My day as the Immunology registrar starts at 8:30am. I’ve been on call overnight and have admitted a 30-year-old man with known hereditary angioedema (HAE) who presented with severe abdominal pain. Although he’s been given C1 inhibitor concentrate and his pain is a little improved, he presented late this time and was in the throes of a severe attack so it will take a while to settle. I make sure he has adequate analgesia and fluids, and we have a brief chat about an action plan for his next attack. He’s considering commencing regular prophylaxis but is unsure; our clinical nurse consultants know him well and will come up and talk him through the details.
I run through the overnight notes for our inpatients and call our team resident to ask her to troubleshoot a few priority issues and do a brief round as I need to head to clinic. It’s our Paediatric clinic day – my favourite.
My first patient is a delightful little six-month-old baby who I first met a few weeks ago when we admitted her with severe eczema; she has done wonderfully well with wet dressings and topical steroids. Her skin looks great and her parents are thrilled, and most importantly, feel confident with the ongoing management of the condition.
I see a teenager with peanut allergy and poorly controlled asthma, it’s a dangerous combination and my consultant and I spend time building rapport and trying to get through to him about his asthma control and taking his allergy seriously. At the end of the consultation we feel like we’ve gotten through to him but it remains a work in progress.
Just as we’re finishing that consultation, the nurses call us out to the food challenge area to see a five-year-old who has broken out in widespread hives during a challenge to see whether she will tolerate milk. She settles with antihistamines but she and her parents are disappointed we won’t be able to clear her of her allergy today.
After clinic we have a meeting to discuss our cases which is always a great learning experience. I enjoy hearing my consultants’ approach to the practicalities of managing complex food and drug allergy, asthma, and autoimmune conditions. We grab a coffee and I head up to the ward to see our inpatients and consults.
We have a patient who came in with a rash and renal impairment; a kidney biopsy has demonstrated pauci-immune glomerulonephritis and she has high titre PR-3 antibodies. I explain the diagnosis of ANCA vasculitis and answer her questions. She has already been pulsed with high dose corticosteroids, but we need to plan for more intensive immunosuppression. The options include cyclophosphamide or rituximab; she is young and wants children and so we discuss the potential fertility implications of cyclophosphamide and give her some time and space to make a decision.
A man living with well-controlled HIV has come in with ataxia; a lumbar puncture suggests tertiary syphilis and we have commenced a two-week course of IV penicillin. A third patient is a diagnostic dilemma with an unusual skin rash, splenomegaly and significant eosinophilia. I take a skin biopsy of the rash and book her in for a PET scan.
I update my consultant on the inpatients and take her to see our new consults. An 18-year-old woman has been admitted under the Neurology team for a week with seizures and psychosis; we suspect autoimmune encephalitis and give advice on the relevant antibody tests to send off. She has been started on IVIG and IV methylprednisone but it’s too soon to expect an improvement. Her family are fearful for what the future might hold, and we speak to them at length about her progress and our treatment suggestions.
We see a patient who has been admitted under the Respiratory team with a severe asthma attack; we have been asked to consider him for a trial of a biological agent for asthma. He meets the criteria for omalizumab and we explain what this entails. He is very keen to take it up and we book him for a clinic review on discharge. We have a cohort of patients on biological therapies for severe asthma, many of whom have had a significant improvement in their quality of life and we are hopeful that we can reduce his hospital admissions and reliance on corticosteroids. I swing back past the patient with HAE; he is a lot more comfortable and will be able to go home tomorrow.
It’s now 4pm and I head back to my desk to edit some letters and make phone calls to my patients. I share an office with the other advanced physician trainees and we chat about our day and share some chocolate. At 5:30pm I head out the door – the commute home is long but I have a steady stream of podcasts to keep me entertained and look forward to seeing my daughter and husband at the end of the drive.
I love the intellectual challenge of Immunology, and the chance to think about complex and rare conditions. It’s an exciting time to be an immunologist given the range of emerging biological therapies and the ever-expanding role of genetic diagnosis. The options for our patients have improved so much even in the few years that I have been an advanced trainee, and I love seeing our patients’ quality of life improve when we make a diagnosis and can offer effective therapy for conditions that we couldn’t treat very well 10 years ago.
We see patients across the full age spectrum – from young children to the elderly. The conditions that we manage are similarly diverse – from autoimmunity, to allergy, to HIV, to primary immunodeficiencies. As much as we are known as a “niche” specialty, in many ways we are generalists because the immune system affects every part of the body. No day is the same and no day is boring. We often look after our patients for many years, and that continuity of care is something that I find very meaningful; it is a privilege to come to understand my patients’ values, priorities and hopes and to try to help them achieve their healthcare goals.
As part of Immunology training we have the opportunity to become dual trained as Immunopathologists (a dual fellowship with the Royal Australasian College of Physicians and Royal College of Pathologists of Australasia). This involves an extra year of training, with two years of advanced training being spent in clinical posts and two years in laboratory posts as well as additional exams. It’s quite different to clinical medicine, but is an excellent opportunity to really understand the tests that we order as clinicians.
Apart from my clinical role, the other awesome part of Immunology is the people. It’s a small, close-knit specialty and I have loved every department that I have worked in as an advanced trainee. On the whole, consultants, trainees and allied health get on very well and this makes all the difference – particularly when you have a long day or are tackling a challenging clinical situation.
I absolutely love my job and would wholeheartedly recommend Immunology training to anyone considering it!
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