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.

WSJ Health Blog Goofs!

The Wall Street Journal Health Blog has now corrected its previous post on the AMA House of Delegates voting in favor of a ban on white coats. The official AMA response (on p. 15 of this document) was to refer the resolution to another committee for further study. As I stated in a previous posting, it would have been surprising for the AMA to pass the resolution given the AMA's generally conservative approach, coupled with the iconic status of the white coat for the profession. Nonetheless, I still believe it makes sense to hang up those germ-laden coats for good.

AMA calls for banning white coats

The Wall Street Journal Health Blog is reporting that the AMA House of Delegates voted today to recommend that hospitals ban white coats. Given the iconic stature of the white coat, I am quite surprised by the vote. Now a real debate will likely begin in the US on the topic. Click here to read more on why the white coat poses infectious risks.

Quote of the day

From Peter Ragusa, a new medical graduate from the University of Minnesota, in the Wall Street Journal Health Blog, on the resolution before the AMA House of Delegates to urge physicians to give up their white coats:

As with many things in medicine, just because we can’t prove it doesn’t mean it’s not true. It’s hard to do randomized double-blind controlled trials with something like this. But I’m a med student and I can look down at my sleeve and see it’s dirty, I can look down at my tie and see it’s dirty.

AMA to weigh in on hospital dress codes

Mike has blogged about this, and has gone to great lengths to encourage a “bare below the elbows” approach to patient care at VCU—but so far I haven’t seen a major professional society or public health authority in the U.S. make any definitive statements. So I find it very interesting that the AMA will be considering a resolution later this month (at their House of Delegates meeting in Chicago on June 13-17) that squarely addresses the role of clothing and accessories (jewelry, wrist watches, etc.) in the spread of pathogens in hospitals. All the resolutions can be accessed here (this one is resolution 720)—since I can’t directly link to it I’ll copy the text below. As you can see, the AMA doesn’t get very prescriptive about what should be done, just advises that hospitals adopt dress codes that “minimize transmission of nosocomial infections, particularly in critical and intensive care units.” But they specifically refer to the UK “bare below the elbows” policy, so I think it leaves the door open for hospitals to begin changing policy in this area….I’ll let Mike weigh in on just how difficult that can be.

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 720 (A-09)
Introduced by: Medical Student Section
Subject: Hospital Dress Codes for the Reduction of Nosocomial Transmission of Disease
Referred to: Reference Committee G

Whereas, Nosocomial infection is a significant cause of morbidity and mortality in the US; and
Whereas, According to the Centers for Disease Control and Prevention, approximately 1.7 million hospital patients contracted nosocomial infections in 2002, resulting in nearly 100,000 deaths; and
Whereas, Patients in critical or intensive care units are most susceptible to nosocomial infection, accounting for nearly 25 percent of all cases; and
Whereas, Neckties, long sleeves, and other clothing items and accessories have been implicated in the spread of nosocomial infection; and
Whereas, In 2007, the British National Health System implemented a “bare below the elbow” hospital dress code, banning neckties, long sleeves, hand and wrist jewelry, and traditional physician white coats; therefore be it
RESOLVED, That our American Medical Association advocate for the adoption of hospital guidelines for dress codes that minimize transmission of nosocomial infections, particularly in critical and intensive care units. (Directive to Take Action)