Developing that immunology spidey sense

“It’s not about knowing each one. It’s about knowing the patterns, the warning signs, the general pathways, and knowing when to ask a friend when you’re a little bit lost.” —Dr. Tamar  Rubin

On this episode of The Allergist, Dr. Mariam Hanna turns the focus to how allergists LEARN to recognize when common presentations may signal a deeper immune problem — and how that diagnostic instinct is built, taught, and sustained.

She’s joined by Tamar Rubin, pediatric allergist and clinical immunologist, Assistant Professor at the University of Manitoba, and a national leader in immunology education. Dr. Rubin makes the case that inborn errors of immunity are not a fringe interest, but central to understanding immunology across allergy, asthma, infection, and biologic therapies — and that allergist-immunologists are the specialists uniquely trained to recognize and teach this.

On this episode, they discuss:

• Why allergist-immunologists “own” inborn errors of immunity, and why teaching these conditions is part of the specialty’s responsibility
• Moving trainees away from memorizing rare syndromes and toward recognizing immune pathways, patterns, and warning signs
• How patient-based teaching, case discussions, OSCEs, and national academic half-day curricula help trainees develop diagnostic “spidey sense”
• What happens when you build dedicated immunology clinics, and how volume and exposure increase once you start looking
• The importance of national collaboration and collegial networks when managing ultra-rare immune conditions
• Practical ways allergists in community practice can stay engaged with inborn errors of immunity, even with limited volume or access to specialized testing
• Knowing when — and how — to ask for help matters as much as knowing the diagnosis.

Because in the end, inborn errors of immunity aren’t just about rare diseases. They sharpen how allergists think, teach, and listen when the immune story doesn’t quite fit.

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The Allergist is produced for CSACI by PodCraft Productions

Transcript

0:00

Dr. Mariam Hanna Hello, I'm Dr. Mariam Hanna and this is The Allergist, a show that separates myth from medicine, deciphering allergies and understanding the immune system. My patients these days have come with caregivers that think that every allergy diagnosis is the tip of the iceberg. Recurrent infections, could there be something else going on? Chronic eczema, is it a missing allergy, is the question they came in with. And then a silence fills the room. As I troubleshoot, I've learned it's okay to let a few seconds of silence fill the room. It means I'm listening, processing and considering, could there be something else? So beneath the surface there's often a deeper structural immune problem that only shows itself if you know what you're looking for. Behind every drug that's modulating a symptom, could there be a bigger process that it's stopping or perhaps redirecting? We don't know what we don't look for, we don't know what we don't consider. And when I start intervening early and with systemic medications, it's because I'm trying to consider what path their immune system is heading towards. But always, always, what I have to remember is those rounds and case presentations and those patients that don't fit the mold, or perhaps they did at some point and later went on to be diagnosed with a genetic cause for their condition. And that shred of learning that I still remember from training and conferences, it's the scaffolding I rely on to get through these consults. Sounds scary, right? Sounds terrifying. And that's why we have to rely so much on what we place into our trainees and our ongoing learning. Today, what we're going to do is we're going to dig into what is the scaffolding that we are providing our trainees in inborn errors of immunity, an area of growing importance, particularly as we get new drugs, and we get new abilities to make better diagnoses. Today, we have a very special guest. Dr. Tamar Rubin is a pediatric allergist and clinical immunologist, but she wears her clinical immunology with flair. She's an Assistant Professor of Pediatrics and Child Health and Internal Medicine at the Rady Faculty of Health Sciences at the University of Manitoba, and she has served as the training program director for Pediatric Clinical Immunology and Allergy at U of M since 2019. Her academic focus is all into inborn errors of immunity, and her big career highlight to date has been developing the Pediatric Clinical Immunology program within the section of Allergy and Immunology at the U of M. Through this work, she's established a medical home for a huge population with immune disorders. You don't find them until you start putting a program in place to find these guys. She frequently lectures to medical trainees and undergraduate and postgraduate levels, as well as to the subspecialists and primary care trainees and physicians, both locally in her region and nationally across the country. She is the chair of the Canadian National Distributed Academic Half Day, which develops and implements the weekly curriculum for all Pediatric and Adult Clinical Immunology and Allergy trainees across Canada, between brackets outside of Quebec, and has recently established an annual faculty-led basic immunology course as part of that National Academic Half Day. So inborn errors of immunity are huge, and this person is the one that makes sure that all our trainees across Canada are getting good foundational knowledge in this. And with this, it's my absolute pleasure to introduce Dr. Rubin. Dr. Rubin, welcome to the podcast. Dr. Tamar Rubin Thanks so much, Mariam. It's a pleasure to be here today. Dr. Mariam Hanna So Tamar, I know you from actual residency training in pediatrics, and I should say to our listeners that Dr. Rubin is in no way related to the other Dr. Rubin that we have recently had on a previous podcast episode, which you might get confused about. So this Dr. Rubin is all about immunology, immunodeficiency in Canada, and I want to start with kind of just understanding why immunology is such an important component in developing competency in our trainees. Dr. Tamar Rubin Yeah, that's a great question. I think one thing is that as allergists, immunologists, we actually kind of own primary immune deficiency or inborn errors of immunity. And what I mean by that is that we are the experts. We are the only specialists where inborn errors of immunity, primary immune deficiency is actually part of our training. So if we don't learn about these rare conditions, if we don't teach the next generation about these rare conditions, no one else is going to have that specialized important knowledge to treat these patients. But I think even going beyond that, as you had kind of alluded to at the beginning today, learning about these pathways helps us learn immunology, and immunology is central to understanding all aspects of our specialty from asthma to food allergy to oral immunotherapy to the biologics and treatments that we're using to treat all of the different conditions within our specialty. So immunology, inborn errors of immunity is central to everything that we do. And we have the ability to also recognize and treat that small population within our specialty in addition to all those common conditions. Dr. Mariam Hanna I also find that inborn errors of immunity are so rare, like the rarity of them makes me think of back in training, actually, there would be these like cross Canada cardiac surgery rounds where like rare cardiac cases would be presented, and then they would talk about like what would be the best intervention in this particular patient. Are we still dealing with like barriers and lack of like, you know, the rarity of these patients and not knowing what to do with them at different sites across Canada? Is that still an issue or a barrier? Dr. Tamar Rubin Yeah, so that's a great question. I think we, in general, inborn errors of immunity as a group, if you kind of take all comers, all different inborn errors of immunity, we know there's many different categories and, and different types, they're not that rare. But there are at every center, individual patients who have a really rare condition, and sometimes multiple individuals with highly rare conditions where, you know, an individual provider maybe has only seen this once in their life, and may never see another case of it again. So cross, I guess, collaboration is so important, right? Having this network of people that you can talk to about these rare cases is super important. So, you know, I have a lot of patients who have like, N of 1, N of 10 in the world kind of cases, but I am super lucky to be able to, you know, call a friend across the country. And I actually think, you know, tying this back to the National Education Program, having this national academic half day where clinical immunology and allergy fellows across the country get to interact with each other, meet faculty across Canada, you kind of feel like you know, your colleagues more. So when we see them at conferences, you're like, Oh, hey, I have a question. Have you ever seen this? Or you send an email to a colleague, because you know that they're an expert in that area. And we're very lucky. I feel like it's a very collegial community in Canada in the IEI world, and in allergies, of course, too. Dr. Mariam Hanna What's the best way to be teaching trainees to think more of the immune pathway rather than just memorizing a syndrome? Dr. Tamar Rubin So I think there's a lot of different ways that we can get trainees to learn immunology, and not to just memorize one condition. I do find that individual patients and clinical exposure is a really good way to start. But that's not enough. So, you know, when I have a trainee come to my clinic, and let's say we see a patient who was referred because of disseminated non-TB mycobacteria, we talk about, okay, so what are the pathways that are important for protecting our body against non-TB mycobacteria, mycobacteria in general? So what parts of the immune system could be affected? And what other types of infections or problems might someone have if those parts of the immune system are knocked out or weak? What biologics might also produce that same thing? And so you kind of talk about an individual case to do that teaching about a pathway, but then you could also get back to a lecture on, you know, Mendelian susceptibility to mycobacterial disease in the half-day. Or maybe you also have a simulation session or an OSCE case relating to a patient with mycobacterial or viral infections. We here in Manitoba have a continuity clinic for our fellows, and we have a logbook so that our trainees can keep track of cases that they've seen or haven't seen so that they can request to book certain types of patients if they haven't seen those. Now, we don't always, of course, have, you know, that extremely rare patient, right? But if we don't, that tells us, okay, we need to make an OSCE case for our trainee about this. Or this is something that we have to sit down and talk about. Or we need to provide a paper for you to read about. So it's impossible to know every single one of the, I can't even keep track of the number of IEIs in the last IUIS iteration, but there's more than 500. And so it's not about knowing each one. It's about knowing the patterns, the warning signs, the general pathways, and knowing when to ask a friend when you're a little bit lost. So we want all of our trainees to have a really solid, spidey sense for when something is needing a workup, feeling confident to order genetic testing when it's needed, and probably order it early, as we have been moving towards in the last number of years, knowing how to interpret it. But when it's negative, or when you get an unexpected finding, or when you don't know how to interpret that finding, or it's just a really rare disease that you don't know about, then knowing who to call, how to ask, where to look. Dr. Mariam Hanna So not having to know everything, but just having great spidey senses and a great approach to it. But some of it, like developing your nose and developing that approach requires volume. Are we at a point now where nationally these cases are presented for others to provide input as to what kind of workup further should be done, or what kind of genetic testing further should be done? Do we do that routinely like on a national level, or is it peer-to-peer that's happening? Dr. Tamar Rubin Yeah, so I think from like an individual program standpoint, the expertise, the experience is growing because we actually have quite a strong immunology interest expertise now across the country, not just at a couple of larger centers. And that's really grown. And I think it's like a new generation of... That's awesome. That's great to hear, actually. It's really amazing, right? So I think thinking about what it was like 10, 15 years ago when we were in our fellowships or residencies, and it seemed like super rare. Only a couple centers knew how to handle this or look for this. It's really changed a lot. So I know when I started as a fellow, I was really excited to be part of the inaugural immune deficiency clinic in the allergy immunology department. And we were seeing two to three patients once a month in our clinics, mostly new consults. Now we have weekly immune deficiency clinics. Our clinics are bursting at the seams. They're a full day. About 50% of our inpatient consults are for inborn errors of immunity or query immune deficiency questions. We've established a joint immunology bone marrow transplant clinic with our Heme-Onc colleagues that happens every month or every other month. So if you build it, they will come. Once you start looking, the volume just kind of floods in. And we're having a hard time keeping up with the volume here. And so whereas 10 years ago, it was like, are our trainees seeing enough? Now with newborn screening, with the immunology clinic, there's lots of exposure, lots of opportunities. And I think that's true for other centers. And speaking with my colleagues, other program directors, other clinician educators, so that's great. And then through the National Academic Half Day, we have dedicated about 50% of lectures to immunology themes and topics, including immunology case of the month, where trainees across the country can share interesting rare cases. But also just in, you know, if a trainee is assigned a lecture on the topic of chronic granulomatous disease, if they have a case locally, they can present that, share it, and also ask questions of their colleagues and peers across the country as part of that National Half Day, which is a great opportunity too. Dr. Mariam Hanna The overlap between other specialties when IEI is part of the question is huge. We have infectious diseases, hematology, sometimes depending on the presentation room, or GI sometimes. And this, this cross specialty is great, but also sometimes leaves the immunologist out of the story, or not knowing how to steer the ship appropriately. And how do you, how do you balance or structure that? In a lot of our patients, they have other downstream symptoms or issues that need other specialists to get involved. How are we training our trainees to be able to find that right balance? And how do you do it right now with your patients? Dr. Tamar Rubin Yeah, so I think learning how to collaborate with other subspecialties, subspecialists, and other areas of medicine is essential. We all work together, we're all serving our patients, and we're all learning together. And that's in fact, even one of our EPAs, for those who aren't familiar with the Royal College EPAs, those are called entrustable professional activities. But the idea is that, you know, we're actually evaluating and making sure our trainees know how and when to collaborate and refer to other subspecialists. A lot of our trainees end up doing selectives during their training in complementary areas. For example, we have electives here set up for infectious diseases, for rheumatology, for GI, for genetics. These are optional, not every trainee is going to choose those. But it's a great opportunity to understand what the scope and strengths of different specialties are, and how we can collaborate and work together. And we try to set up the selectives and the objectives of training in those areas, so that we can really maximize our residents' learning. So for example, in ID, we try to make sure our residents are getting exposure to immunocompromised ID, and to seeing patients, you know, with secondary immune deficiencies, or unusual infections. When they go to genetics, they have the opportunity to learn about ordering, interpretation, counseling related to genetic testing, for example. Dr. Mariam Hanna And this is huge, because the genetics portion is like exploded. And that's great to actually hear. Yeah, yeah, definitely. Dr. Tamar Rubin Right in GI, there's a lot of overlap, obviously, with allergic conditions, right? So like all those non-IG mediated GI diseases that kind of overlap with the allergy aspect, but also early onset IBD, and the evaluation and management of that. And in some cases, joint immunology, other subspecialty clinics is a really valuable way to collaborate together, because we have a lot to teach each other. So I mentioned that we've established an immunology heme–onc BMT clinic. And so we'll see patients post-transplant longitudinally monitor their immune system. And also those complex hematology patients that may be the ALPS-like, the multi-lineage cytopenias that may also have an inborn error of immunity. And I found it really valuable. I learned so much from my heme–onc colleagues. And I think they're hopefully learning a little bit from our slightly different angle in terms of how to best manage these patients and give them the best possible treatments, workup, etc. Dr. Mariam Hanna We do better when we work together. Okay, and then I'm going to leave the trainees alone for a little bit. How do I maintain my competency in community practice? So the first thing that happens is I say, like, I don't have access to these tests. And then I don't really see the volume of these. So I'm going to stick with my allergy hat more. But I really do need to maintain my diagnostic curiosity or confidence to smell out the patients that need further workup. So what do you suggest to those that are in community practice to maintain that level of knowledge? Dr. Tamar Rubin So I mean, I think conferences are a really good way to kind of maintain that exposure, like hear what's new. You know, for example, I think a lot of us have learned that the new name for primary immune deficiency is inborn errors of immunity through, you know, attending conferences. And even if you're not mainly practicing in the area of inborn errors of immunity, or maybe don't have the capacity in your community clinic to order all those specialized tests or, you know, manage patients who may also be more complex of other pediatric subspecialists or adult subspecialists involved in their care, you can still kind of have a sense what's new, what's going on. There are some really great resources. For example, the Clinical Immunology Society, CIS, has a summer school and a diagnostic school, which is both for fellows and for, you know, faculty in practice. And the European Society of Immune Deficiency also has that. And I'll put a plugin for SINC, if you're not familiar with that, that stands for Clinical Immunology Network of Canada. And the SINC network, which a lot of the immunologists across Canada are involved in, has an education subcommittee. And we're actually working on developing a course on biologics and impact of biologics. Dr. Mariam Hanna Amazing, amazing. And then others can travel to a tropical destination and listen to it. So love that both ways. Okay, if you can give one piece of advice to our fellowship directors or faculty that is involved in teaching fellows to strengthen their IEI training, what would be like your biggest pearl in developing, I'm sure, all the curriculum and these approaches to teaching? Dr. Tamar Rubin So I would say to offer that exposure. So if you have someone at your centre that has an interest in IEI or immunology and is either seeing these patients or doing that teaching, make sure to advocate for getting medical students to come to those clinics, making room in the medical school curriculum for these lectures, fostering that interest and excitement. Because I think one of the barriers is that people just don't know about A, our field of allergy immunology, but also about immunology. I give a lecture on inborn errors of immunity to the Med 1 class here. And always after the lecture, I get emails saying, oh, can I come shadow your clinic? And I think that's a great opportunity to really foster that excitement and interest. And so also, if you have an immunologist that's seeing those patients, whether it's from allergy immunology, or even maybe an infectious disease specialist at your centre that's seeing the immunology or a rheumatologist or he-mong person, let your trainees go to those clinics because they may very well just get excited about it and then want to pursue it, want to learn more. And there are lots of opportunities. That's how I got interested. I, as a fellow, got to go to this immunology clinic. I thought it was so interesting. And then I had mentors who really encouraged me to get extra training after fellowship and learn more so that I could come back and establish a more comprehensive immunology program here. So put that effort into your future trainees, whether starting in the undergrad or the medical school or residency or whatnot, or your fellows, and you just may have your next generation of immunology teaching champions. Dr. Mariam Hanna All right. Time to wrap up and ask today's immunologist and professor, Dr. Tamar Rubin, for her top three key messages to impart to patients and physicians, and let's say also teachers, on today's topic, teaching IEI to trainees. Dr. Rubin, over to you. Dr. Tamar Rubin Okay. So number one is, I think, relating back to what I just talked about, is foster that interest in the trainees and the next generation. Get them involved in that early clinical exposure, research opportunities, because you may just be developing that next generation of teachers and clinicians that are going to have that interest and expertise and really enhance your program at your center. Number two, recognize that learning inborn errors of immunity is crucial. A, they're not that, you know, these conditions aren't that rare, and also it's going to help make us stronger clinicians, not just for immunology, but also in allergy, asthma, and all those areas that we manage as allergist immunologists. And number three, clinical immunologists and allergists are the experts in inborn errors of immunity. So we are the ones that are going to establish that medical home for patients with these conditions. We're the ones who are going to find them. So we need to learn and teach these conditions so that we are able to best serve our patients and also be those gatekeepers of knowledge for our colleagues and other specialties. Dr. Mariam Hanna Perfect. Thank you, Dr. Rubin, for joining us on today's episode of The Allergist. Thank you for having me. This podcast is brought to you by the Canadian Society of Allergy and Clinical Immunology and produced in collaboration with PodCraft Productions. The opinions shared by our guests are their own and do not necessarily reflect the views of CSACI. Please remember that this podcast is for informational purposes only and does not provide any individualized medical advice. For show notes and relevant links from today's discussion, visit CSACI.ca. While you're there, check out the Find an Allergist tool to connect with a specialist near you. If you enjoyed this episode, we'd love your support. Subscribe wherever you get your podcasts. Leave a review and a five-star rating. It helps others find the show. And remember, it's time to get excited because we are the experts. Thanks for listening. Sincerely, The Allergist.