The roadmap for allergology in Europe: The subspecialty of allergology as “stop-over” on the way to a full specialty. An EAACI position statement

1 INTRODUCTION

The prevalence of allergic diseases is high with allergic rhinitis ranging from 17% to 29% in Europe,1 and asthma fluctuating from 1.3% to 11% in European surveys among children and adults.2 Increasing trends are also recorded in childhood and allergic rhinoconjunctivitis and asthma affects up to 20% of children worldwide.3, 4 In the UK, from 1990 to 2004, hospital admissions for anaphylaxis have increased by 700%, for food allergy by 500%, for urticaria by 100%, and for angio-oedema by 40%.5

The high burden of allergic diseases imposes substantial demand on health care services. The vision of the European Academy of Allergy and Clinical Immunology (EAACI) and the Union of European Medical Specialists (UEMS) Section and Board (S&B) on allergology is to promote and to establish full specialties of allergology in all European countries. However, allergology is recognized as a full specialty in only 12 (data from 20136) and as subspecialty in six European countries. Some countries do not recognize at all specialists with expertise in allergy. There is an obvious gap between the need and availability of experienced and accredited physicians who can deliver optimal care to the allergic patients. In those countries, where no full specialty in allergology exists, organ-based (sub)specialists or paediatricians and internists with an expertise in allergology may cover allergy care. The different medical systems across Europe do not always stipulate for well-delineated care and training curricula in allergology, and consequently, physicians with different backgrounds, internists, paediatricians or organ-based specialists with an interest in the field should receive specific training in allergy and/or immunology to fill up the gap. Although the minimal requirements for the training of a full specialist have been described in the Logbook and Core curriculum of allergology,7 there are no generally accepted requirements for subspecialists available. Consequently, there is a need to harmonize the education and training for such subspecialists across Europe. This subspecialist is not meant to replace the full specialist, but to provide adequate services. Moreover, the institution of subspecialists should pave the way towards the full specialty, recognized in all European countries. One example is France, which started with allergology as a competence for general practitioners, subsequently instituted a subspecialty and finally established apart from the subspecialty the full specialty in allergology in 2017.

This paper aimed to propose the minimal requirements for training and certification of subspecialists in allergology.

2 METHODS

This consensus document was prepared by the EAACI Specialty Committee. Contributors were Roy Gerth van Wijk (chair) and Norbert Muelleneisen (secretary), both representatives of the UEMS S&B, Jacques Gayraud and Ted Popov representing the European Committee of Continuous Education for Allergologist Practitioners (CEFCAP), Ibon Equiluz-Gracia, Jan Gutermuth, Eckhard Hamelmann, Enrico Heffler, Peter Schmidt-Grendelmeier, Peter Valentin Tomazic, Olympia Tsilochistrou representing EAACI. In January 2016, the EAACI Specialty Committee and a representative of the EAACI National Societies Council met in Zurich to discuss and draft the paper setting minimal requirements for a subspecialist in allergology. The committee convened on 8 January 2016, 10 June 2016 and 3 February 2017 to prepare and finalize the paper.

3 GENERAL ASPECTS OF THE SUBSPECIALTY OF ALLERGOLOGY

Allergology, unlike other medical specialties, does not deal with single-organ/system diseases, but it applies by definition to systemic diseases. Therefore, a systemic approach to allergic diseases has to be the major component of education and training of residents in allergology subspecialty. Allergology either full or subspecialty deals with allergic diseases and involves the diagnosis and comprehensive management of disease while it is strongly related to basic and/or clinical research. This subspecialty programme of EAACI aimed to guide fellows towards the training programme to become medical experts and professionals in the allergy field.8 This programme may offer national authorities a framework to ensure a standard of qualifications of the allergy subspecialists as well as their unrestricted move for training across Europe. We believe that organ specialists involving systems where allergic mechanisms originate and/or take place (eg dermatologists, ENT or respiratory physicians), and those with a systemic approach and management of diseases such as internal medicine doctors and paediatricians should be given the opportunity to obtain dedicated training in order to receive accreditation as subspecialists in allergology. The training in the subspecialty should be focused on competences and skills applicable for all allergy fellows, but these competences and skills can be tailored to the different full specialties. The theoretical background knowledge should be identical for all fellows. EAACI organizes annually the EAACI/UEMS Knowledge Exam in allergology and it is highly desired that this accreditation becomes accepted by national authorities across Europe to certify skills in allergology.

The duration of training must be commensurate with the complexity and variety of topics which will be dealt with both in their theoretical background and in practical settings. Therefore, we believe that a minimum duration of 18 months is required to capture the basic aspects of the subspecialty. This training may not provide the broad spectrum of knowledge and skills as described in the core curriculum of the full specialist in allergology.

The requirements for the proposed paediatric subspecialty are not comparable with the already existing demands for paediatricians trained as tertiary care specialists with the capacity for independent practice (2-3 years of training after common trunk). This training has been described in the European Syllabus in Paediatric Allergology as approved by the European Board of Paediatrics and UEMS9 and published on the EAACI website.10 The subspecialist as described in this paper should be competent to provide good care to patients in an environment lacking those full specialists or tertiary care paediatric subspecialists. We also did not touch clinical immunology. Clinical immunology in Europe is predominantly covered by internists, rheumatologists and allergologists with a combined specialty of allergology and clinical immunology.

3.2 Skills

Allergic disorders are systemic in nature and have a broad spectrum of organ manifestations. Taking this into account, an acceptable level of competence is required for all physicians who take care of allergic patients but who are not allergy specialists.12 This competence should encompass theoretical knowledge and practical skills.

Table 2 gives an overview of skills for all subspecialists and skills tailored to the different backgrounds of specialists.

Table 2. Overview of skills (theoretical and practical) based on consensus between the committee members

4 PERSPECTIVES: THE ROAD TO THE FULL SPECIALTY

In terms of allergy services and allergy care, Europe is characterized by substantial heterogeneity (Figure 1). As stated in the blue print,6 quality criteria in allergy health care comprise the availability of physicians trained in allergy who are able to perform a comprehensive medical allergy history and physical examination. Patients expect safe and adequate allergy testing, optimal preventive advice and treatment and a doctor who is a good communicator in counselling and education. The key person in allergy health care should be the full specialist interacting with general practitioners, occupational health physicians, general and organ-based specialists. Ideally such care should be delivered by an allergy centre, staffed by allergists and supported by appropriately trained allied health professionals. EAACI takes the position that this level of allergy care should be achieved in every European country.

However, also in countries lacking the full specialty of allergology, patients are entitled to have access to the best possible allergy service. Subspecialists can meet the needs of these patients provided that they are competent in diagnosing and treatment of these patients. In the absence of well-defined and well-accepted criteria for the training of such subspecialists, this paper aimed to give guidance regarding the (1) minimal requirements for the disciplines and countries that would like to establish subspecialties in allergology and (2) common criteria for existing subspecialties as well. Without a leading or coordinating allergist, such subspecialists with different backgrounds need to cooperate, share competences and speak a common language. Harmonization in training is the only way to achieve that.

For several European countries like Switzerland and France, subspecialties were the starting point for establishing full specialties. Some other countries are far away from the full specialty. Development of recognizable subspecialties in allergology may be the first step in these countries.

The subspecialties proposed in this document do not have a formal status at the UEMS level which is reserved for the full specialty of allergology as all subspecialists are already part of a recognized specialty. Developing competing specialties is not the aim and the ultimate goal is to set general standards for all specialists dealing with allergic patients.

DISCLAIMER

We unconditionally support allergology as a full speciality in every country of the world. This position paper is however outlining the optimal circumstances related to the organization of training of subspecialists in allergology. It is meant to help countries, where allergology is not recognized as a full specialty, to set up surrogate health care in the field. It is not intended as a legal/mandatory document.

FUNDING

This work was funded by the European Academy of Allergy and Clinical Immunology (EAACI).

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.