Recommendations for Competency in Allergy Training for Undergraduates Qualifying as Medical Practitioners: A Position Paper of the World Allergy Organization

The Council acknowledges specific comments from: The American Academy of Allergy, Asthma and Immunology (AAAAI) (Amal H Assa'ad); The American College of Allergy, Asthma and Immunology (ACAAI) (Mark Dykewicz, D. Betty Lew, Bryan L. Martin); The Argentine Association of Allergy and Immunology (Ledit RF Ardusso); The Argentine Society of Allergy and Immunopathology (Estrella Asayag); The Australasian Society of Clinical Immunology and Allergy (ASCIA) (Jill Smith); The British Society for Allergy and Clinical Immunology (Stephen Durham); The Brazilian Society of Allergy and Immunopathology (Nelson Rosario); The Bulgarian Society of Allergology (Vasil Dimitrov); The Canadian Society of Allergy and Clinical Immunology (CSACI) (Richard Warrington); The Chilean Society of Allergy and Immunology (Jessica Salinas); The Chinese Society of Allergology (Zhang Hongyu, Yin Jia); The Czech Society of Allergology and Clinical Immunology (Jiri Litzman); The Danish Society of Allergology (Lone Winther, Peter Plaschke); The Egyptian Society of Allergy and Clinical Immunology (Kamal Maurice Hanna); The Egyptian Society of Pediatric Allergy and Immunology (Yehia El-Gamal); The German Society for Allergy and Clinical Immunology (Thilo Jakob, Claus Bachert, Bernhard Przybilla); The Hungarian Society of Allergology and Clinical Immunology (Kristof Nekam); The Icelandic Society of Allergy and Clinical Immunology (Björn R. Lúðvíksson); The Italian Association of Territorial and Hospital Allergists (Riccardo Asero); The Italian Society of Allergy and Clinical Immunology (Luigi Fontana); The Japanese Society of Allergology (Sankei Nishima); The Korean Academy of Asthma Allergy and Clinical Immunology (Joon Sung Lee, Hae-Sim Park); The Latvian Association of Allergists (Ieva Cirule); The Lebanese Society of Allergy & Immunology (Fares Zaitoun); The Mongolian Society of Allergology (S. Munkhbayarlakh); The Allergy and Clinical Immunology Society (Singapore) (Chng Hiok Hee); The Allergy Society of South Africa (Sharon Kling); The Spanish Society of Allergy and Clinical Immunology (Tomás Chivato); The Swiss Society for Allergology and Immunology (SSAI-SGAI) (Beat A. Imhof, Andreas Bircher); The Allergy and Immunology Society of Thailand (Pakit Vichyanond); The Turkish National Society of Allergy and Clinical Immunology (Omer Kalayci); and The Venezuelan Society of Allergy, Asthma and Immunology (Luis F Sarmiento).


INTRODUCTION
T he global increased prevalence of allergy is such that between 20 -30% of the world's population now suffers from some form of allergic disease, with considerable and continuing increases in prevalence over the last three decades. 1 Although the specialty of allergy is practiced and recognized in most developed countries, even some developed countries lack adequate resources to manage the local burden of allergic disease. In many developing countries there are few or no allergy specialists due to either the prevailing healthcare infrastructure, to socio-economic reasons, and/or to the lack of recognition of allergy as a clinical specialty. There is often minimal or no inclusion of allergy education/training in the undergraduate medical curriculum, and this shortfall must be addressed if the increasing burden of allergic diseases is to be managed.
The majority of patients with common allergic diseases around the world are treated by primary care physicians, and not by trained specialists. However, a lack of appropriate education and training in allergy at the undergraduate level leaves many medical graduates with low baseline knowledge and skills in the science and practice of allergy. In addition, because it is a relatively new discipline, education and training in allergy in medical schools has lagged behind scientific and clinical developments in this field, and there are few allergy specialists available to teach this multidisciplinary subject. This phenomenon is described by the World Health Organization as the knowledge/practice gap. Unless allergy training is included as an essential part of undergraduate medical education at the clinical level, many physicians will qualify with inadequate competency to manage the diagnosis and treatment of allergic diseases at the primary care level. Thus, a cycle of lack of basic knowledge about the most common allergic diseases, lack of recognition of allergic disease at the clinical level, and inadequate knowledge and skills in the diagnosis and treatment of allergic diseases will be perpetuated.
To help break this cycle the World Allergy Organization (WAO) presents broad guidelines for the curriculum of education and training of medical students in the immune mechanisms of allergic responses, and the commonest manifestations of clinical allergy. Inclusion of these educational guidelines into curriculum development will provide medical graduates with the basic knowledge required to recognize and treat common allergic diseases during postgraduate training or as a general practitioner (care level 1), and the knowledge of when to refer the more complex problems to appropriate organ-based or allergy specialists (care levels 2 and 3). 2 These guidelines outline optimal curriculum content, and are offered for consideration and modification to meet local needs and healthcare provision structures. Although certain immunodeficiency states may accompany allergies or may need to be considered in the differential diagnosis of allergic diseases, this document is not intended to provide a comprehensive guideline on the teaching of immune deficiencies to medical students.

BROAD OBJECTIVES OF THE WAO GUIDELINES FOR MEDICAL STUDENT TRAINING IN ALLERGY
The objectives are concordant with the recommendations made by the WAO in the 2008 WAO Position Statement "Requirements for Physician training in Allergy: Key clinical competencies appropriate for the care of patients with allergic or immunologic diseases" 2 and align with competency at the first level of care. This represents only the first step underlying any training program for physicians who will be seeing patients with allergy.

DIFFERENT FORMATS FOR TEACHING ALLERGY TO MEDICAL STUDENTS
Allergy can be taught in a number of components of the curriculum and can be included among the subjects taught in Medicine, Pediatrics, Microbiology, and Immunology, or as a component of organ-based specialty teaching, for example, dermatology, ENT, internal medicine, and ophthalmology. If allergy is taught as a component of different organ-based specialties, a cohesive program should be developed to ensure that all major allergic disorders are covered. In some countries such programs could be co-ordinated and be established by Allergy departments.
Teaching allergy as part of systematic undergraduate training and as problem solving around cases, are not mutually exclusive and can be combined. Each country can attempt to include the essential topics into existing curricula in different medical school training programs.

A. Systematic Undergraduate Education and Training in Allergy
In this approach, students receive their teaching in two phases:

B. Problem Based Teaching/Problem Solving Around Case Studies
At least 4 cases are recommended and study of on-line cases such as those provided on the WAO Web site (www. worldallergy.org). In this format, utilizing a case history with multiple allergic manifestations as indicated in case 1 (below), it is possible to teach the basic sciences of allergy (as itemized in section B part 1) and clinical disease presentation, and encourage correlation between the two, and also teach pharmacotherapeutics. The combination of cases should cover the common allergens, resources for patients, WAO nomenclature for allergy, 3 and epidemiology of allergic diseases.

1.
A child or an adult who has demonstrated the allergic march from atopic eczema and food allergy to asthma and allergic rhinitis with a strong family history of atopy. 2. Insect venom hypersensitivity to include mechanisms, signs and symptoms, diagnosis, and action plans for managing anaphylaxis, immunotherapy (theory and evidence for efficacy and side effects), and other treatment options. 3. Latex/food allergy or pollen/oral allergy syndrome to illustrate allergenic cross reactivity, avoidance strategies, and pharmacotherapy. 4. Urticaria and angioedema; differential diagnosis, investigations, and management. 5. A case study on anaphylaxis and emergency treatment (eg, use of epinephrine). 6. A case study of acute, severe asthma with respiratory distress that focuses on the differential diagnosis of an asthma exacerbation and the interaction between infection and allergy.

ASSESSMENT OF COMPETENCE IN ALLERGY FOR MEDICAL STUDENTS
Assessment should be made by written and oral examination using either the "problem based approach" or the "systematic teaching approach." Recommended levels of competence are marked in the syllabus.
1. Assessment of Part 1. Basic sciences such as pharmacology, physiology, and immunology should be conducted by written or multiple choice examination and could be examined within the undergraduate Pathology/Pharmacology Semester examinations. 2. Assessment of Part 2. Clinical allergy competence should be conducted by written and oral examination: a. Where a medical student is given an "allergy case" and is asked to examine, diagnose, and then make a case presentation, after which a series of clinical questions are posed around the case (extended matching and/or multiple choice). b. Patients with allergies, for example, atopic eczema, asthma, rhinitis, sinusitis, food allergy, insect/venom allergy could also be included in the clinical cases for the in-course and final evaluations of the students for competence in Medicine and Pediatrics. Assessments could be in the form of long cases or more reproducibly by miniCex (mini-clinical evaluation exercise), OSCE stations and/or PACEs (Practical Assessment of Clinical Examination Skills).

Resources
It is important that textbooks suitable for undergraduate training in allergy are made available to the medical students, as well as electronic learning and on-line teaching modules.
For example: i. The Allergic Diseases Resource Centre of the WAO Web sitewww.worldallergy.org/adrc/ includes numerous educational synopses that provide suitable reading for students.