The delusion continues (part 3)

In response to my last post a reader emailed me the following: Very easy to sit at a keyboard and throw blog bombs...  I would be thrilled to hear your constructive suggestions for a solution(s).

Fair enough. I'll address that. But it's important, I think, to first say a few words about this blog, which is now in its 8th year. From the beginning, we wanted to make controversial issues a focal point, and the issue of the ID workforce (or lack thereof) is controversial and a topic of great interest to readers. In addition, we welcome comments and guest blog posts to offer alternative viewpoints. Eli, Dan, and I don't always agree with each other (as is evident in our posts). The only comments that are censored are those advertising black market erectile dysfunction drugs and other products. And all requests for guest posts have been honored unless the author has conflicts of interest with industry. So readers, please feel free to respond to our posts.

My comments on the workforce/compensation issue and IDSA's response are made in the context of my experience with these issues. In my former job as an infectious diseases division chief in an academic medical center, I had firsthand experience with the difficulties of recruiting fellows and faculty, the inequities that resulted from a purely RVU-based compensation plan, and the toll this took on teaching and morale. At the same time, I was observing a private health system across town crank through a multitude of infectious diseases doctors, each of whom left practice once their guaranteed salary expired and they one by one came to the realization that they couldn't generate enough RVUs to maintain their salaries. Several of these physicians became hospitalists. In my current position, I see my division chief struggling with trying to balance his budget, offer salaries that can compete with other hospitals and medical schools, deal with ever increasing consultation volumes and expectations for rapid responses to consult requests, while trying to minimize the stress all of this has on his fellows and faculty members. We now have starting salaries for brand new nurse practitioners that are within a few thousand dollars of junior ID faculty salaries. I'll be the first to admit that my experience may not be the same as others. In the IDSA compensation survey, one respondent reported a salary of $1.45 million, so obviously his situation is quite different than mine and his views on these issues probably are as well.

I did a little more research on salaries by looking at the AAMC data. The median salary for an infectious disease assistant professor is $152,000, while the median for a hospitalist assistant professor is $207,000. For a third year internal medicine resident, that's a huge difference. At the associate and full professor levels, hospitalists still earn more money than infectious diseases specialists. Moreover, hospitalists salaries are rising yearly at a higher percentage than ID's, so the difference continues to expand.

Another interesting finding is that of salaries for chairs of Departments of Internal Medicine. Unfortunately, if you're an infectious diseases doctor you'll earn significantly less than your chair peer who's an invasive cardiologist, a difference of about $350,000. And what do cardiologists learn in their fellowship about being a department chair that would explain that difference? I hate to sound like Donald Trump, but it's a rigged system. And it follows you throughout your career.

As for constructive suggestions for solutions, I've written about this in older posts, but here are a few:
  • Focus on the parity with hospitalists, since that's our biggest threat with regards to recruitment of residents into infectious diseases. Until ID salaries are at least as good as hospitalists', there's little reason to think that we will turn this around. 
  • Consider shortening the ID fellowship 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? 
  • Develop hybrid models of training to lessen the economic impact on trainees (for example, integrate ID training 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. 
  • If IDSA is working hard to address these issues, it's not apparent from their website or communications with its members. Most importantly, in my view, IDSA needs to own the workforce issue and honestly deal with it. And that begins by calling it what it is--a crisis. A crisis, magnified by the many problems that are in the news every day, like Zika virus and antimicrobial resistance. I'm not a communications specialist, but it seems to me that these issues could be highlighted to help our cause. 
Unfortunately, the two articles and editorial published this week in IDSA's journals spin an unrealistic view of the problem. I doubt that the your-salary's-not-as-bad-as-you-think-it-is campaign will have much impact. Time will tell. In December, we'll see the results of the next Match. 


  1. As the senior author of one of the papers you featured your first of these three posts (the “long awaited survey”), I feel compelled to correct a couple points. First, the majority of those who considered but chose not to go into ID went into General Internal Medicine. This was a distinct category from Hospital Medicine. This does not include hospitalists, but primary care internists and others in GIM. That group does have more comparable salaries. Second, we certainly agree that salary is an issue, but it is not the only issue. As educators who spend significant time with students and residents, there has been a fundamental change in the exposure to Infectious Disease and ID clinicians both in the preclinical and clinical curriculum. We must work to improve salary by improving the perceived value of the ID physician but we must also improve the visibility of our specialty and our involvement in education. Importantly, in the survey, although salary was identified as an issue, when asked if improving salary would improve recruitment to ID, 50% of the respondents said no. Third, although I recognize that this study was funded by IDSA, the study was conducted independently of IDSA and at no time was the content influenced by IDSA. The study is the product of the authors and reflects our own data and conclusions. Fourth, I’m aware of and involved in several IDSA efforts to work on multiple aspects of this problem. We are looking carefully at some of the issues you raise (combined training etc), however I can tell you these are not straightforward solutions and have some significant downsides for our specialty as well. The Society is deeply concerned about trends in trainee recruitment and does view this as a crisis. These issues are complex and not going to be resolved in one years’ time. I can tell you right now that the next match is not likely to be substantially different. There is NO magic wand here. There is a lot of hard work and time that will be required to improve ANY of the forces at play, including salary equity. Continually offering up the December match day as the litmus test for the many efforts that are ongoing is absolutely unrealistic. Continued barbs in all directions aren’t helpful either and don’t make our unique and wonderful specialty look attractive to our trainees. I agree that we have several unique events now (Zika, Ebola, antimicrobial resistance, etc) that can brilliantly support the importance of ID physicians. We must all pull together to work this problem from all angles with creative solutions rather than becoming divisive which won’t solve anything.

    1. Thanks for you comment and pointing out that the biggest competitor to ID is non-hospitalist general internal medicine. Per AAMC (the only comparative salary source I have access to), median salary for a general internist at the Assistant Professor level is >$40,000 higher than for ID at the same level. So it's the same problem. Asking residents to engage in 2-3 more years of training in order to take a pay cut is a non-starter. If NPs were paid less than bedside RNs would we be surprised if nurses stopped pursuing NP training? And if the Match isn't the litmus test of interventions to improve recruitment into ID, what other outcomes measure would you use? Lastly, my posts are not meant to be divisive, but meant to increase interest, engage more people, and give voice to a viewpoint shared by many others.


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