Symposium on Infectious Diseases — February 2017
Tex Med. 2017;113(2):60-62.
By Steven L. Berk, MD
The challenges of infectious diseases, including new pathogens, dangerous outbreaks, antibiotic-resistant bacteria, and the perils of international travel have never been more publically appreciated. These challenges require a well-trained workforce of infectious disease specialists. Just when the need appears to be greatest, however, the interest in infectious diseases among today's young physicians is at its lowest point.
The satirical Gomerblog from July 2016 written by Dr. 991 focuses on the infectious disease consultant. The title of the blog is "Epic consult note starts with 'Once Upon a time,'" and the blog goes on to describe an excessively long note written by an infectious disease (ID) consultant. It quotes a make-believe orthopedic resident saying the note was as long as War and Peace but with better character development. "Sources close to Gomerblog state the plot is full of twists and turns, memorable characters, and the most complete documentation of antibiotics ever given. … The description of the rash is so vivid you feel like you were there at the bedside." The article says the ID physician was not available for comment, as he was still making rounds until after midnight.
This is funny material aimed at the well-known meticulous nature of the ID physician in attaining a history and performing a physical examination. Any ID physician will have some real-time funny material, as well. For example, I recall the young woman I saw on an excessively busy Boston City Hospital obstetrics service. She had a high fever and shaking chills but with a normal abdominal exam and clean episiotomy incision.
Shortly after introducing myself to her as the ID consultant, she explained that she had been to Africa weeks before and wondered if she might have malaria as she had seen malaria patients with similar symptoms. Within minutes, a thick smear proved her to be right. It is nice to have time to take a history.
Then there was the patient who was not responding to treatment despite being on the recommended antibiotic for community-acquired pneumonia. The history obtained included some interesting characters ― six or seven pet parrots, all of whom had died in the same cage, one after another. Treatment for psittacosis saved the patient. As for vivid rashes, every ID physician will remember the telltale petechiae, Osler's node, or Janeway lesion missed by all until the ID consultant emerged to diagnosis and treat endocarditis.
Has the infectious disease consultant become the irrelevant, epic note writer now replaced by hospitalists who try to keep notes brief and consultations as few as possible? Has the antibiotic guru become unimportant because of readily available antibiotic guidelines or by the pharmacists who are the new antibiotic gatekeepers? Or is the ID physician still a bedside superhero who reminds our fellow physicians that the key to diagnosis and treatment is often locked into the individual patient evaluation, especially history and physical examination?
Clearly, all is not well in the field of infectious disease. First of all, if the best and brightest are not attracted to the field, if they are not the most respected bedside clinicians, then what will they have to offer? While there is certainly a pool of outstanding students who choose internal medicine and then ID as a subspecialty, the embarrassing fact is, the most knowledgeable students, at least based on U.S. Medical Licensing Examination (USMLE) 1 scores, are choosing surgical specialties over internal medicine. The average student going into internal medicine has a USMLE score 15 points below the student who has matched in orthopedic surgery. If there is a certain irony here, that is left best unsaid. Internal medicine continues to be a relatively noncompetitive field for U.S. graduates.
At the level of fellowship, the news also is not good. Recent match results from the National Resident Matching Program show there is a decline in the number of ID fellowship positions filled, a decline in the total number of applicants, and a decline in U.S. and international medical graduates. Only 49 percent of ID fellowship programs were filled in 2015.2 Elite academic programs sometimes went unfilled.
Subspecialty Selection Factors
Bonura et al3 surveyed graduating internal medicine residents to determine the factors that went into choosing a subspecialty. Learning experiences in medical school were important. Mentorship and scholarship during residency training often influenced the resident who chose ID as a specialty. Salary and preference to be a generalist were dissuading factors for those considering infectious diseases.
If the choice of an ID subspecialty is linked to medical school experiences, then how we teach microbiology, antibiotic therapy, and the management of HIV disease could be a factor in the declining interest in the field. Methods of teaching basic science in medical schools are rapidly changing. Problem and team-based learning is being substituted for lectures, and the principle of self-directed learning has never been more at the forefront of medical education. There is probably no specialty more dependent on self-directed learning than ID. ID physicians of my generation were not taught about HIV disease during fellowship training. Young infectious disease physicians today are piecing together the complexities of Zika virus on their own.
Southwick,4 in a paper titled "Spare Me the PowerPoint and Bring Back the Medical Textbook" suggests active learning techniques such as essays and short-answer questions, peer instruction, and using basic medical textbooks enhance student learning. Southwick et al5 also prepared a commentary titled "Infectious Diseases Society of America Guidelines for Improving the Teaching of Preclinical Microbiology and Infectious Diseases." The authors believe a new approach that emphasizes active learning may "rekindle interest in the field of infectious disease." They also recommend a national consensus on factual content with the goal to reduce information overload. It makes sense that if we are adding to the list of antiviral drugs every year for HIV treatment, perhaps we can go easy on the clinical manifestations of smallpox or tetanus.
I have not quite let go of the importance of lecture as an influence on student specialty choice. Training in Boston, I know that I was influenced to choose ID by the lectures of Louis Weinstein on endocarditis, William McCabe on gram-negative sepsis, and Maxwell Finland on pneumococcal pneumonia. I hope in vain that some of the traditional lectures I still give might influence just a few to pursue ID as a lifetime adventure.
Perhaps the real issue gets back not to lectures but to mentorship as was noted in the paper by Bonura. Without enthusiastic mentors, students are unlikely to be attracted to internal medicine or ID. Third-year medical students will find a level of intensity and passion in the delivery room, the emergency room, and the operating room that might be hard to match in the internal medicine or ID clinic. Nevertheless, ID has a special excitement of its own.
Calderwood,6 as president of the Infectious Diseases Society of America (IDSA), also emphasizes the value of mentors. IDSA, of course, has a great interest in the issue of declining ID interest and potential remedies, including advocating higher pay, improving mentorship, and representing ID physicians as the true antibiotic stewards. The society has a membership category for students and residents, and its foundation provides scholarships for students. It has also paired mentors and students at the national meeting.
Anthony Fauci,7 in a New England Journal of Medicine article titled "The Perpetual Challenge of Infectious Diseases," just might capture that excitement for this generation of medical students. "Among the many challenges to health, infectious disease stands out for the ability to have a profound impact on the human species." In fighting ID, the stakes are high, the challenges are global, the breakthroughs astonishing, and the future is frightening and hopeful. The diseases are preventable with public health education, patient education, and vaccination. The desire to travel and play a part in international cooperation and health care are easily met.
History proves to us that there will constantly be new challenges, new opportunities to be at the front line of protecting the public and new avenues for research. To observe in my career the treatment of AIDS as going from hopeless to an arsenal of at least six different types of drugs, all based on the intricate understanding of viral replication, is awesome.
To those who are torn between specialty training and primary care, there is no more challenging primary care venue than the care of the HIV patient over many years. Bartlett,8 in his essay on "Why Infectious Diseases," describes the value of the ID practitioner as magnified by the crisis of antibiotic resistance, the expanding consequences of international travel, the introduction of sophisticated new diagnostics, and the emphasis on infection prevention.
The decline in ID interest does not match up well with various surveys of physician satisfaction. This is not surprising as competitiveness of residency or fellowship position does not correlate with national surveys of physician satisfaction. According to a recent Medscape survey,9 about 50 percent of orthopedic surgeons were satisfied with their specialty. Fifty-one percent of obstetrician-gynecologists, 50 percent of plastic surgeons, 53 percent of urologists, 49 percent of general surgeons, and 54 percent of ID physicians, including HIV specialists, were satisfied with their jobs. Only dermatology is significantly different, with 63 percent of dermatologists happy with their choice.
The decline in fellowship interest cannot be easily tied to dissatisfaction in the field. In this survey, the average ID physician salary was $213,000, but the range of salaries in the field is enormous, depending upon academic or private practice in academic medicine, professional rank, and years in service. The decision to develop an infusion therapy practice and the number of hospitals covered and patient mix are also factors. While improving salary is always a quick solution to attracting residents in any field, it is true that higher-paid hospitalists who have fewer years of training than ID physicians are a source of competition.
Of course, many potential suggestions have been made to remedy the lack of ID interest. Linking ID fellowship to a year of critical care fellowship has been proposed, and Kadri et al10 have reported this combination has yielded a high level of satisfaction, even among fellows who have completed this training in separate institutions. Separating ID consultation careers from the primary care of HIV patients would be attractive to some fellows. Those more interested in primary care and those considering a career in general internal medicine might be happier in an HIV clinical practice, while others might prefer the old-time acuity of care that ID used to represent.
ID training could be supplemented by a master's degree in public health (MPH), perhaps giving the fellow a wider range of practice options. Several ID fellowship programs offer this MPH option or include the option of certificates in global health or traveler's health.
Medical school administrators choose their faculty, their students, and their curriculum and define their mission. When students graduate and choose a distribution of fields that is not in the best interest of the country's manpower needs, the nation's medical schools have some responsibility to right the ship. Texas Tech University Health Sciences Center School of Medicine and 11 other medical schools have worked to develop a family medicine accelerated track to encourage students to choose a career in family medicine. The program has increased the percentage of students going into family medicine dramatically. The need to address shortages in geriatrics and psychiatry may also create innovative solutions in these areas.
The recognition of an impending shortage of ID physicians is relatively new. Clearly, it will lead to a variety of innovative ideas and new programs that will focus on mentoring and fair payment for the unique role the ID physician plays now and will assume in the future. It will also involve finding the best students early on in medical school, presenting ID's exciting challenges, and identifying add-on roles and responsibilities that are recognized and reimbursed, such as public health and antibiotic stewardship.
Charles Bryan11 wrote a tribute to Sir William Osler, MD, in an essay titled "Fever, Famine, and War: William Osler as an Infectious Disease Specialist." He quotes Dr. Osler as saying, "Man's redemption of man is nowhere so well known as in the abolition and prevention of a group of diseases which we speak of as fevers and acute infections. This is the glory of the science of medicine."12 Specialties over the next century will come and go, but the future of ID is secure.
Steven L. Berk, MD, is executive vice president, provost, and dean of the Texas Tech University Health Sciences Center School of Medicine.
- Dr. 99. ID's Epic Consult Note Starts with "Once Upon a Time." Gomerblog. July 16, 2016: http://gomerblog.com/2016/07/epic-consult-once-upon-a-time/.
- Chandrasekar PH. Bad news to worse news: 2015 infectious diseases fellowship match results. Clin Infect Dis. 2015;60(9):1438.
- Bonura EM, Lee ES, Ramsey, K, Armstrong S. Factors influencing internal medicine resident choice of infectious diseases or other specialties: a national cross-sectional study. Clin Infect Dis. 2016;63(2):155–163:
- Southwick FS. Theodore E. Woodward Award: spare me the PowerPoint and bring back the medical textbook. Trans Am Clin Climatol Assoc. 2007;118:115–122.
- Southwick F, Katona P, Kauffman C, et al; Infectious Diseases Society of America Preclinical curriculum Committee. Commentary: IDSA guidelines for improving the teaching of preclinical medical microbiology and infectious diseases: Acad Med. 2010;85(1):19–22.
- Calderwood SB. The power of mentoring: we all can help recruit more ID specialists. Infectious Disease News. February 2015. http://www.healio.com/infectious-disease/practice-management/news/print/infectious-disease-news/%7B6ba48a83-9bd6-4988-b02e-99ff73ba29f4%7D/the-power-of-mentoring-we-all-can-help-recruit-more-id-specialists.
- Fauci AS, Morens DM. The perpetual challenge of infectious diseases. N Engl J Med. 2012;366(5):454–461.
- Bartlett JG. Why infectious diseases. Clin Infect Dis. 2014;59 Suppl 2:S85–S92.
- Kearns M. Which specialty produces the happiest doctors? Medical Practice Insider. April 24, 2015. http://www.medicalpracticeinsider.com/news/which-specialty-produces-happiest-doctors.
- Kadri SS, Rhee C, Magda G, et al. Synergy, salary, and satisfaction: benefits of training in critical care medicine and infectious diseases gleaned from a national pilot survey of dually trained physicians. Clin Infect Dis. 2016;63(7):868–875.
- Bryan CS. Fever, famine, and war: William Osler as an infectious diseases specialist. Clin Infect Dis. 1996;23(5):1139–1149.
- Osler W. Man's Redemption of Man. New York, NY: Paul B. Hoeber; 1913.