Current trends in medical education affecting allergy and immunology physicians and learners.

OBJECTIVE: To review current and relevant trends in medical education, undergraduate medical education, graduate medical education, and continuing medical education for the allergy and clinical immunology (A/I) community. DATA SOURCES: English-only published literature from the past 5 years were obtained by means of a PubMed search and Google Scholar searches in addition to pertinent review articles and relevant textbooks as selected by the authors. STUDY SELECTIONS: A total of 62 articles were selected for their relevance to the article's objective. Older references regarding medical education trends were included when they were felt to be essential. RESULTS: Competency-based medical education is the contextual framework for curriculum, instruction, and assessment. Current trends influencing competency-based medical education are the following: e-learning; interprofessional education; simulation-based medical education; diversity, inclusion, and equity; and mentoring. This review clarifies terminology and offers examples of the potential impact of these trends within the A/I educational community. The development of knowledge and skills related to these topics can be achieved through formal faculty development, mentoring, and self-directed, asynchronous instruction. CONCLUSION: Medical education continues to evolve as health care adapts to meet the changing needs of the health care system and our patients. The A/I physicians should be aware of current trends because these trends impact their roles as instructors and lifelong learners.

An Examination of the Intersection of Climate Change, the Physician Specialty Workforce, and Graduate Medical Education in the U.S.

Issue: As U.S. healthcare systems plan for future physician workforce needs, the systemic impacts of climate change, a worldwide environmental and health crisis, have not been factored in. The current focus on increasing the number of trained physicians and optimizing efficiencies in healthcare delivery may be insufficient. Graduate medical education (GME) priorities and training should be considered in order to prepare a climate-educated physician workforce. Evidence: We used a holistic lens to explore the available literature regarding the intersection of future physician workforce needs, GME program priorities, and resident education within the larger context of climate change. Our interinstitutional, transdisciplinary team brought perspectives from their own fields, including climate science, climate and health research, and medical education to provide recommendations for building a climate-educated physician workforce. Implications: Acknowledging and preparing for the effects of climate change on the physician workforce will require identification of workforce gaps, changes to GME program priorities, and education of trainees on the health and societal impacts of climate change. Alignment of GME training with workforce considerations and climate action and adaptation initiatives will be critical in ensuring the U.S. has a climate-educated physician workforce capable of addressing health and healthcare system challenges. This article offers a number of recommendations for physician workforce priorities, resident education, and system-level changes to better prepare for the health and health system impacts of climate change.

Time to develop more clinician-educators in allergy and immunology.

Clinician-educators in the field of allergy and immunology (A/I) in the United States teach and assess trainees (medical students, residents, and fellows), provide professional development to primary care physicians and advance practice providers, and are essential in developing a pipeline of academic A/I specialists. According to data from Doximity and the Association of American Medical Colleges, the United States appears to be facing a shortage of clinician-educators and academic allergists in A/I. Without adequate numbers of A/I specialists focused on medical education, institutions will find it difficult to train fellows and introduce the field of A/I to medical students and residents. It is now imperative that the field focus on empowering more A/I specialists to become clinical teachers and clinician-educators. There are specific strategies that individuals, as active agents in their own development, can take in planning for this rewarding and fulfilling career. Individuals can pursue professional development opportunities, join medical education communities of practice, seek education mentors, and join in scholarship activities. It is also essential that systems-level support be provided for clinician-educators, given the increasing business pressures in medicine. Academic institutions, national organizations, and professional societies can provide resources, including structured programs in medical education, protected time, and grants. This article outlines strategies for individuals, institutions, and professional organizations that will promote the development of the next generation of A/I clinician-educators.

Skin testing and oral amoxicillin challenge in the outpatient allergy and clinical immunology clinic in pregnant women with penicillin allergy.

BACKGROUND: Penicillin allergy is frequently reported. In pregnant women, reported penicillin allergy is associated with negative health outcomes and suboptimal group B streptococcal prophylaxis. For individuals having penicillin allergy, skin testing followed by an observed oral challenge is recommended. Previous data indicate a low risk of adverse reaction with skin testing in pregnant women, but the subsequent oral challenge was not routinely pursued. OBJECTIVE: To determine whether skin testing followed by the outpatient oral challenge is tolerated by pregnant women. METHODS: We conducted a retrospective review of all pregnant women who underwent penicillin allergy evaluation at an outpatient allergy and clinical immunology clinic. The patients underwent oral amoxicillin challenges based on the discretion of the allergy provider. We evaluated the index reaction history, skin test results, oral challenge results, and subsequent antibiotic exposure. RESULTS: A total of 46 pregnant women underwent skin testing without adverse reactions, of whom 44 patients (95.6%) received negative results. A total of 18 women (39%) completed an oral challenge without adverse reactions. Patients challenged vs not challenged did not differ in patient age, gestational age, latency since index reaction, or reaction history risk level. Notably, 28 women received intrapartum antibiotics. There was no difference in intrapartum antibiotic administration between those who did or who did not complete an in-office oral challenge (P = .90). CONCLUSION: Penicillin skin testing and oral challenge in pregnant women can safely be performed in the outpatient setting. There was no difference in the intrapartum antibiotic use between women who were and those who were not challenged. Further research is needed to determine the utility of oral challenge in pregnant patients.

Safety of Intranasal Steroids: an Updated Perspective.

PURPOSE OF REVIEW: Intranasal corticosteroid sprays have been available as over-the-counter (OTC) medications since 2013. As such, clinicians need to be up-to-date with the risks and the safety of INS, as patients may have concerns and detailed questions. The following is a review of the recent medical literature regarding the safety profile, adverse reactions, and special populations using INS. RECENT FINDINGS: The latest research on intranasal steroid sprays (INS) continue to confirm that INS rarely have significant local side effects, such as severe and persistent epistaxis. Recent studies looking at systemic side effects such as hypothalamic pituitary axis suppression, growth effects, and ocular effects do not indicate any new concerns nor have found significant differences from the past literature. The use of combination INS and topical antihistamine medications did not reveal any new safety issues. Use of INS with topical decongestants found some limited effects of tachyphylaxis and rebound congestion. Studies continue to support the use of newer INS for children and continued monitoring of growth in this population. The HIV population should avoid use of INS with the prescription of ritonavir, given demonstration of adrenal suppression. This updated perspective has found that newer generation INS should be used at the lowest effective dose for the selected population, that clinicians can inform patients using the OTC INS preparations that there are very few safety concerns, and that regular follow-up visits can provide further reassurance with physical examinations and address patient's questions. Future research regarding the safety of INS should study newer preparations when developed and if used in combination with other topical agents.

Suspected food allergies in a septuagenarian with recurrent anaphylaxis.

Anaphylaxis is an acute, life-threatening reaction that can occur due to a variety of triggers. It is often associated with allergen exposure, such as food, venom, or medications; however, there are other less-common causes, and many patients are ultimately classified as idiopathic. In this report, we described a patient with recurrent reactions attributed to food exposure. Further evaluation revealed an alternative, less common diagnosis.

How Likes and Retweets Impacted Our Patients During the COVID-19 Pandemic.

The growing dependence on social media for health-related information boomed during the COVID-19 pandemic, posing unprecedented challenges in navigating the vast amounts of information available right at our fingertips. Social media had a major impact on clinical decision-making affecting individuals, communities, and societies at large. In this review, we discuss the role of social media in amplifying information and misinformation as well as factors contributing to its reliance and prevalence. We review how medical providers have been impacted by this changing landscape, useful communication strategies to employ with in-office patient encounters, and how we can be active players in using social media as a tool for health promotion, correcting misinformation, and preparing for future pandemics.

A Document Analysis of Nationally Available Faculty Assessment Forms of Resident Performance.

BACKGROUND: Written feedback by faculty of resident performance is valuable when it includes components based on assessment for learning. However, it is not clear how often assessment forms include these components for summative and formative feedback. OBJECTIVE: To analyze prompts used in forms for faculty assessment of resident performance, guided by best practices in survey research methodology, self-regulation theory, and competency-based assessment. METHODS: A document analysis, which is a qualitative approach used to analyze content and structure of texts, was completed on assessment forms nationally available in MedHub. Due to the number of forms available, only internal medicine and surgery specialties were included. A document summary form was created to analyze the assessments. The summary form guided researchers through the analysis. RESULTS: Forty-eight forms were reviewed, each from a unique residency program. All forms provided a textbox for comments, and 54% made this textbox required for assessment completion. Eighty-three percent of assessments placed the open textbox at the end of the form. One-third of forms contained a simple prompt, "Comments," for the narrative section. Fifteen percent of forms included a box to check if the information on the form had been discussed with the resident. Fifty percent of the assessments were unclear if they were meant to be formative or summative in nature. CONCLUSIONS: Our document analysis of assessment forms revealed they do not always follow best practices in survey design for narrative sections, nor do they universally address elements deemed important for promotion of self-regulation and competency-based assessment.

Patterns of North American Women Authorship in 2 Allergy/Immunology Journals: 1997-2017.

BACKGROUND: Disparities in the frequency of publications by gender have been reported in various medical subspecialties. OBJECTIVE: Review author gender in the Journal of Allergy and Clinical Immunology and Annals of Allergy, Asthma and Immunology from 1997 to 2017. METHODS: Data on frequency and patterns of authorship by gender were collected in 5-year intervals and analyzed by journal, article type, and year of publication. Logistic regression was used to analyze factors associated with a greater likelihood of first authors being women. We compared these patterns with the frequency of women AAAAI (American Academy of Allergy, Asthma & Immunology) members and AAAAI fellows-in-training. RESULTS: Women were first authors in 36.5% of publications, increasing from 26.6% in 1997 to 48.1% in 2017 (P < .001). Their share as first author was highest (42.5%) for original articles and lowest (17.1%) for editorials. Share of women as last authors increased from 18.1% in 1997 to 30.9% in 2017 (P = .001). Women were less likely to be sole authors: 17.7% (P < .001). Articles with women as first authors were observed more frequently when women were last authors (odds ratio [OR], 3.14; P < .0001). This association was more likely in original investigations (OR, 2.1; P < .001) and articles published more recently (2007, 2012, 2017) (OR, 1.75; P < .001). The increasing rate of women first authors correlated with rising proportions of women AAAAI members (Pearson correlation = 0.96; P = .01) and fellows-in-training (Pearson correlation = 0.96; P < .01). CONCLUSIONS: Women authorship has become more frequent in the Journal of Allergy and Clinical Immunology and Annals of Allergy, Asthma and Immunology. The probability of women being first authors is more likely in articles with women as last authors, implying that mentorship of women by women may encourage women to become more active in scholarship.

Interprofessional educator development : Build it and they will come.

BACKGROUND: We describe an interprofessional educator development program, designed intentionally, that was implemented at an academic healthcare centre. In 2014, we purposefully adapted our pre-existing educator development program to be able to include all interprofessional educators at our institution. The program's goals were to enhance educator skills, a common need due to requirements of accreditation, and to create a local interprofessional community of teachers. The framework of the program was based upon adult learning principles, reflective practice, experiential learning and peer groups, all key characteristics of faculty development programs. It was also longitudinal and immersive. Kirkpatrick's program evaluation model was used for identifying results; participants' self-reported evaluation forms were collected and their narrative comments were analyzed. RESULTS: After we opened our educator program to all interprofessional staff, our number of program participants increased. The interprofessional participants included, but was not limited to, physicians, physician trainees, nurses, physician assistants, audiologists, perfusionists, and basic science researchers. Our number of program sessions and program faculty were expanded. Our interprofessional participants reported that they were able to learn essential knowledge, skills and attitudes for their growth and development as educators, in the context of an interprofessional community, while also appreciating the diversity of their peers. DISCUSSION: We share our insights with the redesign and implementation of an interprofessional educator program so that others can learn from our experiences. Key takeaways include using a conceptual framework for teaching effectiveness, involving interprofessional stakeholders and obtaining their perspectives, reviewing interprofessional literature and competencies, and highlighting best practices across the disciplines.

Targeted Feedback in the Milestones Era: Utilization of the Ask-Tell-Ask Feedback Model to Promote Reflection and Self-Assessment.

BACKGROUND: The Accreditation Council for Graduate Medical Education's Milestones Project focuses trainee education on the formation of valued behaviors and skills believed to be necessary for trainees to become independent practitioners. The development and refinement of behaviors and skills outlined within the milestones will require learners to monitor, reflect, and assess their own performance over time. External feedback provides an opportunity for learners to recalibrate their self-assessments, thereby enabling them to develop better self-monitoring and self-assessment skills. Yet, feedback to trainees is frequently generic, such as "great job," "nice work," or "you need to read more." PURPOSE: In this article, we describe a feedback model that faculty can use to provide specific feedback, while increasing accountability for learners. We offer practical examples of its use in a variety of settings in the milestone era. INNOVATION: The Ask-Tell-Ask (ATA) patient communication skills strategy, which was adapted for use as a trainee feedback model 10 years ago at our institution, is a learner-centered approach for reinforcing and modifying behaviors. The model is efficient, promotes learner accountability, and helps trainees develop reflection and self-assessment skills. A feedback agreement further enhances ATA by establishing a shared understanding of goals for the educational encounter. CONCLUSION: The ATA feedback model, combined with a feedback agreement, encourages learners to self-identify strengths and areas for improvement, before receiving feedback. Personal monitoring, reflection, self-assessment, and increased accountability make ATA an ideal learner-centered feedback model for the milestones era, which focuses on performance improvement over time. We believe the introduction of the ATA feedback model in surgical training programs is a step in the right direction towards meaningful programmatic culture change.

Hyperpigmented cutaneous lesions that flare-up with scratching: Darier's sign.

We present the case of a 40-year-old male with a past medical history of urticaria pigmentosa (UP) who presented for consultation to the Allergy clinic for an opinion of systemic mastocytosis. Previous workups included elevated serum tryptase level, UP on skin biopsy and an increased number of CD117-positive/CD25-positive mast cells on bone marrow biopsy. This case emphasizes the importance of physical findings such as Darier's sign in patients with hyperpigmented lesions, which virtually supports the diagnosis UP, raises the suspicion for systemic mastocytosis and guides further diagnostic evaluation. This case also outlines the management of systemic mastocytosis.

Antibiotics are an important identifiable cause of perioperative anaphylaxis in the United States.

BACKGROUND: The diagnosis of perioperative anaphylaxis (PA) remains challenging, given its clinical setting, exposure to multiple medications, and rarity. Previous reports have found that PA is most frequently caused by neuromuscular-blocking agents. OBJECTIVE: To determine characteristics and causes of PA at our center. METHODS: We performed a retrospective medical record review to identify patients with anaphylaxis. Cases were further categorized by manifestations of anaphylaxis, age, sex, atopy, timing, tryptase level, and previous PA events. Cases with a cause identified by skin or in vitro tests were classified as IgE-mediated anaphylaxis. RESULTS: Thirty cases were identified. Seventeen (57%) had an identifiable cause: antibiotics in 10 (59%)-ß-lactams in and metronidazole in 1; latex in 3 (18%); and neuromuscular blockers in 4 (23%). There was no identifiable cause in 13 cases. The most frequent presenting sign of PA was hypotension (97%). Seven patients (23%) presented with cardiac arrest. A minority (17%) exhibited urticaria. Only four had a history of atopy. Most of the reactions occurred during the anesthesia induction phase. Elevated serum tryptase level was found in 10 of 10 (100%) cases of IgE-mediated anaphylaxis compared with 4 of 10 (40%) cases without an identifiable cause. CONCLUSIONS: We found that antibiotics were the most common identifiable cause of PA. Our findings imply that antibiotic exposure warrants careful attention in the evaluation and management of patients with PA, particularly for those who require repeat and/or future surgeries.

Penicillin allergy: consider trying penicillin again.

A history of allergy to penicillin does not necessarily rule out using penicillin again. With skin testing and, in some cases, desensitization, most patients with a history of penicillin allergy can safely receive the drug.

Modified oral metronidazole desensitization protocol.

The Center for Disease Control guidelines recommend desensitization to metronidazole in patients with trichomoniasis and hypersensitivity to metronidazole. There is only one published oral metronidazole desensitization protocol. The purpose of this study was to design a new, more gradual oral desensitization protocol to decrease systemic reactions that may occur when using the previously published protocol. We present two patients with presumed IgE-mediated allergy to metronidazole who underwent oral desensitization using our modified protocol. Case 1 was a 65-year-old woman with trichomoniasis who presented for metronidazole desensitization with a history of intraoperative anaphylaxis and positive skin tests to metronidazole. The patient tolerated six doses of the modified desensitization but developed systemic symptoms of nasal congestion and diffuse pruritus after the 25- and 100-mg doses. Both reactions were treated with intravenous (i.v.) antihistamines. Because of gastrointestinal irritation, the desensitization was completed at a dose of 250 mg orally every 6 hours. Case 2 was a 42-year-old woman with trichomoniasis and a history of hives immediately after administration of i.v. metronidazole who presented for desensitization. The patient had negative skin-prick and intradermal testing to metronidazole. She developed lip tingling and pruritus on her arms 15 minutes after the 10-mg dose. Fexofenadine at 180 mg was given orally and symptoms resolved. She tolerated the rest of the protocol without reaction and received a total dose of 2 g of metronidazole. Our oral metronidazole desensitization for presumed IgE-mediated reactions offers a second option for physicians wishing to use a more gradual escalation in dose.

Nonallergic rhinitis: common problem, chronic symptoms.

Nonallergic rhinitis can significantly affect a patient's quality of life. It is difficult to distinguish from allergic rhinitis, but it has different triggers, and its response to treatment can vary. We review its differential diagnosis, causes, and treatment.