Headlines reporting new infectious disease (ID) outbreaks instill public panic and fear. Those of us in ID have led the response to these and many other threats that never reach the media. We are the physicians trained to treat patients, guard the health of the public, and contain cost. Yet, the future of our essential specialty may be in danger.
In the 1970s, advances in medicine led to a perception that the specialty of ID, a subspecialty of internal medicine and pediatrics, was bound for extinction. However, within that decade, tuberculosis was on the rise; human immunodeficiency virus (HIV)—as yet unrecognized—was gaining a foothold that would eventually lead to the global AIDS pandemic; Ebola made its first identified appearance in humans; and a viral infection (hepatitis C) was initially suspected as a cause of post-transfusion hepatitis. Today, ID physicians continue to treat transmissible illnesses—often in the context of poverty, mental illness, addiction, discrimination, and incarceration, where complex care coordination to facilitate successful treatment takes on added public health import.
Although crude infection-related mortality declined in the first half of the twentieth century, rates have been stable for the past 35 years. Spikes in mortality over the last century are universally due to infectious causes, such as influenza, pneumonia, and HIV. Mortality rates related to drug-resistant pathogens have not improved since 1980, and some have predicted that 10 million deaths annually will be attributable to resistant organisms by 2050 [1]. Antimicrobial resistance has become such an important global health threat that, in September 2016, a high-level meeting on this topic was held at the United Nations. Novel therapeutic interventions directed against other diseases, including chemotherapeutic agents, transplantation, and biologics, predispose to atypical and refractory infections among immunocompromised hosts. Still today, 1 in 20 deaths in the United States is attributed to an infectious cause [2].
Through prevention measures and antimicrobial stewardship, ID physicians also play a critical role to reduce hospital-acquired infections (HAIs) and their associated costs. Preventable HAIs, such as catheter-associated urinary tract infections ($1000/infection) and surgical site infections ($35000/infection), conservatively result in an annual financial toll of $5.7–$6.8 billion, comparable with the annual national direct medical costs of treating stroke ($6.7 billion), complicated diabetes mellitus ($4.5 billion), or chronic obstructive pulmonary disease ($4.2 billion) [3]. Mandated by the Medicare Hospital-Acquired Condition Reduction Program, ID clinicians discontinue or narrow the spectrum of prescribed antibiotics to more effective, less-expensive alternatives and manage home antibiotic regimens to reduce length of stay and readmissions [4]. Demonstrative of their value, Centers for Medicare & Medicaid Services recently proposed that hospital antibiotic stewardship programs would be essential for participation in Medicaid and Medicare [5].
Given their tripartite role in patient care, public health, and cost containment, ID specialists are more essential now than ever. But akin to the dwindling pipeline of new antibiotics, the numbers of trainees entering ID has steeply declined since 2011. In 2015, while the Ebola outbreak in West Africa and the spread of Zika in the Western hemisphere were overlapping global crises, fewer than half of US ID fellowships filled their incoming classes. This statistic is just one example of a concerning trend that ID leaders have been noticing: between the 2009–2010 and 2016–2017 fellowship matches, the number of adult ID programs filling all of their positions dropped by 41% (Figure 1) [6]. Simultaneously, the number of applicants declined by 31%. Whereas in 2009–2010, programs had seen an average 1.1 applicants per position, in 2016–2017, they saw 0.7 applicants per position (81% vs 95% acceptance rate). This trend took place despite an increased number of fellowship-eligible physicians graduating from internal medicine residencies. Modest improvements were seen in 2017–2018, likely due in part to the newly instituted requirement that all positions be offered through the match. Nevertheless, 20% of ID programs remain unfilled, and ID continues to have a substantially higher percentage of vacant positions than most other medicine subspecialties, including fields like rheumatology, endocrinology, and hematology-oncology. Although pediatric ID has only participated in the match since 2013–2014, trends are similar to their adult counterparts, with only 0.7 applicants per pediatric ID position offered and with 38% of positions unfilled for the 2017 appointment year [6, 7].
Trends in US national residency match program specialties matching service, infectious disease programs filled and unfilled, 2009–2017
Why the gross mismatch between clear demand and emerging supply? A recent report suggested some possibilities, noting the value of the ID specialty has been under-recognized, undercompensated, and among the last specialty choices for new physicians making career selections [8]. Although individuals who pick ID are drawn to the field’s intellectual stimulation, new physicians are also influenced by the low salary of this career choice [9]. Data indicate that ID specialists rank among the lowest compensated among physicians [10]. In fact, pursuing additional training in the specialty actually leads to lower starting salaries than if such physicians remained generalists. Although trainees are not driven by dollars alone, >86% of medical students graduate with debt (approximately $120000/student), which weighs heavily as they plan for the future [11]. Ultimately, despite the comparatively low pay, ID specialists often rank among the most fulfilled physicians, scoring more satisfied than their highly compensated ophthalmologist, orthopedic surgeon, and cardiologist counterparts [12].
We are already beginning to see the impact of this fragile pipeline. The majority of persons living with HIV in the United States are managed by ID physicians. The successes of antiretroviral therapy have expanded the numbers of persons living with HIV, and the numbers of HIV-trained physicians are expected to fall significantly short of the numbers required to provide their care within the next 5 years [13]. The 2015 HIV and hepatitis C outbreak in Scott County, Indiana, driven by the emerging opioid epidemic, might serve as another example. In just a 6-month period, 169 new cases of HIV infection were diagnosed in southwest Indiana, a region that had previously diagnosed HIV at a rate of approximately 5 cases per year; >80% were also hepatitis C virus coinfected [14]. However, the absence of even a single ID physician in the county likely deterred outbreak detection, treatment intervention, and transmission interruption.
At a time of substantial uncertainty in the financing of medicine, one thing is for certain: immune to politics, emerging infectious threats will continue to endanger individuals and the public. Deeply concerned about ensuring a stable work force, the Infectious Diseases Society of America (IDSA) and HIV Medicine Association held a Town Hall meeting at IDWeek 2016 to address this topic. Informed by that discussion, several opportunities are already being addressed through IDSA and individual institutions to expand trainee interest in ID; these include efforts to foster mentor/mentee relationships, enhance trainee conference attendance, and advertise the vast array of career alternatives offered by the field. Other proposals require coordinated efforts with broad advocacy. We propose several tangible initiatives (Box 1). First, we are underutilizing potential creative training opportunities: we in the field must support innovative teaching methods and enhanced exposure to ID (including emerging topics and outbreaks), microbiology, and global health during undergraduate and medical education; residents and fellows might consider pursuit of combined board certification pathways such as ID/clinical microbiology and ID/critical care; and senior fellows would benefit from training in public health or externships with pharma as they consider alternative successful career pathways. Second, ID should be added as a qualifying specialty for the National Health Service Corps, which would assist physicians with loan repayment while mobilizing them to underserved areas. Third, the National Institutes of Health/National Institute of Allergy and Infectious Diseases should: respond to the trainee shortage with programs that enhance early exposure to ID, as other institutes have done with R25-funded programs for undergraduates; expand the number of funded T32 training programs to bolster training opportunities; and increase opportunities for success for K and first-time R01 recipients. Fourth, a reform to the reimbursement structure for cognitive specialties is overdue. The successes of our 21st-century medical care rely both on proceduralists and cognitive specialists alike, yet compensation diverges widely in per unit of time allotted to patient care. Government and nongovernment payers must also invest in undersupported antimicrobial stewardship programs, which require quality as an endpoint; ID specialists—who are dually trained in epidemiology or who receive additional didactics in quality improvement and outcomes—may be best equipped to design and execute interventions toward improved outcomes. Lastly, the public health infrastructure should be stably financed to support the response to frequently emerging, often unexpected, epidemics with money earmarked for workforce salaries commensurate to the debt doctors accrue in training.
| 1 | Create potential training opportunities for alternative careers, including dual board certification in infectious disease/clinical microbiology or infectious disease/critical care or externships in public health or pharma. |
| 2 | Add infectious disease as a qualifying specialty for the National Health Service Corps |
| 3 | Develop novel programs within the National Institutes of Health/National Institute of Allergy and Infectious Diseases to enhance early research opportunities in the field of infectious disease (eg, new R25-like programs, expansion of T32 training programs, improved paylines for K and first-time R01 recipients) |
| 4 | Reform the reimbursement structure for cognitive specialties, including support for antimicrobial stewardship programs |
| 5 | Support an infrastructure toward stably financing necessary resources available during emerging epidemics, including money earmarked for workforce salaries |
| 1 | Create potential training opportunities for alternative careers, including dual board certification in infectious disease/clinical microbiology or infectious disease/critical care or externships in public health or pharma. |
| 2 | Add infectious disease as a qualifying specialty for the National Health Service Corps |
| 3 | Develop novel programs within the National Institutes of Health/National Institute of Allergy and Infectious Diseases to enhance early research opportunities in the field of infectious disease (eg, new R25-like programs, expansion of T32 training programs, improved paylines for K and first-time R01 recipients) |
| 4 | Reform the reimbursement structure for cognitive specialties, including support for antimicrobial stewardship programs |
| 5 | Support an infrastructure toward stably financing necessary resources available during emerging epidemics, including money earmarked for workforce salaries |
| 1 | Create potential training opportunities for alternative careers, including dual board certification in infectious disease/clinical microbiology or infectious disease/critical care or externships in public health or pharma. |
| 2 | Add infectious disease as a qualifying specialty for the National Health Service Corps |
| 3 | Develop novel programs within the National Institutes of Health/National Institute of Allergy and Infectious Diseases to enhance early research opportunities in the field of infectious disease (eg, new R25-like programs, expansion of T32 training programs, improved paylines for K and first-time R01 recipients) |
| 4 | Reform the reimbursement structure for cognitive specialties, including support for antimicrobial stewardship programs |
| 5 | Support an infrastructure toward stably financing necessary resources available during emerging epidemics, including money earmarked for workforce salaries |
| 1 | Create potential training opportunities for alternative careers, including dual board certification in infectious disease/clinical microbiology or infectious disease/critical care or externships in public health or pharma. |
| 2 | Add infectious disease as a qualifying specialty for the National Health Service Corps |
| 3 | Develop novel programs within the National Institutes of Health/National Institute of Allergy and Infectious Diseases to enhance early research opportunities in the field of infectious disease (eg, new R25-like programs, expansion of T32 training programs, improved paylines for K and first-time R01 recipients) |
| 4 | Reform the reimbursement structure for cognitive specialties, including support for antimicrobial stewardship programs |
| 5 | Support an infrastructure toward stably financing necessary resources available during emerging epidemics, including money earmarked for workforce salaries |
Detecting, preventing, treating, and communicating the threat of infectious diseases before their impact spills across health systems depends first on a prepared and vibrant workforce. Investments and political will toward reform in the financing of training, research, reimbursement, and stewardship are critical to ensure a robust workforce of ID physicians dedicated to fighting the unrelenting infectious threats to individual and public health.
Notes
Acknowledgment. The authors thank Antigone Barton for her critical review and assistance with this article, as well as Amy Zheng for her technical assistance.
Potential conflicts of interest. R. W., C. d. R., and W. A. have received institutional grant support from the National Institutes of Health. C. d. R. and W. A. have received institutional grant support from the Emory Center for AIDS Research. R. W., C. d. R., and W. A. are members of the HIV Medicine Association (HIVMA) Board of Directors. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that editors consider relevant to the content of the manuscript have been disclosed.
References
Author notes
Correspondence: R. P. Walensky, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA 02114-2696 ([email protected]).
