The immune system has an impact on all other systems throughout the
body. It is complex and intricate and the diseases that result from its
disturbance are in themselves fascinating. Diagnosis requires the
integration of laboratory and clinical aspects and is commonly not
clear-cut. One contributor selected this specialty because of its lack of
confinement to any one particular organ system and its broad spectrum of
disease manifestations, especially the systemic inflammatory type such as
vasculitis and connective tissue disease. Another practitioner was attracted
by the academic challenge of undertaking original laboratory research.
Clinical skills are vital: you need to be able to take a good
history and perform a thorough examination. You should possess good general
medical knowledge and be able to think laterally and deal with uncertainty
since many diseases have no ‘gold standard’ diagnostic test. Being able to
judge the significance of laboratory results in the context of each case is
also important. An interest in pathology and laboratory testing is helpful
if you wish to train in both pathology and clinical medicine however joint
training is not necessary.
In New Zealand the work primarily involves outpatient or ambulatory
care and consultative work. Care of inpatients is usually a component of the
role in Australia, particularly in hospitals where patients are admitted
under subspecialists. Supervising laboratory activities, interpreting test
results and providing advice are also significant components for those
trained in pathology, although the extent of this role will depend on the
individual laboratory. A number of the tests overlap with other pathology
specialties: LabPlus has a collaborative approach where clinical oversight
is shared closely with related disciplines. For example protein work
is done in the immunology laboratory but interpreted by chemical pathology.
Flow cytometry for primary immune deficiency disorders is done by
haematology but interpreted by the immunopathologist.
The specialty is relatively new in New Zealand and is currently
grossly under-serviced. There is a major need to improve the education of
medical students and GPs in this area, since management of patients could be
improved at the primary level. Another challenge is to keep up-to-date with
developments, as the molecular natures of diseases are increasingly
recognised and new treatments that target precise abnormalities become
available (for example monoclonal antibodies to various cytokines, and gene
therapy).
This is an exciting field of work. Because the specialty it is not
sufficiently established in New Zealand, at least some training should be
obtained overseas where the experience is vast and broad and the specialty
is well established. One contributor recommends that you should undertake
training that covers clinical and pathological aspects because much of
immunology is laboratory based and dual training will keep your options open
but this is not necessary as the greatest demand is in the clinical field.
Contributors agree that there is a vast unmet need in New Zealand at
present. Three specialist positions have become available in the past couple
of years and there is huge need in both public and private sectors.
Training for the dual fellowship and undertaking overseas training
requires a significant time commitment, although interruptions to training
are possible. Travel can, however, be part of training: many registrars from
Australasia spend time in the United Kingdom or United States. You will need
to travel internationally for conferences once you are established in
practice as a specialist. Since the specialty is emergent and has undergone
recent expansion, specialists are (on average) younger than those in many
other disciplines so there may be greater understanding displayed towards
parental leave. One contributor commented that she has had no problems
arranging parental leave in Australia or New Zealand and that the job lends
itself to flexible or regular part time hours because of the predominance of
ambulatory care.
Contributors agree that weeks are very busy, with frequent demands
made for activities such as talks or manuscript reviews (as there are few
people to share these responsibilities with at present) resulting in a heavy
workload that requires substantial after-hours input. However, this is
compensated by the minimal call and weekend work requirements that allow for
uninterrupted time with family. It is important to note that in certain
parts of Australia (such as Sydney) general medicine as such does not exist,
so individual subspecialties provide continuous rosters. This can mean that
registrars and specialists are very busy, particularly with the heavy HIV
caseload.
Dual training for FRACP and FRCPA is only one year longer than for
FRACP alone, so the time commitment is not excessive in comparison with
other subspecialties. The funding situation in New Zealand and knowledge
with regard to this specialty is improving and there is reason for optimism.
Immunology and allergy has evolved into an exciting and broad specialty in
Australia thanks to the perseverance of its pioneers.
Basic training and one or two years of advanced training could be
done in New Zealand, but you should be prepared to go further afield after
that. One contributor recommends Sydney in particular as it offers broad
clinical training that includes the fields of allergy, HIV medicine, primary
immunodeficiency, connective tissue disease, vasculitis and laboratory
immunology. The various teaching hospitals in Sydney also offer a good
immunology tutorial programme which trainees from all hospitals are able to
attend, thereby increasing the breadth of experience and allowing
collegiality to develop between registrars at different hospitals.
