NIH Clinical Center Building
NIH Clinical Center
The majority of clinical training in the Allergy & Immunology (A&I) Fellowship Program takes place at the NIH Clinical Center, based on the NIH main campus in Bethesda, MD. The NIH Clinical Center includes 200 inpatient beds and 93 day hospital stations, as well as 15 outpatient clinics. All patients admitted or seen at the NIH Clinical Center are enrolled on research protocols.
NIAID Inpatient Ward Rotation (1.5 months in first year)
During this 1.5-month rotation at the NIH Clinical Center, fellows work with senior investigators and supervise and teach a team of four internal medicine residents from George Washington University and Georgetown University in the evaluation and care of patients with complex immunologic and allergic diseases, as well as complications associated with these diseases.
This rotation affords the unique opportunity to evaluate and manage opportunistic infections in adult and pediatric patients with a range of inherited and acquired immune defects. The NIAID inpatient ward admits 40 to 60 patients per month who are enrolled in various infectious diseases and immunology clinical research protocols.
Some of the conditions that fellows see during this rotation include but are not limited to HIV/AIDS, immune reconstitution syndrome; tuberculosis (drug-sensitive and -resistant); parasitic infections; chronic granulomatous disease and hyper-immunoglobulin E (Job’s) syndrome with invasive bacterial and fungal opportunistic infections; immune disorders that cause susceptibility to disseminated mycobacterial infections; bronchiectasis disorders that lead to increased susceptibility to pulmonary mycobacterial infections; chronic active Epstein-Barr virus infection; X-linked agammaglobulinemia; X-linked severe combined immunodeficiency; leukocyte adhesion deficiencies; hyper-immunoglobulin (Ig)M syndromes; and GATA-2 mutations resulting in increased susceptibility to both infectious and hematopoietic complications.
The inpatient ward team also manages patients who have undergone stem cell transplantation for these immunodeficiencies and evaluates patients admitted with opportunistic infections due to as-yet-undefined immune defects. Through exposure to this unique array of conditions, fellows acquire an in-depth understanding of immunology and how dysregulation of specific arms of the immune system confer particular infection susceptibilities.
NIAID Outpatient Rotation (3 months in first year)
This 3-month rotation (split into two 1.5-month blocks) provides fellows with exposure to patients with complex allergic and immunologic patients in the outpatient, clinical research environment. Through this experience, fellows gain expertise in diagnosing and managing immunologic diseases and associated complications by working with senior NIH investigators. Typical disorders seen in the NIAID outpatient clinic include autoimmune lymphoproliferative syndrome, PI3K deficiency, monogenic allergic disorders with atopic dermatitis, hypereosinophilic syndromes, eosinophilic gastrointestinal disorders, mastocytosis, hereditary alpha tryptasemia syndrome, physical urticaria, DOCK8 deficiency, hyper-IgE syndromes, common variable immunodeficiency with gastrointestinal complications, and chronic granulomatous disease.
NHLBI Pulmonary/Pulmonary Function Laboratory Rotation (3 weeks in first year)
The NHLBI pulmonary consult and pulmonary function lab rotation provides training in the laboratory evaluation of airway function (including pulmonary function testing, methacholine challenge, and exercise challenge testing), asthma diagnosis and management, asthma management in special circumstances (e.g., pregnancy), occupational lung disease, allergic bronchopulmonary aspergillosis, and the evaluation of pulmonary disease in patients with immunologic diseases.
Allergy and Immunology Consultation Service (1.5 months in first year; 1.5 months in second year)
The allergy and immunology consultation service provides consultations for patients on protocols through the NIH Clinical Center, including the Undiagnosed Diseases Program. Fellows manage the consultation service for 1.5 months each year during the first and second years of training. Areas of particular focus are immunologic reactions to drugs and biologic agents, radiocontrast reactions, anaphylaxis, and immunodeficiency evaluations. Fellows provide consultations under the supervision of the faculty of the consultation service, with case-based teaching and literature reviews. Procedural competency developed during this rotation includes skin testing, graded challenges, and induction of drug tolerance.
NIAID Genomics Rotation (3 weeks in first year)
Fellows receive specific didactics on genetics in immune disorders. In the second half of the year during the genomics rotation, fellows develop competencies in approach to genetic disorders, gaining confidence in assessing research variants for patients receiving exome and whole genome testing on NIAID protocols. Fellows work closely with genetic counselors and molecular geneticists to develop competencies in variant interpretation.
NIAID Primary Immune Deficiency Continuity Clinic (11 clinics in second year)
The NIAID Primary Immune Deficiency (PID) Clinic provides second-year allergy and immunology fellows with ongoing development of advanced clinical immunology laboratory and genomics interpretation skills in the diagnosis and management of patients with complex or undiagnosed primary immune deficiency and immune dysregulatory disorders. Second-year fellows evaluate patients with attending supervision and participate in case presentations and discussions of the patients with other fellows and faculty who have experience with these disorders. Development of independent assessments and treatment plans and the use of patient-based literature reviews is strongly encouraged. In addition, fellows are integrated into the patients’ research teams and are involved in the investigation of novel immune deficiency diseases, including publications that result from their contributions. Third-year fellows are required to attend and participate in the PID Clinic Case Conference twice a month, where cases are discussed with the broader NIH, Children’s National Health System, Johns Hopkins, and George Washington University PID community.
Rotations Outside NIH
Schreiber Clinic (3 months)
Fellows have the opportunity to spend time in a well-run private practice environment with high volume covering the breadth of common allergic and immunologic diseases. Fellows learn how to prepare and prescribe allergen immunotherapy, biologics, and food oral immunotherapy. Management of the spectrum of conditions including venom allergy, drug allergy, sinus disease, and contact dermatitis, as well as ample procedures are seen at this clinic with Dr. Rachel Schreiber. Fellows gain comfort in practice management concepts, billing/coding as well as cost and insurance considerations during their training at this site. Read more about the Schreiber Clinic.
Children’s National Hospital System
The pediatric allergy and immunology rotation at Children’s National Health System is designed to provide training in the breadth of allergic and immunologic disease seen in children. Initial workup, diagnostic testing, management, and follow-up care for these disorders will be emphasized. Over a 3-month block, first year fellows will receive education and training in outpatient clinics with multidisciplinary exposure in pulmonology, bone marrow transplant, gastroenterology, and/or rheumatology. Procedural experience with hypersensitivity skin testing, allergen immunotherapy, food and medication challenges, prescription of gamma globulin replacement and biologic treatments, and interpretation of pulmonary function testing will also be included. Fellows will gain experience with interpretation and management of newborns with abnormal TREC assays for T-lymphopenia/SCID. In-patient consultation will be provided for allergic/immunologic problems (including pediatric drug allergy, atopic dermatitis, asthma, and immunodeficiency diseases) and for select patients on hematopoietic stem cell transplantation service (with immunologic diseases). Clinical training will be supplemented with lectures and journal clubs. In addition to the Primary Immune Deficiency Continuity Clinic, fellows can elect this site for their basic allergy and immunology continuity clinic.
Johns Hopkins Hospital
John Hopkins University Hospital (1 time per week for 3 months)
While on the 3-month Children's rotation, first-year fellows have an elective rotation one day per week at Johns Hopkins University designed to expose them to advanced training in the diagnosis and management of food allergy, eosinophilic esophagitis, and atopic dermatitis in children. Fellows participate in food challenges during this elective rotation to complement the training at Children’s National Medical Center.