ID Match 2017: Turning point or artifact of "all in" approach?

The dust is still settling from this year’s ID Match, but at first glance it looks like a much-needed step in the right direction. Compared with last year, the number of unfilled positions (on match day, that is, which doesn’t count positions that will be filled after the match) is down to 80 from 117, and the number of unfilled programs is down to 54 from 82. This is not to minimize the pain for programs that didn’t match—>50 is still way too many, and comparable to the number of unfilled programs in 2014.

This dramatic shift from the trend of the last three years must be due in part to the “all-in” strategy that IDSA is pursuing (requiring that all ACGME positions be offered in the match, trying to minimize those positions offered before or after). The question is how much of this shift reflects an absolute increase in the number of trainees after the post-match numbers are included. For example, there is still the chance that interested individuals opt out of the match, hoping to snag a good position afterwards (obviating the expense, time and anxiety the interview circuit). 

The challenges to attracting the next generation of ID physicians remain daunting, and this one-year change in match results (temporally associated with a new “all in” policy) shouldn’t detract from the urgency of these efforts. We’ll have a much better sense of how we are doing (at least from the training program side) after another 1-2 years of the “all in” match. If programs and applicants continue to adhere to the "all in" approach (i.e. how will it be enforced?), at least it should give us a more accurate assessment of the supply-demand situation.

I’d welcome input from other program directors, IDSA leadership, and anyone else with thoughts on this year’s match results!

Declining interest in ID: Paul Sax interviews Mike Edmond and Wendy Armstrong

Open Forum Infectious Diseases has a podcast feature, which I highly recommend. The latest installment is a very insightful discussion of the future of ID as a specialty, and how we should respond to the decline in fellowship applicants. We’ve covered many of these issues on this blog before, and I encourage you to either listen to (MP3 link) or read (transcript) this interview.

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.

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. 

Guest Post: IDSA’s Take on the Match Results

This is a special guest post by Dr. Stephen B. Calderwood, MD, FIDSA, President, Infectious Diseases Society of America (IDSA)

The first annual IDWeek Mentorship Lunch, IDWeek 2014    

The IDSA community is over 10,000 doctors strong, and we’re all concerned with the match results for this year. But the dumpster fire metaphor is only half right: Yes, it’s a crisis, but we aren’t shrinking from it. Everyone at IDSA is fighting for our specialty, and we need our whole community to join in. 

Compensation

HAI Controversies has talked before about this, and Mike Edmond put the blame squarely on the economics of being an ID doctor. The Society continually advocates for better compensation for ID services and how to value their input differently under health care reform. This past year, IDSA has pushed hard for ID specialists to be required for hospital stewardship programs. To help individual doctors with compensation, several IDSA veterans compiled The Value of the ID Specialist, a comprehensive study that documents how ID consultations result in better outcomes and lower costs.  And for IDSA members, we offer a Value Toolkit (login required), which collects presentations, videos, and documentation to help ID doctors make the case to their own employers, hospital administrators and health plan executives.

Funding for Research and Public Health

Funding cuts in research and public health affect all of us, not just ID specialists, and IDSA joined hundreds of other professional societies to Rally for Medical Research. In addition, our policy and government affairs team works tirelessly, advocating for more research funds for HHS agencies and encouraging the White House and Congress to commit more of the federal budget to infectious disease research and public health.

We actively encourage our members and the public to join these efforts. In three minutes, you can let your congressional representatives know that budget cuts hurt the infectious disease community, and ultimately the patients we serve. Of course, you can also contribute more directly: the IDSA Education and Research Foundation supports medical students and young investigators with fellowships, travel grants, and research funding to help recruit more people to our specialty and to help with their early career development.

Mentorship

Mike Edmond’s post led with a moving tribute to the mentor who inspired him to choose ID. IDSA is dedicated to expanding our mentorship efforts. In addition to our two Fellows’ meetings every year and our scholarships for medical students, we launched a new Mentorship Program at IDWeek 2014. Students, residents, and fellows were teamed up with seasoned ID professionals and explored the meeting together. We’re actively trying to expand our mentorship programs, and encourage our members to volunteer for these efforts.

Responding to the match is a community effort that will require a multi-pronged approach. We at IDSA are all thankful to have an active, involved, and passionate community of ID doctors in our Society who want to see the specialty thrive and expand; we welcome all thoughts individuals may have in better addressing this issue. We certainly want to ensure that we continue to attract the very brightest and committed individuals to our specialty. We’re committed to ensuring that the future workforce brings the clinical expertise and new knowledge needed to address the many problems we face, including the enormously important areas of antimicrobial resistance and stewardship, HIV, TB, emerging infectious diseases (such as Ebola!), and all the other key areas our specialty contributes to so uniquely on a daily basis.