Čojstvo - Humanity - My hope for 2016

Mike has written often about humanism in the context of the white coat debate. He contrasts humanism with professionalism with humanism focusing on the welfare of humankind and professionalism primarily seeking to strengthen a personal professional identity. With that in mind, I was just listening to The Gist and Mike Pesca was retelling the story (around minute 22 of the podcast) behind his favorite sentence for 2015. While on a tour in Montenegro this past summer, he heard the guide try to explain the ethical ideal of the Montenegrin people - Čojstvo i Junaštvo, which roughly translates to Humanity and Bravery, using this sentence:

"Bravery is very easy - it is when you defend yourself from others but humanity is more difficult - it is when you defend others from yourself" - Nino Markovic (Montenegrin Tour Guide)

So from Mike Pesca's sentence for 2015, I've found my hope for 2016:

Čojstvo - Humanity

You better not cough!

I have to thank Eli for rekindling my interest in the mandatory influenza vaccination controversy. I had resigned myself to it being water under the bridge and had not thought much about it until the last week. What I didn't realize is that another Cochrane review was published last year on influenza vaccination of healthy adults. This is very useful to our discussion since most healthcare workers fall into the category of healthy adults. A free full-text version of the review can be found here. This review examined 69 clinical trials involving 70,000 participants, 27 cohort studies with 8 million subjects, and 20 case control studies with 25,000 participants. The bottom line is that the parenteral vaccine was 60% efficacious in preventing influenza, which didn't seem surprising to me. However, the absolute difference in influenza infections between the vaccinated and unvaccinated groups was only 1.3%. That knocked my socks off! All of the energy and resources consumed and ill will created in trying to increase vaccination rates in healthcare workers, including firing people, for a vaccine that reduces infection by 1% is about as stupid as it gets. Merry Christmas!

Photo: NBC News

Mandatory Influenza Vaccination for Healthcare Workers: Agreeing to Agree

This is a guest post from Sanjay Saint, MD, MPH, the George Dock Professor of Internal Medicine at the University of Michigan, the Director of the VA/University of Michigan Patient Safety Enhancement Program and the Chief of Medicine at the Ann Arbor VA Medical Center.

----

I begin by thanking my friend and colleague, Dr. Eli Perencevich, for allowing me use of “Controversies in Hospital Infection Prevention” for my first blog post. 

Our recent editorial in The Wall Street Journal on mandatory flu vaccination for healthcare workers elicited strong opinions, especially on social media. The impetus for our editorial was a recent paper published in Infection Control and Hospital Epidemiology in which we found through a national survey of lead infection preventionists that 42.7% of nonfederal hospitals had a policy mandating flu vaccinations for healthcare workers while only 1.3% of VA hospitals did.

In his 22 December 2015 blog post, Eli clarified his position by writing that he is “in favor of mandating influenza vaccination of healthcare workers (for now)”. I am in agreement. While the data supporting mandatory healthcare worker flu vaccination is perhaps not as robust as researchers would like – when is it? – in my opinion, it is compelling enough to move forward unless new data emerge that reveal the mandate to be unnecessary or ineffective.

What are the most compelling studies supporting mandatory vaccinations?

The first is a systematic review from Faruque Ahmed, PhD -- a senior scientist in the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC) – and four other CDC researchers.  I paste below the Results and Conclusions from their abstract:

Results. We identified 4 cluster randomized trials and 4 observational studies conducted in long-term care or hospital settings. Pooled risk ratios across trials for all-cause mortality and influenza-like illness were 0.71 (95% confidence interval [CI], .59–.85) and 0.58 (95% CI, .46–.73), respectively; pooled estimates for all-cause hospitalization and laboratory-confirmed influenza were not statistically significant. The cohort and case-control studies indicated significant protective associations for influenza-like illness and laboratory-confirmed influenza. No studies reported harms to patients. Using GRADE, the quality of the evidence for the effect of HCP vaccination on mortality and influenza cases in patients was moderate and low, respectively. The evidence quality for the effect of HCP vaccination on patient hospitalization was low. The overall evidence quality was moderate.

Conclusions. The quality of evidence is higher for mortality than for other outcomes. HCP influenza vaccination can enhance patient safety.

How could influenza vaccination affect all-cause mortality? I am not sure but previous studies have found influenza vaccination reduces cardiovascular events and venous thromboembolism.  How vaccination may affect these outcomes is not known - but it isn't irrational to also include all-cause mortality as an outcome given the myriad benefits of influenza vaccination.

The second study (not included in the aforementioned systematic review, but mentioned in the postscript), is a cluster randomized trial of hospitalized patients in the Netherlands published in June 2013. I paste the abstract below:

Nosocomial influenza is a large burden in hospitals. Despite recommendations from the World Health Organization to vaccinate healthcare workers against influenza, vaccine uptake remains low in most European countries. We performed a pragmatic cluster randomised controlled trial in order to assess the effects of implementing a multi-faceted influenza immunisation programme on vaccine coverage in hospital healthcare workers (HCWs) and on in-patient morbidity. We included hospital HCWs of three intervention and three control University Medical Centers (UMCs), and 3,367 patients. An implementation programme was offered to the intervention UMCs to assess the effects on both vaccine uptake among hospital staff and patient morbidity. In 2009/10, the coverage of seasonal, the first and second dose of pandemic influenza vaccine as well as seasonal vaccine in 2010/11 was higher in intervention UMCs than control UMCs; all p<0 .05="" span=""> At the internal medicine departments of the intervention group with higher vaccine coverage compared to the control group, nosocomial influenza and/or pneumonia was recorded in 3.9% and 9.7% of patients of intervention and control UMCs, respectively (p=0.015). Though potential bias could not be completely ruled out, an increase in vaccine coverage was associated with decreased patient in-hospital morbidity from influenza and/or pneumonia.

A third study (from another group in the Netherlands) used decision-analytic modeling to estimate the effects of healthcare worker influenza vaccination in the hospital setting.  The abstract is below:

Nowadays health care worker (HCW) vaccination is widely recommended. Although the benefits of this strategy have been demonstrated in long-term care settings, no studies have been performed in regular hospital departments. We adapt a previously developed model of influenza transmission in a long-term care nursing home department to study the effects of HCW vaccination in hospital wards. We study both the effectiveness and efficiency in reducing the hazard rates of influenza virus infection for patients. Most scenarios under study show a similar or higher impact of hospital HCW vaccination than has been predicted for the long-term care nursing home department. Therefore, it seems justified to extend the recommendations for HCW vaccination, based on results in the long-term care setting, to short-term care settings as well.

Eli recently wrote: “There is no data supporting the benefits of healthcare worker vaccination in acute care hospital settings…We are basing acute-care hospital policy on one observational study.” I would thus modify this by stating we are basing acute-care hospital policy on a cluster randomized trial done in a hospital setting, an observational study performed in a hospital setting, a decision analytic model explicitly focusing on an acute-care setting, and 4 randomized studies from long-term care settings as part of a well-done systematic review.

While the opinion of professional societies is not always correct, I am impressed by the strong support in the scientific community for mandatory influenza vaccination for healthcare workers.  The list of societies that support mandatory influenza vaccination for healthcare personnel includes: American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Hospital Association, American Public Health Association, Association for Professionals in Infection Control and Epidemiology, Infectious Diseases Society of America, National Patient Safety Foundation, and Society for Healthcare Epidemiology for America.

Finally, is mandating flu vaccination for healthcare workers ethical? For guidance I turn to Arthur L. Caplan, PhD, one of the country’s foremost medical ethicists and whose opinion about white coats was highlighted on this blog. Writing in 2013, Professor Caplan states:

“The moral case for limiting health care workers' choice concerning influenza vaccination rests on 4 principles: the professional duty to put patients' interests first, the obligation to do no harm, the requirement to protect those who cannot protect themselves, and the obligation to set a good example for the public. It is hard to see how the invocation of personal liberty claimed by some health care workers who oppose mandates could overcome this powerful “four-legged” moral case in support of an influenza vaccination mandate…Mandating vaccination is consistent with professional ethics; benefits many, some of whom must rely on health care workers to protect them; and sets an example that permits honest engagement with the public in educating them to do the right thing about all recommended vaccines.”

Festivus Grievances: Are Mandatory Influenza Vaccination Policies and Banning White Coat Ceremonies Ethically Equivalent?

"Welcome, new comers. The tradition of Festivus begins with the airing of grievances. I got a lot of problems with you people! And now you're gonna hear about it!"  - Frank Costanza

BB8 is for BBE

(Warning: Mild Star Wars spoiler at the end, although I surveyed folks here and no one complained)

Outside my recent posts on influenza vaccine mandates, I have very few infection control grievances to air this year. To start, 2015 saw the return of original science to the annual SHEA spring meeting, a tradition that will continue in the May 2016 meeting chaired by Silvia Munoz-Price and Tom Talbot. And the year ended with NIH planning to spend $461 million in FY 2016 on antimicrobial resistance research, an increase of $100 million over FY 2015. On a personal note, University of Iowa was selected as one of CDC's new Prevention Epicenters. Our team is honored and excited to join the other 5 new centers for the kick-off meeting this January. Thus, things are truly looking up in our fight against antimicrobial resistant bacteria. If we can convince congress, NIH and CDC to continue to gradually increase research funding over the next decade, we should have many things to celebrate in 2025. That is, if we can fix the ID fellowship match and the reimbursement issues that have plagued us the past 10+ years.

...but back to influenza vaccine mandates. Several folks have wondered how we bloggers could support banning white coats and at the same time question influenza vaccine mandates, especially since both interventions have similar levels of evidence (i.e. biological plausibility, math models, observational data, limited RCT data). This is an interesting question. Just to clarify, Mike is against compulsory influenza vaccine policies and I grudgingly support them and neither of us wants to ban white coats - we favor voluntary policies that make it OK not to wear a white coat - which is exactly what Mike instituted at VCU and plans here at Iowa, starting in 2016.

Yet ignoring our policy stances, the assertion that bare below elbow policies are somehow equivalent to vaccine mandates from an ethical standpoint is incorrect. Let's consider the current situation in the US with white coat ceremonies and the pressure that medical students, housestaff and faculty are under to wear white coats. If white coats are harmful (and many would agree that it is equally likely that white coats harm patients as influenza vaccines protects patients), then the current situation would be the ethical equivalent of forcing healthcare workers to not get vaccine.

That is, white coat ceremonies force healthcare workers to cause harm to their patients, which is not morally or ethically the same as requesting healthcare workers to help protect themselves and their patients by receiving an influenza shot. In a Star Wars context, forcing FN-2187 to murder villagers on Jakku (wearing white coats) is not ethically equivalent to requesting that Finn defend the people of Takodana from a First Order attack (influenza vaccine). 

Forcing healthcare workers to wear white coats that they deem to be harmful is wrong. We need to eliminate white coat ceremonies and stop coercing healthcare workers into wearing white coats.

Clarification: I'm in favor of mandating influenza vaccination of healthcare workers (for now)

There's been some misunderstanding of the motivation behind my recent posts offering suggestions for improving the implementation of compulsory influenza vaccination policies and acknowledging the limitations of the existing data supporting vaccine mandates. Most of the snark was on twitter where folks challenged my commitment to infection prevention and my interpretation of the data. If I can dish it, I better be able to take it. With that being said, however, I still feel a need to clarify my support for mandatory influenza vaccination policies in both acute care and long-term care settings. But...

1) I will only support such policies for 4-5 years. If those that push these policies can't come up with better clinical trial data during that time, I'm going to call BS. There is simply no excuse for stretching the existing data to drive change now and not validating your claims. Recommend the mandate, but then do the proper studies.

2) CDC and others must fund studies evaluating the benefits of mandatory vaccine policies in acute care settings. There is never going to be a better time than now, when hospitals are implementing mandatory vaccination programs, to fund the necessary cluster-randomized and quasi-experimental studies. Wouldn't it be great if we could find 50 or more hospitals planning to implement an influenza vaccine mandate and then fund a mixed-methods, stepped-wedge cluster randomized trial as those hospitals implemented the policy over the next 3-4 years? I think it can happen and SHEA, IDSA, PIDS and APIC need to demand such a study.

3) As Sara Cosgrove and I wrote in the 2007 SHEA Business-Case Guideline: "Most hospital epidemiologists or infection control specialists want to increase the resources available for infection control activities, but it is important to avoid overestimating benefits or underestimating staff and time costs. Overestimation in an initial analysis may improve the situation in the short term, but it will hinder efforts and necessary trust in the long term after actual resource audits are performed." There's simply no excuse for hand waiving and over promising the benefits of healthcare worker influenza vaccination. It erodes trust and prevents the necessary validation studies from being funded. Please take the long view and don't be afraid to challenge dogma.

Happy holidays!

Root causes underlying the emergence of influenza vaccine mandates

Those that follow me on twitter or the blog have probably noticed my recent focus on trying to understand the emergence of compulsory influenza vaccination of healthcare workers. Before moving on from this topic, I wanted to share what I've learned in the process.

(1) There doesn't appear to be any estimate of the burden of nosocomial influenza in the US. We know healthcare-associated influenza does occur, but we don't have estimates for the proportion of influenza cases that occur in hospitals. Even if we did know the incidence, we don't have reliable estimates for what proportion is acquired from healthcare workers vs. visitors or family members. It seems like we'd need those numbers before pushing for a mandate.

(2) There is no data supporting the benefits of healthcare worker vaccination in acute care hospital settings. If we look at the CDC systematic review everyone quotes, there were only 4 randomized trials and all 4 were from long-term care settings. If we generously include the observational studies, 3 were from long-term care and only one was from a hospital setting. We are basing acute-care hospital policy on one observational study.

(3) Again from the CDC systematic review, "HCP vaccination rates ranged from 48% to 70% in the intervention arms and 5% to 32% in the control arms." Thus, there is no evidence that raising vaccination above 48% or 70% is beneficial in long-term care settings. Thus, if we have vaccination rates near 50%, do we need a mandate?

The last two things I learned are that none of the above matters. Science is not what is driving the push for mandates, unless you consider the studies showing mandates raise influenza vaccination rates among healthcare workers. Probably didn't need a study to show that.

(4) Yesterday, I wrote a post trying to bias the respondents of a twitter survey in favor of being cared for by a masked unvaccinated healthcare worker over a vaccinated one. As you can see by the results (below), despite my efforts, the large majority want their healthcare worker to be vaccinated. This is critical - despite the science, we just want people to be vaccinated. A huge driver behind influenza vaccine mandates must be this desire. Additionally, it's likely that masks are viewed negatively by patients. Vaccine mandates make folks feel safe and masks don't - very patient centered.

(5) The finally bit that occurred to me is that the reason vaccine mandates exist is because CMS and other governing bodies require hospitals to collect and report influenza vaccine coverage among their workers. There is also a target of 90% coverage that must be met. Thus, we have a QI target that exists despite minimal scientific evidence that it protects patients but we have to meet the target. And the only way to meet such an arbitrary target is through mandates. QED

Influenza Vaccine Mandate Math

Last week, I described five steps individual hospitals, systems and society should take when implementing compulsory influenza vaccination of healthcare workers. One component of many influenza vaccine policies is mandatory surgical masks for healthcare workers who refuse or otherwise cannot receive the vaccine. Does masking unvaccinated healthcare workers even make sense? Or rather, who is more likely to spread influenza in hospitals - an unmasked, vaccinated healthcare worker or an unvaccinated, masked healthcare worker? Let's look at the numbers.

Let's assume influenza vaccine is 50% effective. In 2014-15, overall effectiveness was 19% while in 2012-13 and 2013-14 it was 49% and 51%, respectively. I'll give the vaccine a mulligan last year since during the prior decade, vaccines were far more effective. Let's further assume with vaccine mandates, 90% of healthcare workers receive the vaccine and 10% do not.

If 90% receive a vaccine that is 50% effective, we will have 45% of healthcare workers in our hospital protected and 45% unprotected. The tricky thing is that we won't know who is protected or unprotected. And what if the 45% vaccinated but non-immune healthcare workers assume they are immune and work while sick? You can imagine them saying - "I'm sick, but it's not influenza because I was vaccinated, so I'll do my ICU shift." Any mandatory vaccination policy should consider that scenario or it's possible that the mandate could make hospitals less safe. But what of the 10% required to wear masks? I suspect they'd be more likely to stay home if sick, but even if they don't they'll be wearing a mask!

Finally, if I had a choice between being cared for by a vaccinated, unmasked healthcare worker or a masked, unvaccinated healthcare worker, I'd chose the mask. That is, until we implement influenza prevention bundles that focus on presenteeism.

Note: Mike wrote a fantastic quantitative post (in 2010!!) comparing a vaccine mandate to a presenteeism reduction policy. His conclusion: "Reducing presenteeism by 1 percentage point (from 70% to 69%) would have the same impact as increasing vaccination from 70% to 98%." It's too bad not many read the blog back in 2010...

Pronovost weighs in on the white coat

Peter Pronovost, arguably the nation's leading expert in patient safety, gave us his thoughts on the white coat debate yesterday on The Armstrong Institute's blog Voices for Safer Care. His conclusion: there's enough evidence to ditch the white coat.

Here is the core of his argument (in his words):

We could voluntarily ditch the white coats without needing a clinical trial to tell us it’s OK. We know that white coats can carry pathogens, and it is logical to think that germs could be transmitted from physician to patient. Given that confirming this theory could be prohibitively expensive, we can look at the implications of acting and not acting. While the risks of maintaining the white coat tradition are clear — potentially more infections and preventable deaths — the risks of removing this potent symbol of professionalism would be less significant, though certainly real for some clinicians. How would patients react? Studies disagree on whether they prefer the white coats — some may find them reassuring, but others may see them as elitist. 

Some experts may argue that we should instead focus on proven infection control practices, such as hand hygiene. Yet it's hard to see how voluntarily giving up your white coat would distract from that. It may even raise awareness in general about the importance of hand hygiene once clinicians consider the pervasiveness of germs on their attire, stethoscopes and keyboards. The risks of doing nothing seem much greater than of making the change.

As we have said for several years, mandates should be reserved for interventions with the highest level of evidence to support them. Neither banning the white coat nor mandating flu vaccine for healthcare workers are backed by evidence at that level. But there's enough evidence to suggest that hanging up your white coat and getting a flu shot are probably the right things to do. And to get a flu shot you have to take your white coat off anyway. So do both and leave the coat behind!

Mandatory Influenza Vaccination of Healthcare Workers: The end or just the beginning?

"Just don't let the human factor fail to be a factor at all" - Andrew Bird, Tables and Chairs

We are all in favor of protecting patients from preventable harm. No question. With that aim, the intervention du jour (in the US) is mandatory influenza vaccination of healthcare workers. SHEA, IDSA and PIDS support such a policy, yet a recent Cochrane review stated "there is no evidence that only vaccinating healthcare workers prevents laboratory-proven influenza or its complications (lower respiratory tract infection, hospitalization or death due to lower respiratory tract infection) in individuals aged 60 or over in LTCIs and thus no evidence to mandate compulsory vaccination of healthcare workers."

Yet given the inevitability of mandatory influenza vaccine policies in the US, what can we do to protect our patients from healthcare-acquired influenza and other viral illnesses since mandates would be expected to have minimal or even negative effects on nosocomial influenza transmission? To explain this further, compulsory vaccination policies are technical interventions which are relatively simple to implement. But we have seen over and over that ignoring the human equation or socio-adaptive factors behind infection prevention initiatives leads to failure. As Sanjay Saint and Sarah Krein have written eloquently in their recent book: "Our research has shown that the principle reason is the failure of the hospitals to win their staff's active support of the infection prevention initiatives. In their focus on the technical aspects of an initiative, these hospitals have give short shrift to the human aspects." (You can read my Doody review of their book at Barnes & Noble here)

What are the additional components that we need to consider when implementing an influenza vaccine mandate? Some suggestions:

1) First, acknowledge that we know the vaccine is imperfect through the develop of communication strategies that highlight the proven benefits of the influenza vaccine to the individual health care worker. Since the data supporting direct benefits to patients is more theoretical at this point, highlighting the protective effects for the individual receiving the vaccine - including reduced risks of cardiovascular outcomes could improve acceptance of the mandate.

2) Next, mandate additional components in our influenza prevention bundle, especially those highlighted in the Cochrane review which included "hand-washing, masks, early detection of influenza with nasal swabs, antivirals, quarantine, restricting visitors and asking healthcare workers with an influenza-like illness not to attend work."

3) Offer additional sick leave to healthcare workers required to receive the vaccine. Policies that include bans on presenteeism (working while sick), should be accompanied by additional paid sick leave. In this specific instance, influenza vaccine is associated with fever (especially high-dose vaccines that are associated with benefits in older adults). Providing additional sick leave shows our understanding of vaccine side-effects, demonstrates support for staying home sick and most importantly, respects the individual health care worker.

4) Include in the mandate bundle a plan to de-implement the vaccine mandate if future studies demonstrate that they're ineffective. Doing this will gain more trust with our healthcare workers, which may, counterintuitively, improve the effectiveness of the mandate.

5) Finally, fund large studies evaluating the efficacy, effectiveness and implementation (i.e. barriers) of influenza vaccine mandates in our health care systems. Funding research acknowledges that the data around vaccine mandates isn't perfect, but we are doing the best we can to protect patients now, while simultaneously validating the safety and efficacy of this policy to protect future generations of patients AND our healthcare workers.

There are many things we need to consider as we implement mandatory influenza vaccine policies. The mandate is just the beginning. We have a long road ahead before we can state convincingly that our hospitals are safe from hospital-acquired influenza.

"And how 

How I wish 

I, I had talked to them 

And I wish they fit into the plan"

-Andrew Bird, Tables and Chairs

MCR-1 on NPR - Another sign of the antibiotic apocalypse

Just a quick heads up that there will be a discussion on the newly discovered plasmid-mediated colistin resistance mechanism (MCR-1) during the second hour of "On Point" with Tom Ashbrook today on your local NPR station, podcast and online. This strain was recently detected in animal, raw meat and patient samples in China and was just reported in Lancet ID. After this discovery, investigators in Denmark scanned their collection of approximately 3000 salmonella and E coli samples and found one patient who was infected (bacteremia) with an MCR-1 with five additional food samples positive for MCR-1. An overview by Mary McKenna of the original report can be found over at National Geographic (here) and she continued the great coverage of the emergence of MCR-1 with further strains detected in Denmark and the UK. (new post here)

The radio program/podcast will feature Maryn McKenna, Lance Price from George Washington University and Robert Skov from Statens Serum Institut in Copenhagen. Three fantastic discussants. Hope you have time to listen.

FS for CS - When The Public Helped Fight Tuberculosis

This past weekend, there were lots of public tributes for Ol' Blue Eyes, as Frank Sinatra would have been 100 years old.  Given the season and limited public health funding for tuberculosis research and programs, I wanted us to remember a time when the public was directly involved in an infectious disease (i.e. TB) fight. The Christmas Seals were first issued in 1907 to fight tuberculosis, but are now used more broadly to fund respiratory disease research. Maybe it's time to bring back campaigns to fight underfunded infectious disease research programs? MDRO Seals? Happy Christmas everyone.

Letting the dumpster fire burn on and on

Over the past few weeks, we've seen a flurry of activity on the blog surrounding the decline of interest in the specialty of infectious diseases, as judged by the ever worsening Match results with fewer physicians entering the field. My post on IDSA's response (or lack thereof) generated a number of postings from IDSA officers. I appreciate their comments and have thought about them carefully. In the end, I'm sorry to say that I remain unconvinced that IDSA has a handle on either the problem or the solutions. I guess we'll know in a year when the next Match results are released.

In a nutshell, I think the present inability to recruit resident physicians into infectious diseases is due to loss aversion. We humans seem to be hard wired to avoid loss. Losses have been shown to be twice as powerful as gains in decision making. Thus, the resident weighing their career options gets fixated on the fact that 2-3 additional years of training will result in a significant loss of income likely over their entire career. All of this is magnified by educational debt. And to add insult to injury, choosing infectious diseases over hospital medicine will also mean longer hours and less control over their work schedule. Thus, the disparities in income and lifestyle between the two options are impossible for most to overcome, even when ID may be seen as more interesting, satisfying, and intellectually challenging. Putting myself into the shoes of an internal medicine resident, I have to admit that I probably would have chosen the hospitalist path but for the fact that it didn't exist in 1989.

Much of what IDSA is focused on (e.g., generating more interest in the field), while noble, doesn't address the core problem. Most worrisome is the fatalism in the comments made on Eli's post regarding compensation. The message in essence was: RVUs are low for cognitive specialties; that's just the way it is, get over it. The hospitalists, who are victims of the same E&M coding/RVU system have been much more creative. They have convinced hospital administrators to subsidize their operations. Moreover, in most compensation models, full time clinical activity means just that (full time clinical activity), with perhaps some reduction given for scholarly activity for those in academic settings. But the hospitalists have redefined math. For them 0.5 = 1.0; that is, full time clinical activity for a hospitalist means working every other week. And at a fair wage, I might add.

Economically punishing individuals who undertake more training to become specialists is and will continue to be a losing proposition for ID. From a results-oriented perspective, IDSA's approach isn't working. Solutions will need to be out-of-the-box game changers not incremental baby steps. As the field of infectious diseases continues to die a slow death, I fear IDSA's response will be the same as it ever was: too little, too late.

Photo: New York Times

The real reason ID docs are the lowest paid physicians: AMA's Relative Value Scale Update Committee

In keeping with our annual tradition, Dan recently posted on the declining interest in ID fellowship slots filled through the match. Re-reading his 2013 and 2014 posts, it's quite clear things have not improved. It's also clear that IDSA takes the decline very seriously. In fact, two IDSA presidents, Dr. Stephen Calderwood and Dr. Johan Bakken, have taken time to post IDSA's diagnosis and responses to the public health problem. Both described the relatively poor compensation provided for ID services.

Quoting Dr Bakken: "There is no question in my mind that the financial student loan burden and inadequate reimbursement for ID services are major disincentives for young physicians contemplating a career in ID. IDSA alone does not have the power or means to rectify the problem, but we are working very hard with legislators and policy makers on Capitol Hill."

Without getting too much into the weeds, I wanted to share with you why I think Infectious Diseases is so poorly reimbursed compared to every other subspecialty. The reason is as old as politics - we have no representation on the AMA's Relative Value Scale Update Committee (RUC). Since 1991, CMS has collected advice from this AMA Committee on how much "physician work" is involved in delivering a particular service. This committee is important, since CMS agrees with the committee's recommendations almost 90% of the time. And as you can see in the figure I posted below, there is unequal and unfair representation on this committee. Some specialties are under-represented based on the number of services they provide (i.e. primary care) and certain medical subspecialties (e.g. nephrology, hematology) are only represented on a rotating basis while others (e.g. cardiology) have a permanent seat. Looking closely at the list of subspecialties, I don't see any Infectious Diseases representation!

So, if we want to fix ID, we need permanent representation on this committee. It is a complete travesty that the highly reimbursed procedure-focused subspecialties are fully represented but the "cognitive" subspecialties (endocrinology, ID, rheumatology) are invisible. IDSA needs to demand equal and fair representation.

Orange is the new nudge

A few year's ago, I read the book Nudge, and ever since I've been fascinated by the concept. A nudge is a stimulus that leads to a desired behavior but doesn't force it. For example, in school cafeterias placing fruit at eye level results in more fruit consumption. No one is forced to eat more fruit and potato chips aren't banned, but more fruit gets eaten. Another example is painting horizontal lines on highways, which causes drivers to slow down. So, the million dollar question for hospital epidemiologists is: how can we nudge healthcare workers to wash their hands?

There's a very interesting paper in Health Psychology that attempts to identify hand hygiene nudges (free full text here). At the University of Miami, investigators randomized approximately 400 HCWs and visitors at the entrance to an ICU into three groups: a control group that received no stimulus, a group that was given an olfactory stimulus (citrus smell dispersed by an aroma dispenser), and a group given a visual stimulus (a photograph of eyes placed above the alcohol gel dispenser). The last group was subdivided: for some the photo was middle age male eyes and for others the photo was female eyes.

Hand hygiene in the control group (no stimulus) was 15%. Those who received the olfactory stimulus had a hand hygiene compliance of 47% (p=.0001). The photo of female eyes was associated with a compliance of 10% (p=.626), and male eyes, 33% (p=.038). So, a photo of male eyes above the alcohol gel dispenser doubled hand hygiene compliance and citrus smell tripled it.

The same investigators in a previous study showed that citrus scent was associated with significantly higher rates of hand hygiene compliance when medical students and interns examined standardized patients in a simulation center.

Start slicing the oranges!

Guest Post: IDSA President Johan Bakken, M.D., Ph.D.

Dr. Johan Bakken posted a response to Mike's post yesterday about the ID subspecialty match. We thought we'd highlight the response for our readers, and we thank Johan for his thoughtful comments.   

I can assure all IDSA members and other health care providers who are concerned about the future supply of well-trained ID physicians that the ID future manpower issue is one of the top priorities on the strategic plan that IDSA formulated at our strategic planning meeting last June. IDSA has for several years actively worked on how to attract more talented young physicians to our field, starting as early as medical school. We are currently trying to affect changes to the microbiology teaching programs for medical students, in order to elevate the awareness and evoke interest to our field at an early stage of training. You are probably aware of the survey that was conducted among IM residents last spring and summer by Wendy Armstrong and Erin Bonura to try to understand the factors that influence young physicians in choosing a career in medicine; the survey results are still being scrutinized. Once the final data analysis has been completed we will inform all our members of the conclusions and recommendations. We were gratified to see a record attendance of medical students and residents at ID Week this fall (>400 combined), which indicates a growing interest in our field.

There is no question in my mind that the financial student loan burden and inadequate reimbursement for ID services are major disincentives for young physicians contemplating a career in ID. IDSA alone does not have the power or means to rectify the problem, but we are working very hard with legislators and policy makers on Capitol Hill to educate them about the possibility that America soon may not have the necessary workforce in public health to tackle future epidemic outbreaks, researchers to combat antibiotic resistance, inadequate supply of active antibiotic drugs due to lack of R & D, inadequate supply of trained ID physicians to direct the mandated ASPs in hospitals and long term care facilities, as well as provide excellent care for complicated patients with severe infections, chronic HCV and HIV infections and so on, unless the reimbursement structure for services is legislatively improved. The financial solution to these issues lies in the hands of our elected lawmakers, and IDSA will continue to advise our members of Congress on these issues. Pivotal to this point, Congress needs to find a solution that can ease or solve the loan repayment burden for young physicians, to make it attractive for them to choose a career in ID.

Next year all ID fellowships will be distributed via the all-in process, which will provide equity and fairness to the selection process and give us truer numbers of who and how many of the residents end up in an ID fellowship. 

All the issues I have outlined, and how IDSA plans to tackle these problems, were discussed by Steve Calderwood, IDSA past president, at the IDSA business meeting in San Diego last October, continue to be worked on by the IDSA staff and members of the IDSA board of directors. Please be assured that we hear your concerns are doing all we can to ensure that our future workforce will grow to handle all the ID challenges that lie ahead. 

IDSA: What--me worry?

Yesterday, we witnessed another disastrous match for Infectious Diseases, nicely (and sadly) described by Dan here. I just went to the IDSA website to look for the official response of our professional society. Guess what? There is no response! I was, however, encouraged to find a tab on Workforce and Training. Here's what it contains:

Wow--look at those efforts to support a robust infectious diseases workforce! Obviously, this is a top priority given that the most recent statement is from 2013 and it doesn't even address the current problem. Alfred E. Neuman is clearly in charge at IDSA. In all seriousness, could a professional society be more disinterested in its own future?

Annual ID Match Day post: Someone get a fire extinguisher!

Last year I described the ID Match as a dumpster fire. Subsequent posts discussed why the specialty of infectious diseases is in trouble, and what we might do about it. I re-read those posts tonight, and I have nothing to add to them. My only question is: how does this end? The trend in unfilled programs, below, is shocking, with about 60% of fellowships now going unfilled, and 117 unfilled ID training positions. I’ve reviewed the list of unfilled programs, and without naming institutions I can tell you that it includes many of the top programs in the country, from coast to coast. 

The problem now is that busy internal medicine residents who are interested in ID may consider their options and decide it is best to skip the match entirely, and to grab one of the many excellent training opportunities available after the match is over. Once this happens, the whole system begins to break down. My prediction is that the NRMP will kick our specialty to the curb sometime in the next couple years, and we’ll be back to recruiting trainees the old fashioned way.