The dumpster fire (part 2)

Earlier this week Dr. Stephen Calderwood, President of the Infectious Diseases Society of America, posted on our blog a response to several posts that we have written to shed light on the problems plaguing the specialty of Infectious Diseases, which are primarily the interlocking issues of low pay relative to other subspecialties of Internal Medicine as well as hospitalists, and the dwindling number of young physicians pursuing training in our field. While we thank Dr. Calderwood and IDSA for his post, we remain unconvinced that the leadership of IDSA appreciates the gravity of the situation at least as gauged by their response.

I spent some time this morning reviewing IDSA’s website with regard to the issues of low reimbursement/salaries and the inability to recruit new trainees. I couldn’t find much. In a recent newsletter to the membership, Dr. Calderwood mentions “the decline in match results” in one sentence that contains a link to his post on our blog. That’s as much as I could find about this year’s dumpster fire. There are also a few letters to CMS urging some reforms in payment.

Dr. Calderwood rightfully points out the importance of mentoring our trainees to foster more interest in ID. But ethical mentoring now requires that we have frank discussions about the relatively low pay of ID physicians with young doctors who are in the process of career discernment. I tell would-be ID physicians that they need to come to terms with the fact that they will work harder and make less money than their peers who are hospitalists. And the issue isn’t just about money, it’s about how valued you feel. Several months ago in the midst of such a discussion with an internal medicine resident, the response of the idealistic young doctor was jarring. “I know all about the salary problems in ID,” he said. “My dad is an ID doc who had to close his practice because he couldn’t generate his salary.”

The situation for ID is likely to worsen. There is now a CMS demonstration project on eConsults. In this model, primary care doctors ask specialists for consults that are electronic only (chart review without seeing the patient) with expectations for a response within 72 hours. Sort of like a curbside on steroids. Here’s the really crazy part of the concept: for this service the requesting physician is paid the same as the specialist who provides the consult (i.e., each receive 1 RVU). Who’s the loser here?

As I see it (and as many others do from my discussions with colleagues across the country), ID is in free fall, yet we have a la-belle-indifference response. To give benefit of the doubt, I guess another explanation could be that IDSA is actively engaged but too shy to let its members know. As I think through all these issues, for the first time I’m asking myself: why am I a member of IDSA?

There are many questions that should be addressed. Here are some:
  • How do we truly demonstrate the value we add? The few papers that address this question don’t provide convincing results (i.e., they seem to underestimate our value and provide fodder for maintaining the status quo).
  • How can compensation models be changed to fairly reward the work we do and acknowledge the additional training and skills we possess? More directly, why is the pay of the ID subspecialist less than the pay of the hospitalist?
  • Should the ID fellowship be shortened to positively affect the cost-benefit calculus of additional training? Do trainees who plan to enter private practice really need hands-on training in research or scholarly activities? Would it be more fruitful and time conserving for these trainees if research projects were substituted with more training to better interpret evidence? 
  • Should hybrid models of training be developed to lessen the economic impact on trainees (for example, could training be integrated with hospitalist practice? Various models could be envisioned—such as one month hospitalist attending, alternating with one month ID fellowship)? This would increase the fellow’s salary, and even if the total duration of training were extended, may entice more residents to consider ID training). Some would probably continue this model beyond training into employment.
The reality is that few people are pursuing ID training, and even among those who do, very few want to pursue an academic career. Despite all the voting that residents have done with their feet, we continue to mostly offer a one-size-fits-all training model with financial punishment when training is over. It's time to put out the dumpster fire and thoughtfully begin to rebuild our specialty. But first we should spend some time contemplating the words of Albert Einstein: “Insanity is doing the same thing over and over again and expecting different results.”


  1. Bold and daring post Dr. Edmond!

    Fellows that do two years of ID training followed by one year of Critical Care seem to do well economically and professionally. My personal experience in private practice (a decade ago) is that there was a lot of money to be made in ID, but it required seeing a large number of patients a day. Back then academia seemed more appealing...but then RVUs came along...and academia transformed itself into a poorly remunerated version of private practice. Not doing procedures is a major limitation of our specialty.
    We could also expand the ID training into Quality and Patient Safety.

  2. I continue to wonder why nobody (at least as far as I can discern) is discussing the issue of supply and demand. There is no doubt that the supply of qualified ID specialists is declining as old specialists retire and young residents avoid the field. Sooner rather than later this trend is going to have a significant and substantial impact on salaries. This seems inevitable to me. Thus I tell young doctors: "Go into ID now. This is a classic opportunity to buy low and sell high"

    1. Medicine is not a competitive market. This could be the subject of a longer post but if you draw your supply and demand curves and then artificially set a low price (salary) for ID services like CMS does in the US, you see how low the supply of ID services becomes and how high demand is because ID consults have no cost relative to anything else in medicine. When was the last time someone said "don't call ID we need to control costs"? Never.

      There is no evidence that CMS will raise reimbursement and it certainly is true that CMS doesn't use supply or demand to set fees. They give cardiology more money because cardiologist are on the panel not because there's a dirth of cardiologists.

  3. The notion that medicine is not a competitive market doesn't take into consideration the fact that not all payment is controlled by CMS. Here are some examples: transplant programs need ID physicians, hospitals need ID specialists to provide key services to key programs like CV surgery, orthopedics etc; hospital systems need hospital epidemiologists, all hospitals need help when periodic issues like "Ebola preparedness" and flu epidemics occur, Medical schools and tertiary care centers need ID clinicians. Also more and more specialists are hired to provide services to health systems and these salaries can and will respond to supply and demand considerations. Finally although you are right in stating that CMS does set a low price for ID services, sooner or later things are going to get so far out of whack that change will occur. Past behavior of CMS and other payers is not a guarantee that their future behavior will stay the same.

    1. You make strong points, however, most of these other services are at the margin and it is unclear if they will ever be enough to raise the average salary of ID docs. Certainly there will be those ID docs who provide services to ortho or oncology that will negotiate higher salaries. But if your entire field is based on the forward thinking or generous behavior of hospital administrators or physician-groups, your field is in trouble.

      Also, I suspect there will be so few ID trained docs around to benefit when and if CMS raises ID reimbursement rates. More likely, ID docs will be replaced by other subspecialties, such as ID pharmacists or hospitalists for stewardship, QI trained folks for infection control and since anyone can prescribe antibiotics, probably radiologists for inpatient consults.

      That last point is humor.

  4. This is a great discussion. I agree with Silvia that the key to making things work in a "private practice" environment (one that is rapidly disappearing as a model) is to see a LOT of patients. And my colleagues who do this tell me that the treadmill keeps speeding up (i.e. each year they need to see more patients to keep their income stable). Another key to success is driving a fair bargain with your hospitals to provide the additional services D alludes to (contracts in place for hospital epidemiology, antimicrobial stewardship, etc.), and for which some guidance does exist from IDSA and SHEA. But it isn't easy to carve out any time to take on those tasks if you are cranking out the RVUs.

    Like D, I also tell trainees that going into ID now (whether with interest in academic or community practice careers) is like buying when the stock market is low--at least as regards job security. I think there will be many many options for ID physicians well into the foreseeable future. What I can't reassure about is the remuneration, or the practice model(s) that will eventually predominate. I keep getting pulled to meetings about eConsults, phone consults, and other "tele-health" models that are seeking to utilize our cognitive skills without involving a physical interaction with a patient. Less satisfying, in my view, and unclear to me how it will be reimbursed (currently much of it is not reimbursed). We have an increasing number of areas in our state that have no ID coverage--thus our faculty find themselves co-managing patients with hospitalists who are calling in from hours away, for zero reimbursement. If critical shortages of ID specialists do occur, one potential future involves ID docs holed up in their own little "ID Command Centers", managing phone, email and web interactions with providers across entire regions of the country. Not sure who'd sign up for that…

    Given the current popularity of the hospitalist model, I think consideration should be given to two approaches: (1) combined ID-hospitalist models, as Mike alludes to above, and (2) convincing hospital C-suites that financial support for ID (and certain other subspecialties, like nephrology) should be treated similarly to the support provided to hospitalist programs. ID and nephrology are the two specialties that have the biggest problems in terms of a mismatch between interested trainees and available training spots, and they are also the two busiest inpatient consult services at our hospitals. Any large acute care hospital has to have both specialties in order to function. There should be some leverage there.


  5. I am a long time hospitalist and wished to weigh in.

    ID suffers, perhaps, from what ails primary care as a future career choice: regret aversion.

    What do trainees see:
    1) IDer's acting as abx stewards, approving (or not) drug use...
    2) or regulatory police as infection control officers...
    3) with shrinking (or stalled rx) armamentarium due to a dysfunctional drug development pipeline...
    4) and rounding on many patients with thick charts, long stays, and unhappy long term outcomes.

    Make the case to a PGY-2?

    (I should add, along with geri and PC, my most rewarding and fulfilling professional encounters occur with my ID colleagues. You will always have my support).

  6. "There is now a CMS demonstration project, ... primary care doctors ask specialists for consults that are electronic only (chart review without seeing the patient) with expectations for a response within 72 hours." In our multispecialty group, ID has been forced to provide this service pro bono. The EMR has facilitated stripping ID of intellectual labor without compensation.


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