Need for ID specialists grows as new threats emerge
To mark our 30th anniversary, Infectious Disease News examined some of the infectious diseases that have defined and changed the field over the past 3 decades.
The field of infectious diseases has changed dramatically over the past 30 years. Breakthroughs in ART have extended the life spans of people living with HIV to near-normal ranges. Polio is on the verge of being eradicated globally. Curative therapies have transformed the treatment of hepatitis C. The growing threat of bacterial resistance has pushed humanity to the brink of a post-antibiotic era.
However, as the need grows for more experienced physicians to manage infectious disease threats, the proportion of students filling ID fellowship programs in the United States in recent years has declined, experts warn.
Since 2013, the yearly proportion of ID programs participating in the National Resident Matching Program (NRMP) that were filled has ranged between roughly 42% and 66% — levels well below those seen just 10 years ago. Individual doctors have also taken fellowship positions at a lower than desired pace.
“Despite the continued broad interest in the field, ID fellowship applications have dropped off over the last decade,” David R. Andes, MD, chief of the infectious disease division at University of Wisconsin Hospital, told Infectious Disease News. “Individual programs and the IDSA leadership have focused on trying to understand this trend and develop approaches to better educate students about opportunities in the field.”
Having fewer ID professionals has dire implications for public health, according to Thomas A. Moore, MD, a clinical professor of medicine at the University of Kansas School of Medicine at Wichita.
“The decline in applications to ID fellowship translates later into a dearth of physicians trained in HIV care and an inability to address the needs of this population,” Moore said in an interview. He added that antimicrobial resistance is a threat that also requires a sufficient ID work force.
“The nation needs people trained to use these agents wisely and patrol their use by others in order to assure the continued effectiveness of these agents, which really are precious resources not to be squandered,” he said.
Peaks and valleys
ID fellowship recruitment has fluctuated over the years. In 1997, just 61 of 107 ID programs (57%) participating in the NRMP’s Specialties Matching Service (SMS) were filled. Of 224 individual fellowship positions available that year, 156 (69.6%) were filled. Recruitment improved over the next decade, with 99 of 117 programs (84.6%) and 254 of 275 individual fellowship positions (92.4%) filled.
In 2013, 89 of 134 ID programs (66.4%) were filled through SMS. Of 334 individual fellowship positions available, 270 (80.8%) were taken. In the following 3 years, the proportion of ID programs that were filled dropped to 59%, 49.3% and 42.3%, and the proportion of doctors taking fellowship positions slipped to 77.4%, 69.7% and 65.1%, respectively. Figures rebounded in 2017, when 63.3% of programs were filled and 79.6% of fellowship positions were taken.
IDSA members have suggested that the recent recovery may be due to the “All In Policy,” which requires all participating programs to fill fellowship positions through the NRMP. The presumption is that “All In” would provide a more accurate picture of fellowship recruitment, with fewer doctors being lost to nonparticipating programs and remaining hidden from recruitment tracking.
However, in terms of the total proportion of ID fellowship programs that were filled in 2017, ID still lags behind the overall SMS rate (79%).
More recent data on the number of programs filled and the placement of individual doctors are expected in December.
Following the money
Experts have listed a variety of reasons for the decline in fellowship applications. Financial barriers are a key concern, Moore said.
He explained that research conducted by the IDSA and other groups has shown that graduates are often drawn to higher paying fields.
“What we’ve come to realize is that people are interested in ID,” he said. “But they often can’t get into the profession — not because it’s crowded, but because they can’t afford it financially. Most of these medical students are coming out of school with a significant amount of debt ... and they are forced to choose a profession that allows them to pay it off more quickly.”
Moore added that the draw to higher paying fields does not always last.
“Many of them are going into hospital medicine, which is lucrative,” he said. “But [among] the people who are going into hospital medicine, there’s a significant burnout rate. We have seen people go into hospitalist work to pay off their loans, then start to look into the subspecialty they’re interested in, whether it’s ID or something else.”
Studies have shown that compensation is one of the main reasons students steer away from ID. In one study, 548 students who had considered ID but chose another field were asked which of 13 factors most influenced their decision. Salary was the third most cited reason, given by 14.9% of participants. Another 16% said they were most influenced by a desire to be a generalist rather than a consultant, and 18.1% said they felt that ID provided less intellectual stimulation.
When the participants were asked which among 10 factors was the most important in generating interest in ID, increasing salaries easily topped the list, with 32.4% checking off that option.
According to the 2017 Medscape Compensation Survey, ID physicians are the fifth lowest paid in a list of 27 specialties. The average annual salary in the field is $228,000, according to Medscape. At the bottom of the list is pediatrics, at $202,000, while orthopedics is at the top, at $489,000.
In a 2011 survey of more than 40,000 new physicians, those in ID reported a median starting salary of $158,000, compared with $165,000 for hospitalists.
To reignite interest in the field, veteran ID physicians have suggested several recruitment strategies. Some address fiscal concerns head on.
Moore mentioned a strategy that is used by physicians in other fields to keep new doctors in town.
“Some of the gastroenterologists in my city and in other places, in an effort to bring people back to their cities, sign a contract with people coming out of residency or medical school,” Moore said. “They say, ‘If you complete your fellowship, we’ll pay you a certain amount of money up front or give you a signing bonus, and you have a job when you come back.’ There are ways to sort of prehire, if you will, people to provide income and offset some of their [student debt] burden.”
Moore cautioned that increasing medical students’ involvement in ID on the national level requires more complicated strategies.
“The national issue is working with Congress in an effort to provide some sort of tax break or deduction that would allow physicians with significant educational debt to go into ID and practice in areas where the need is greatest,” Moore explained. “And IDSA has been working with representatives and senators in Congress to craft some legislation to allow that.”
Mentors can also exploit the ID field’s widespread appeal, according to Andes.
“The field has always been and continues to be of interest to a wide spectrum of learners, given its broad scope,” he said. “For those who are clinically oriented, the field has historically been attractive due to the diagnostic dilemma. More recently, the emergence of antimicrobial stewardship has led to additional interest in therapeutics. Public health and epidemiology have also been traditional pillars.”
Andes added that hospital infection control and global health are two additional areas in which new medical students have expressed interest.
Moore said that challenges in ID can be a draw for some students.
“The great thing about the field of ID is that it is ever-changing, always interesting, and those who are attracted to it stay in it because it is a daily challenge,” he said.
Andes emphasized the importance of engaging students early on and to offer evidence of ID physicians’ job satisfaction to help get students interested.
“We need to be better at getting the word out about the exciting opportunities in the field, as well as the very high career satisfaction that is reflected in recent surveys,” he said. “At both the national and local level, we are trying to present these career opportunities to medical students and residents earlier through interest groups and involvement in our major national meeting, IDWeek.”
New needs, new roles
Recent mandates in response to infectious disease threats have created numerous positions that need to be filled, Moore said.
“It’s ironic because this comes at a time when the number of opportunities for people to go into ID is dramatically increasing,” he said of the decrease in fellowship applications. “CMS has made it a requirement of participation in Medicaid and Medicare services for all institutions that have a contract with CMS to have an antibiotic stewardship program and an infection prevention program. Well, that has, practically overnight, created a bunch of positions that need to be filled urgently by people trained in ID and antibiotic stewardship.”
Studies have shown that consultation with ID specialists improves diagnosis and patient outcomes.
“Getting ID physicians involved in patient care reduces costs, and it provides better care for the patients,” Moore said. “All the parameters that you want to look at as indicators of quality care and favorable outcomes are enhanced when ID physicians are involved in the care of patients ... That’s known to ID physicians, but it’s not known to people outside the field. This is a tremendous opportunity for us to toot our horn and educate people about the importance of our profession.” – by Joe Green
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- National Residential Matching Program. Report Released! 2017Appointment Year Largest on Record for NRMP Fellowship. www.nrmp.org. 2017. Accessed Nov. 15, 2017.
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Disclosures: Andes and Moore report no relevant financial disclosures.