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.

IDSA response: Guest post by Dr. Dan McQuillen

The following is a guest post from Dr. Daniel McQuillen, IDSA Chair for the IDWeek 2016 Program Committee, and President of the Massachusetts Infectious Diseases Society.

With the acknowledgement that IDSA needs to expand communication/marketing efforts in this area, I wanted to offer some information on ongoing activities our society has been engaged in for several years, beginning with IDSA’s leadership level membership in the Cognitive Care Alliance, an organization that has evolved from a loose coalition to a more formal structure last January. The Alliance hopes to take advantage of the collective power and footprint of cognitive specialties to advance the agenda that the current payment system seriously undervalues cognitive services. Change is slow and incremental in this area, but some of the reforms in payment delivery coming along offer opportunities for ID to improve our reimbursement position in the clinical arena and more importantly in the non-clinical arena (antibiotic stewardship programs (ASP), infection prevention (IP), overall system quality). You'll note that the Alliance member who signed this letter to the Senate Finance Committee (John Goodson from SGIM) is also the author of the recent NEJM article regarding fixing the Medicare Fee Schedule.

IDSA representatives to the AMA CPT/RUC committees have been involved in development and valuation of codes for physician supervision of OPAT infusion, RVU revaluation (upwards) of Evaluation & Management codes and transitional/continuing care codes. In addition, the IDSA Board approved a partnership between the Valuation Workgroup that I lead and The Advisory Board, a consulting group with a healthcare focus, to formally develop the concept of an ID Hospital Efficiency Improvement Program. Such a program will contain ID service lines that are threads throughout healthcare systems, and can serve as templates for members to use when they are proposing new or expanded ASP, IP and OPAT programs to their hospitals or systems. The IDSA Board of Directors previously funded our work with an external expert valuation firm to establish that the benchmarks for “fair market value (FMV)” for ID executive compensation should be higher than the FMV numbers usually thrown out by hospital executives at ID docs. The compensation survey just published by the IDSA Clinical Affairs Committee (CAC) complements this and represents an effort to generate accurate data to counter the inaccurate data promulgated by MGMA and Medscape, not a ‘spin’ that everything is fine. It is just one piece of a broad effort to bolster the value of ID specialists to the systems they work in and support. I note that SHEA has recently surveyed its membership on compensation and await a report on the findings in hopes that it serves as another more accurate benchmark reference. The FMV data along with examples of medical executive co-management agreements for non-clinical activities with sample contracts can be found in the “Value of ID Specialists Toolkit” on the IDSA website (membership login required).

A major thrust of what the IDSA Clinical Affairs Committee, Value Task Force, and Valuation Workgroup have been doing for several years is to establish a robust set of tools with supporting evidence that will serve to increase the benchmarks for what we get paid for our non-patient care activities. New trainees coming out of fellowship have little idea how to establish the value of and negotiate for fair compensation for those activities (I know I had no clue). Success in these efforts will go a long way to increasing overall compensation and have potential to yield far more reward than increasing payments for E&M services would. Our specialty’s inherent altruistic nature, especially in academic settings but still in many clinical practice settings, gives our expertise away with too much ease. We have to change that.

Finally, two IDWeek plugs: the IDSA CAC has organized a session for several years that explores the issues of Health Care Reform as they affect our specialty. This year will feature talks on Health Care Reform trends by a speaker from The Advisory Board, ID-led ASP, and how ID specialists fit in a bundled payment environment. Second, in lieu of their annual Business Meetings, the Presidents of IDSA and HIVMA will be hosting an ID “State of the Specialty” Town Hall Meeting Friday evening at IDWeek. Please attend with suggestions in hand.

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. 

The dumpster fire burns on...

I'm in Park City, UT at the Infectious Diseases Winter Course, always a great review of the hot topics in ID. This morning I led a meet-the-professor breakfast session. I assumed that the discussion would revolve around topics in hospital epidemiology, but interestingly, the participants were most interested in discussing the future of Infectious Diseases as a specialty (i.e., the dumpster fire). After about 20 minutes, one participant suggested that we change topics since everyone seemed to be getting depressed.

We've previously blogged on the problems that the specialty faces, particularly the compensation issues and the dying interest in the field by physicians in training. Along these lines, there are two new papers that are worth reviewing. The first is a paper in CID that very nicely outlines the value that ID physicians add in the care of individual patients and also in population health. The second is a commentary by Dick Wenzel and myself that focuses on infectious diseases in the academic setting. Still missing, in my opinion, is a fully engaged advocacy group for ID doctors that plays an effective role in addressing our issues.

Photo: The view from my hotel room at the ID Winter Course

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.”

Infectious Diseases and the Terrible, Horrible, No Good, Very Bad Match

Here we go again. Another internal medicine subspecialty “match day” and another record (bad) day for ID. How bad? The previous record (set last year) for unfilled ID programs was 54. This year 70 programs went unfilled, meaning that for the first time ever there were more programs that didn’t fill than that did. Almost 100 funded ID training positions unfilled in a single year!

We’ve blogged about this trend before, here and here, and discussed some of the reasons that ID is in decline as a specialty (along with some suggestions for how to turn this around). I don’t have any new insight, except to make the point that this is now beyond a crisis situation for our specialty. It’s a dumpster fire.

Infectious Disease: JAMA Theme Issue

This week's JAMA is a special ID Theme Issue with a publication coinciding with IDWeek 2014. For the infection prevention inclined there is a Viewpoint by Dan Morgan (along with Dan Diekema and Keith Kaye) that asks us to consider contact precautions as secondary/adjunctive measures for MRSA and VRE but suggests that their use is prudent for MDR-GNR. I guess the BUGG study has me convinced that contact isolation works for MRSA, so I'll have to disagree with my esteemed colleagues. There are two important trials of candidate vaccines for avian influenza and an excellent editorial by John Treanor bringing us up to date on pandemic influenza options. There is also a cluster-randomized trial of SDD and SOD from the Netherlands by Marc Bonten's group with an editorial by Kollef and Micek. I'm sure we'll expound on this study more in the future. Besides the CDC's hospital antibiotic use study that I posted on earlier, there is a CDC outbreak investigation describing a 39-patient NDM-E. coli (CRE) outbreak associated with duodenoscopes. In the accompanying editorial, Rutala and Weber ask "whether current US endoscope reprocessing guidelines are adequate to ensure a patient-safe gastrointestinal endoscope."

I would be remiss if I didn't point you to the Editorial by the ID-Issue Editor, Preeti Malani. She did a wonderful job pulling this issue together and in her editorial outlines the many broad threats to human health that we still face from infectious diseases. In particular she highlights the "worldwide, major disparities (that) cause many individuals to lack access to clean water, safe food, and fundamental elements of infection prevention, such as hand hygiene and basic sanitation." She also worked closely with Cassio Lynm, the medical illustrator who created the cover image (above). Clouds ominously bring forth climate change as the sea harbors new pathogens and threatens those sequestered safely on shore. And the one barrier we have against the multitude of threats? Contact (and droplet) precautions. I couldn't agree more.

Whither infectious diseases?

One morning in October 1983, when I was a 22-year-old second year medical student just recovering from infectious mononucleosis, I arrived at school for my medical microbiology lecture. At that point, several weeks into the course, I found myself with no real affinity for the subject matter. The lectures seemed to focus on the minutiae of biochemical tests for various bacteria that I planned to memorize for the exam then forget. But that October morning we were scheduled to have a clinical correlation lecture. I always looked forward to those lectures--talks about real diseases by real doctors. The lecture was on meningitis and given by Rashida Khakoo (shown in photo), a young infectious diseases doctor. It was incredibly fascinating and I was forever hooked. Over the course of the next several years, I rotated with Rashida several times on the Infectious Diseases consultation service, and knew that ID was my calling. It's hard for me to estimate how much I learned from her. She's an amazingly brilliant physician and incredible bedside teacher who reads incessantly and has the capacity to remember everything that she has ever read. The joke among the medical students was that you could not find a bound journal in the library that did not have her name on the library check-out card (I realize younger readers won't get that joke). Three decades later, I still believe she's the best doctor I have ever encountered.

For me and many others, Infectious Diseases remains a fascinating specialty. What other field has new diseases and challenges continuing to emerge at the rate of our specialty? We remain the disease detectives, the go-to doctors when no one else can figure out what is wrong with the patient (think Gregory House, MD, only nicer!). We add value in many other ways by working as hospital epidemiologists, antibiotic stewards, and public health experts. This morning's New York Times has multiple articles regarding infectious diseases. This should be our heyday. But instead, the field of infectious diseases appears to be in rapid decline. This past year, only 137 US medical school grads applied for fellowship positions in Infectious Diseases and only 41% of available positions were filled. We have recently heard numerous reports that fellowship programs, increasingly desperate for trainees, are violating rules of the National Resident Matching Program (NRMP) and offering candidates positions outside of the match process.

The cause of ID's demise is purely economic. Put yourself in the shoes of a 30-year-old 3rd year internal medicine resident with two young children and a $300,000 educational debt. You find the field of infectious diseases to be very interesting but you are forced to make a choice between 2-3 years of additional training at a fellow's salary or entering the workforce now as a hospitalist. The median annual salary of a hospitalist currently exceeds $250,000 and on average a hospitalist works 40 hours per week. As a hospitalist you will earn a salary 30% higher than your ID colleagues and work 30% fewer hours. Most hospitalist positions offer predictable hours and frequent, extended periods of time off. Can we blame young doctors for choosing the hospitalist option?

Unfortunately, most physician compensation plans reward volume not value, and that's a losing proposition for us. You can't evaluate a patient with fever of unknown origin in 20 minutes. There are no RVUs earned for spending three hours reviewing the medical records of a highly complex patient. In my previous job, the departmental administrator chastised me for spending too much time with my patients. Although I knew my work was important, that referring physicians were pleased and that my patients were grateful, I no longer felt valued.

The work of the ID doctor has never been glamorous, the pay has never been as good as most other specialties, and the hours have always been long. You don't enter ID to have a good lifestyle or get rich. But what has changed over the past decade is that internal medicine residents now have an option that offers higher pay and better hours, without pursuing additional training. Until ID becomes more economically competitive with hospital medicine, the odds of a comeback are slim. This isn't rocket science. And it's really a shame that the Infectious Diseases Society of America, our professional society that should be advocating for us, seems incapable of articulating an effective message about the crisis that the field of ID faces, the value that we add to health care, or potential economic solutions.

Sadly, we must ask: will the last ID doctor please turn out the lights?

JAMA Infectious Diseases Theme Issue: Deadline April 15, 2014

Just in time for the holidays, Santa has left a gift for ID folks under the tree. I'm not talking about the recent action by FDA to ask the livestock industry to stop using antibiotics for growth promotion, nor am I talking about the FDA's proposed rule to "require manufacturers to provide more substantial data to demonstrate the safety and effectiveness of antibacterial soaps (that contain triclosan or triclocarban)."  While I'm very excited about those developments, I'm pretty sure Santa doesn't work at the FDA.

What I am attempting to highlight is JAMA's ID theme issue planned for October 2014. I offer a few select quotes from the call for papers written by Preeti Malani and Michael Berkwits:

"Ironically, while advances in public health have been driven historically by management of infections, the body of evidence that guides contemporary practice in infectious diseases remains relatively limited."

"Clinical trials rarely can fill a journal issue, and important clinical questions far exceed the number of trials that can be planned, so we invite authors to submit research with other designs and approaches."

"Studies that present new information relevant to optimizing treatment strategies and prevention efforts, and those that enhance the understanding of quality-of-life and economic consequences of infection are also of interest."

Let's hope this theme issue has some new science in the fields of infection prevention, antibacterial resistance and stewardship. Deadline April 15th!

A specialty in decline?

It was “match day” today for the internal medicine subspecialties. For some fields, there are far more applicants than training positions. Thus hundreds of would-be gastroenterologists and cardiologists find themselves out in the cold, unable to pursue their chosen profession. Not so for infectious diseases (ID). This year marks a new record for unfilled ID programs (54), with many training programs unable to fill a single training spot in the match. Given current trends, we are approaching a situation in which half of all programs will have unfilled positions. As funds for graduate medical education become increasingly scarce, some of these programs will likely reduce the number of training positions they offer, or shut down altogether. 

There are several explanations for this trend, including reimbursement of ID specialists (train longer to make less!), the educational debt burden of trainees, the rise of the hospitalist, and reductions in research funding for academic careers. I have no easy answers, but it is urgent that we address this slow motion train wreck. Multiple drug resistant bacteria already far outnumber the contingent of ID doctors, and that situation is bound to get worse over the next several decades. Some things to work on: (1) perform studies to demonstrate the value provided by the ID specialist, (2) advocate for increased funding for ID research and training, and (3) provide role models who demonstrate that ID is an incredibly interesting and rewarding career!

Happy Friday - 21st Century ID Consults

Many of us went into ID because of the diagnostic challenges of complicated fever work-ups or the occasional excitement of a trop-med case. But we ended up here. Oh, is there a separate billing code for doing discharge summaries for other services?

And if you haven't read Harold Horowitz's NEJM Perspective on Fever of Too-Many Origins yet, it's well worth reading.

The parasite-stress hypothesis

I ran across an interesting article in this week's Economist, which covers a new paper in the Proceedings of the Royal Society of Biology--an ecologic study that correlates countries' population burden of infectious diseases to levels of intelligence. The authors of the paper conclude that countries with the the highest rates of infectious diseases have the lowest IQs, even when controlling for confounders such as GDP, education, and climate. The investigators hypothesize that the energy consumed by infections in early childhood affect brain development, leading to lower intelligence. The paper is intriguing, the association seems biologically plausible, and the authors seem careful to identify potential confounders and caution the reader on the limits of observational studies.