patients are very different to them, you know, deficient patients. You need a lot of care. You do follow them up, so we have our regulars. And if you enjoy that, if you enjoy being able to, if someone you know, a colleague mentions what patients' name and you instantly know them, you know their background, you know their history, a little bit like primary care, but you follow them through as they grow older and you like that level of familiarity with your patients, then you'd enjoy this as well.

SPEAKER_00 12:08

I guess sorry, am I am I branching off? No, no, no, no. I was just gonna say I think that's really important because the way a lot of hospital medicine is becoming, we're losing that continuity of care. And actually, that's one of the best things about being a doctor, that you get to see the effects of your, you know, either your treatment options or you get to see how a patient is progressing and actually really be involved in their care throughout their journey.

SPEAKER_01 12:33

And most of our patients, even if I'd mentioned like if I've spoken about them and I just mentioned their first name, even their second name, most people in the department will know exactly who I'm talking about because of that continuity of care. I like that. It makes it easier to be a good doctor for that patient when you know their full full background, makes it easy to pick up on different complications, care for them holistically. So, like I said, it's really important that we actually understand how so with our patients, because it tends to be multi-system disorders, it's important for us to have an understanding of what could go wrong in the liver, for example, what could go wrong with the kidneys, and psychologically as well. So having that continuity allows us to identify when they're not quite right and intervene early.

SPEAKER_00 13:16

And Tammy, what I always try and ask anybody doing this podcast is to discuss an interesting or just a typical case that they may see, or an interesting case, and I'll appreciate with certain kind of patient populations that can be quite difficult in protecting a patient's confidentiality. But do you have a case that we could possibly discuss? Because I think that's the best way for our listeners to really know what working in that specialty is like.

SPEAKER_01 13:43

Yeah, so I'll do so, like for example, you we may have a patient referred in, a young adult who has had a couple of episodes of meningitis, and they've isolated a slightly atypical serotype of Nessarea meningitis from the cultures, and someone said this is a little bit odd for this young girl to be catching this type of infection, and she's had it twice, maybe, so let's refer her in. So we would initially take a full history, examine her, ask about a family history, and sorry, I'm keeping this kind of anonymous, but like no no no no, that's great. Yeah, so then we would do some blood tests. At this point, we'd be looking at kind of general things that could go wrong. So the level of white blood cells, I'm keeping it really simple. So the level of white blood cells, have they got the right level? Are they functioning? Which types are we interested in? Now we're really interested in the complement system, so a group of proteins that would normally fight off this type of infection, and the initial test we may do might show that the level is right, but then if we actually think further, we would want to test how well those proteins are functioning. So we send a further sample off to look into the functional aspect of these proteins. So um so C8, so one of the complement proteins, for example. This is done in the lab, so this is where our understanding of the lab comes in, knowing how that is tested. So you normally put in the patient's serum into erythrocytes which are coated with antibodies. I don't want to complicate it, and you just want to see how quickly they lie, so to identify how well the complement system is functioning in the patient, and that comes back as being zero or nil. So something's knocked out completely in this patient. We can actually delve in even deeper and then start looking at each protein in the complement cascade and identify that the patient has got a specific complement deficiency and that makes them prone to meningiococcal disease and quite severe disease and particularly atypical kind of serotypes. So, all these how we would manage this patient is we tell them to take prophylactic or epenicillin. It makes a difference because this condition would most likely be hereditary. Sometimes it's a de novo mutation, but it's most likely hereditary. And it has implications for that person going forward in family planning, it has implications for their siblings, for the parents, and then we would request genetic testing to look into any mutations that we could identify. That's sorry, like a really quick summary of a case.

SPEAKER_00 16:10

No, that's really interesting, and that just made me kind of wonder in these kind of patients or in the patients that were worried about recurrent infections, what are your cutoffs for referral?

SPEAKER_01 16:21

Yeah. So for things like allergy clinic, we've had to guide it. So when I mention things like challenge testing, the guidance that I understand at the moment is if they're allergic to two classes of antibiotics, then refer them in because we can challenge test them and create options for them going forward. So we have guidelines for some aspects, anaphylaxis, things like that. However, for immunology, we don't have any strict guidance. I think it's a lot of it's just clinician dependent. And I think it's just that maybe that sixth sense that something is a little bit off here. I think particularly young patients with persistent infections that are odd or severe infections or recurrent infections, and if they're of different kinds of like, for example, empyemers in a young person, not interested in things like UTIs as much, but yeah, I think I'd say it's severe infections in young patients and maybe recurrent infections in elderly patients are the really kind of crude kind of way of putting it, maybe.

SPEAKER_00 17:12

Okay, okay. No, that's really useful because to be honest, for me, anytime someone comes into MAU with a recurrent infection, I just need to do a HIV test, and that's about as far as L I'll go.

SPEAKER_01 17:22

If it's your 90-year-old with diabetes and probably other risk factors, then fine. But if they're growing really odd bugs and they've been on some sort of treatment in the past that has wiped out maybe a part of the immune system, and you're thinking, actually, has that not recovered maybe? Have they developed a secondary immunodeficiency because of that chemotherapy agent? It's just things like that that would make you think, hmm. And then you refer them into it. And to be honest, we see most things. We're happy to kind of to say that's fine. We've done our panel of tests, we don't want to do any more, and then discharge them.

SPEAKER_00 17:52

Yeah, okay, great. I think that's the end of my questions. I'm sorry for the number of them for really drilling down. Thank you so much for joining us today. That was really, really interesting, and I think it's really opened up the world of immunology to our listeners, and it's definitely something you know to be considered for anyone that wants to avoid the med reg rotor.

SPEAKER_01 18:15

Yeah, yeah. Yeah, I mean, it's probably the first push kind of to toward the group two speciality when the when the medreg rotor becomes too much. But I do think you do get a lot of the fun of medicine, but you don't get that heavy on call rotor that goes with it. I don't know if things may change in the future, but yeah, I think I don't know, I'm obviously biased, but I think it's a it's a specialty with a really good mix of conditions. Generally, the teams are small and they take and you know, everyone I've spoken to, so they're fabulous.

SPEAKER_00 18:44

That's great. Thank you so much for talking to us today. And have a lovely evening, you two. Thank you.