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.”

The smoldering dumpster

I’m a bit delayed this year in commenting upon the ID Match results—go here for our prior posts on this topic (and the broader issues affecting recruitment into our specialty).

IDSA has a good summary of the results, and the figures below are taken from that article. The overall message is: the dumpster fire is no longer raging, but the dumpster is still smoldering! We’ve basically held steady since the new “all-in” Match started last year, with similar percentages of programs and positions filled. 

How to interpret the numbers? I think the “all-in” rules have reduced some (most?) of the outside-the-match ‘strategery’ that some programs and applicants were practicing. Thus after a couple years of “all-in”, we have a more accurate picture of the supply-demand relationship for ID training. This picture is far from pretty—a third of programs are going unfilled, representing one in five of our training spots. Clearly, “train longer to make less” is still a difficult reality to overcome, even for a specialty as fascinating and fulfilling as ID.

So we have a lot of progress to make, and it will have to be made against some pretty stiff headwinds. Easily lost in the numbers is the substantial proportion of positions filled by international medical graduates. This is a great thing in my view, bringing diverse experience and perspective to our programs—but it also makes demand for ID training highly vulnerable to corrosive political forces that may make it less inviting to come to the U.S. for training and employment. If IMG numbers fall, the dumpster fire will rage anew.

Finally, the political landscape will undoubtedly also shape the U.S. healthcare system in ways that are unpredictable, but which could reverse some of the trends favorable to ID (e.g. focus on population health and value, with requirements that promised to provide more fulfilling job options for ID—stewardship and infection prevention among them). The strong anti-regulatory mood of the current administration, along with increases in the uninsured population, could reduce incentives for healthcare systems to invest heavily in quality and safety. 

To sum up, this year’s match should serve as a continued call-to-action, as we still have huge challenges ahead as a specialty.

-->

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

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.

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

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.  

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.

The delusion continues

There's a new paper in Clinical Infectious Diseases on the highly anticipated survey of Internal Medicine residents to solve the enigma of why no one is going into infectious diseases. It never seemed to be a mystery to me, but having data is always helpful, providing that you interpret it correctly. And here that caveat concerns me a great deal.

The survey results were divided into three groups: those applying or intending to apply to ID fellowship, those interested in ID but deciding not to apply, and those with no interest in ID. Of those who had an interest but didn't apply (the group that we should have some hopes of capturing), the number one reason for not going into ID was SALARY. Moreover, when asked what is the most important factor to increase interest in ID, all three groups said SALARY. For those going into ID and those who considered it, the percent responding salary was two-fold higher than the next most commonly cited factor (early exposure to the field of ID).

So no surprises here. But what was both surprising and alarming to me was that the discussion in the paper and the accompanying editorial both seemed to downplay salary as a factor in the current dearth of applicants to ID. The authors wax eloquently on career choice models, pedagogical techniques, the importance of mentors, etc. Salary is buried in half a paragraph of the eight paragraph discussion. The authors of the editorial even seem somewhat astonished that the top career choice of those who considered ID but didn't apply was general internal medicine, a specialty that they note "is not typically considered a high remuneration specialty." I think there's no surprise here either for two reasons: (1) hospitalists make significantly more money on a per hour basis than most infectious diseases doctors, particularly in the academic setting, and (2) whatever that difference in salaries is, it's magnified by the fact that two more years of training (at least) results in a lower salary. That is, you are punished economically for additional training, which many folks find too unpalatable to move beyond.

My bet is that the paper and editorial are nicely in line with IDSA's thinking since IDSA sponsored the study. And I suspect that IDSA will continue to pretend that all is well while the dumpster fire burns away. Once we get the microbiology courses in medical schools to stop making the students memorize so much, the students will come racing to ID!

Carry on then.