Whither infectious diseases?

One morning in October 1983, when I was a 22-year-old second year medical student just recovering from infectious mononucleosis, I arrived at school for my medical microbiology lecture. At that point, several weeks into the course, I found myself with no real affinity for the subject matter. The lectures seemed to focus on the minutiae of biochemical tests for various bacteria that I planned to memorize for the exam then forget. But that October morning we were scheduled to have a clinical correlation lecture. I always looked forward to those lectures--talks about real diseases by real doctors. The lecture was on meningitis and given by Rashida Khakoo (shown in photo), a young infectious diseases doctor. It was incredibly fascinating and I was forever hooked. Over the course of the next several years, I rotated with Rashida several times on the Infectious Diseases consultation service, and knew that ID was my calling. It's hard for me to estimate how much I learned from her. She's an amazingly brilliant physician and incredible bedside teacher who reads incessantly and has the capacity to remember everything that she has ever read. The joke among the medical students was that you could not find a bound journal in the library that did not have her name on the library check-out card (I realize younger readers won't get that joke). Three decades later, I still believe she's the best doctor I have ever encountered.

For me and many others, Infectious Diseases remains a fascinating specialty. What other field has new diseases and challenges continuing to emerge at the rate of our specialty? We remain the disease detectives, the go-to doctors when no one else can figure out what is wrong with the patient (think Gregory House, MD, only nicer!). We add value in many other ways by working as hospital epidemiologists, antibiotic stewards, and public health experts. This morning's New York Times has multiple articles regarding infectious diseases. This should be our heyday. But instead, the field of infectious diseases appears to be in rapid decline. This past year, only 137 US medical school grads applied for fellowship positions in Infectious Diseases and only 41% of available positions were filled. We have recently heard numerous reports that fellowship programs, increasingly desperate for trainees, are violating rules of the National Resident Matching Program (NRMP) and offering candidates positions outside of the match process.

The cause of ID's demise is purely economic. Put yourself in the shoes of a 30-year-old 3rd year internal medicine resident with two young children and a $300,000 educational debt. You find the field of infectious diseases to be very interesting but you are forced to make a choice between 2-3 years of additional training at a fellow's salary or entering the workforce now as a hospitalist. The median annual salary of a hospitalist currently exceeds $250,000 and on average a hospitalist works 40 hours per week. As a hospitalist you will earn a salary 30% higher than your ID colleagues and work 30% fewer hours. Most hospitalist positions offer predictable hours and frequent, extended periods of time off. Can we blame young doctors for choosing the hospitalist option?

Unfortunately, most physician compensation plans reward volume not value, and that's a losing proposition for us. You can't evaluate a patient with fever of unknown origin in 20 minutes. There are no RVUs earned for spending three hours reviewing the medical records of a highly complex patient. In my previous job, the departmental administrator chastised me for spending too much time with my patients. Although I knew my work was important, that referring physicians were pleased and that my patients were grateful, I no longer felt valued.

The work of the ID doctor has never been glamorous, the pay has never been as good as most other specialties, and the hours have always been long. You don't enter ID to have a good lifestyle or get rich. But what has changed over the past decade is that internal medicine residents now have an option that offers higher pay and better hours, without pursuing additional training. Until ID becomes more economically competitive with hospital medicine, the odds of a comeback are slim. This isn't rocket science. And it's really a shame that the Infectious Diseases Society of America, our professional society that should be advocating for us, seems incapable of articulating an effective message about the crisis that the field of ID faces, the value that we add to health care, or potential economic solutions.

Sadly, we must ask: will the last ID doctor please turn out the lights?