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Dwindling fellowship applicants cast doubt over next generation of ID care
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The steadily decreasing number of medical students applying for ID fellowship positions through the National Resident Matching Program has raised serious concerns among ID specialists.
Photo courtesy of IDSA
“People in infectious diseases have been taken aback over the last several years ... the match hasn’t provided us a full complement of people who could participate and learn infectious diseases,” William Schaffner, MD, professor of preventive medicine at Vanderbilt University and an Infectious Disease News Editorial Board member, said during an interview. “The population is growing, and it’s aging. Our medical interventions are permitting more and more people with a variety of degrees of immunocompromise to live productive lives, but that also puts them at increased risk of infection. It is a concern that we are not sufficiently recruiting bright, young, talented people.”
To explore this ongoing issue, Infectious Disease News spoke with several ID specialists about the decline of applicants and how best to attract prospective students to the field.
Low NRMP participation leaves fellowships unfilled
Data reported by the National Resident Matching Program (NRMP) suggest that more than half of the 138 participating ID programs remained unfilled upon completion of the 2015 cycle. In addition, there were 99 offered positions left unfilled and just 254 applicants to the program’s infectious disease specialty — the lowest count reported in recent years.
“What we certainly know is that there are decreasing numbers of medical residents who are applying through the infectious disease match, and that number has declined fairly significantly every year for the past several years,” Wendy S. Armstrong, MD, FACP, FIDSA, chair of the Infectious Diseases Society of America Training Program Directors Committee, professor of medicine and program director of the ID fellowship program at Emory University, told Infectious Disease News. “It is interesting that other subspecialties we often compare ourselves to — rheumatology, for example, a mostly diagnostic and cerebral specialty rather than a procedure-oriented specialty — are not seeing the same situation, so we’ve really been trying very hard to understand the forces at play in infectious disease.”
NRMP reports from earlier cycles have raised alarms as well. In a 2014 editorial published in Clinical Infectious Diseases, Pranatharthi H. Chandrasekar, MD, division chief of infectious diseases and professor of medicine at Wayne State University, and colleagues highlighted the steady decline and its effect on future engagement with the program.
“The NRMP mandates that 75% of all programs with available positions in a given year register for the match and that 75% of available positions within the specialty be registered with the NRMP,” they wrote. “The pressure to fill openings has now caused some program directors to offer positions outside the match. This practice forces programs remaining in the match to draw from a smaller group of applicants, and therefore they have a higher chance of not filling. Programs that do not fill are often subject to administrative scrutiny for possible reduction in positions, creating significant pressure to fill the program.”
Low NRMP engagement and a potential shortage of new trainees are currently among IDSA’s “top priorities,” according to IDSA President Johan S. Bakken, MD, PhD, FACP, FIDSA. Although he agreed that the dwindling number of NRMP applicants is cause for concern, the total number of residents seeking fellowships outside of the program is still unknown. This has led IDSA’s board of directors to recommend implementation of the NRMP’s “All In Policy,” which would require participating programs to fill all open fellowship positions through NRMP. Along with offering equal opportunity to all individuals interested in ID training programs, Bakken said this policy would provide a more reliable indication of whether the field is facing a shortage.
“We are very concerned about our future, but we think that the supply of talented ID physicians seems to be relatively stable,” Bakken told Infectious Disease News. “We hope to get a better understanding of the numbers once we have the results of the ‘all in’ matching program.”
ID experts in high demand
The warning of a potential recruitment shortage comes as the demand for new ID specialists is increasing. Issued by President Barack Obama in September 2014 and released by the White House the following year, the National Action Plan for Combating Antibiotic-Resistant Bacteria outlines several expansions to antibiotic research efforts that will require the expertise and contributions of more ID specialists in both industry and academia.
“If we don’t have infectious disease physicians involved in antibiotic research with the aim of developing novel antibiotic compounds ... we may have a situation down the line where patients are dying of infections because there are no active drugs available to take on that challenge,” Bakken said.
The national plan not only targets drug development, but antibiotic use and resistance surveillance in hospitals as well. In the months after the release of the White House’s plan, CMS announced a proposal requiring that antibiotic stewardship programs be in place at long-term care facilities receiving program benefits, a move that Bakken anticipates will be extended to general hospitals within a few years. These programs are best led by ID physicians with expertise in managing antibiotic use and educating their peers, but according to Armstrong, many hospitals throughout the country do not currently employ a full-time ID specialist.
Furthermore, there is evidence to suggest that the value of staffing ID specialists extends beyond antibiotic resistance and into general patient care. In 2013, Steven Schmitt, MD, FIDSA, FACP, staff physician in the infectious disease department at Cleveland Clinic, and colleagues examined the administrative Medicare claims of 272,327 inpatient hospitalizations involving infection recorded from 2008 to 2009. They found that patient stays with ID interventions were less likely to experience readmissions (OR = 0.96; 95% CI, 0.93-0.99) and mortality (OR = 0.87; 95% CI, 0.83-0.91), and patients who had contact with an ID specialist within 2 days of admission had reduced mortality outcomes, shorter hospital and ICU lengths of stay, and fewer Medicare charges and payments compared with those whose ID intervention was delayed.
“The association of ID involvement with reduced readmission rates suggests an important role for ID specialists in transitions of care from the acute care hospital to the outpatient setting, which has been identified as a critical opportunity for improvement in the health care system,” Schmitt and colleagues wrote. “Taken as a whole, these data suggest that appropriate inpatient specialty care may generate value for the health care system.”
In addition to ensuring that currently underserved subspecialties such as HIV remain appropriately staffed, both Armstrong and Bakken said a steady stream of new specialists is necessary to maintain public health’s emergency outbreak capacity.
“Say that we have an outbreak similar to Ebola, but now occurring in the United States,” Bakken said. “We need to have individuals who are then ready and able to tackle such an outbreak, and we need to have a well-trained public health force.
“Whether it’s overseas with Ebola or whether it’s in our own country with influenza, multiresistant bacterial organisms in outbreak situations, the enterovirus D68 outbreak last year and so on ... we feel it’s very important to maintain a very robust workforce going forward.”
An issue of compensation
To discover the reasons why young medical students may not be drawn to ID, Schaffner’s advice is simple: “Follow the money.”
“Finances are a core problem,” he said. “We don’t wear scrubs. We don’t do procedures, which means that we don’t have a practice element that is highly remunerative. We’re thinking doctors, and thinking doctors are not paid nearly as well as doctors who do procedures.”
In a 2013-2014 salary survey of more than 40,000 newly graduated physicians, ID specialists reported a median starting salary of $158,000. Although this amount is much lower than the $222,000 and $360,000 salaries earned in hematology/oncology and cardiac surgery, respectively, it is also lower than the $165,000 reported among hospitalists — a similar field that does not require an additional 3 years of training.
These disparities can act as a barrier to lower paid specialties such as ID, according to Armstrong and Erin Bonura, MD, assistant professor of medicine at Oregon Health and Science University, who conducted a survey of medical residents that was presented at IDWeek 2015.
Armstrong said salaries were among the most important factors cited by residents both inside and outside of ID when choosing their specialty. As such, related specialties boasting higher rates of compensation often become much more appealing to prospective ID fellows facing additional education and student loans, she said.
“Infectious disease physicians are one of a handful of physicians whose salaries aren’t commensurate to years of training,” she said. “The additional [training] to become an infectious disease doctor actually reduces salary when compared to individuals in, for example, hospital medicine or some areas of general medicine.”
Schaffner said the movement toward hospital medicine should not come as a surprise. Hospitalists enjoy the benefit of static work hours and engage their patients in many of the same ways as ID physicians.
“Many of the aspects of hospitalist care overlap in philosophy and attraction to people in ID,” Schaffner said. “You treat very sick people. You have to deal with them very, very comprehensively. Infection is often part of the problem, so it’s a reasonable alternative.”
To make compensation within ID more appealing, Armstrong said physicians need to remind hospital administrations that the impact of ID specialists on patient outcomes and long-term financial savings is indisputable. Bakken took another approach, calling upon lawmakers to remove the barrier of student loans.
“We’ve already seen loan forgiveness programs enacted for ID fellows that go into research,” Bakken said. “We need help from our legislators on Capitol Hill to find solutions where the loan burden becomes less of a detraction. We need to make them understand that if the practice is not financially viable, then there may be very dire consequences for future patients who are increasingly afflicted with difficult-to-treat infectious medical conditions.”
But while inadequate compensation may hamper recruitment, it also could prove beneficial to some degree. According to Schaffner, reduced salaries filter out the less-passionate applicants in favor of those who are more dedicated to their patients and to research within the field. This sentiment was shared by Infectious Disease News Editor Emeritus Theodore C. Eickhoff, MD, who warned that increasing compensation could lead to a culture shift within the field.
“People obviously don’t go into infectious disease as a get-rich-quick scheme,” Eickhoff said during an interview. “Let’s say the infectious disease reimbursement was double what it is now. There undoubtedly would be more people electing to go into infectious disease, but are they the kind of people we want? I won’t answer that question, but it is certainly something to think about.”
Engaging students early on
The issue of compensation may weigh heavily on a student’s mind, but it is not the sole factor in their decision, Armstrong said. Meaningful exposure to ID and intellectual engagement with the various challenges of the field can also make a strong impact.
“In the research that we’ve done it’s very clear that no matter what field a trainee chooses, mentorship in that area, role modeling in that area, attending scholarly conferences in that area — those are all very key influences,” Armstrong said. “Our study suggests that the majority of residents first became very interested in a specialty as medical students or earlier, so exposing medical students and even younger college students to our specialty is important.”
In the past, this early exposure would often occur naturally as a medical student pursued their required course work. However, recent curricula changes adopted by many institutions no longer present ID as a self-contained field.
“In the past there was a very traditional structure to medical school curricula — typically, there were multi-week classes of microbiology and infectious disease and so on,” Armstrong said. “Now, many schools are shifting to what we call more organ-based curricula, so there will be classes on the lungs and heart and kidneys and so on. We talk about the infectious diseases that may happen with each of these organs, but it’s a less cohesive experience in some ways, and may be a less impactful exposure.”
According to Schaffner, many residents will decide to pursue another specialty before encountering ID specialists and discovering what the field has to offer.
“Infectious disease is fun, but it’s no longer on the list of possibilities because they’re already committed,” he said.
Therefore, ID programs should make an effort to engage residents and medical students as early in their careers as possible, Sanjay Revankar, MD, professor of medicine and program director of the ID fellowship program at Wayne State University, told Infectious Disease News.
“The earlier you interact with the medical trainees, the better your chance of finding someone who has developed some interest in either microbiology or clinical microbiology and infectious disease,” Revankar said. “We try to identify individuals who do have that interest early and get them involved in rounding with us on the wards and research projects, and show them how microbiology relates to clinical infectious disease.”
On a larger scale, Bakken highlighted several IDSA programs designed to increase students’ exposure to the specialty. Along with offering memberships specifically for students and residents, the society offers free admission and scholarships for medical students who participate in the annual IDWeek conferences. In addition, the Infectious Diseases Research Careers Meeting and the Clinical Fellows Meeting allow fellows to speak with experts in research and clinical practice about challenges and careers in these fields.
“Both of those programs have been very, very well received, and I think they are very valuable,” Bakken said. “We ask individual ID physicians or clinical practice ID physicians to be involved in the Fellows Meeting and share their experiences so that fellows who are in training are exposed to the world of private practice, which they see little of during their fellowship training period.”
Bakken also emphasized the important role of mentorship, which he said is among the most powerful ways an individual ID specialist can share their inspiration with an interested student. Eickhoff cited his own mentors as the primary reason he pursued ID, and advised practitioners in particular to make the extra effort.
“Academic doctors have much more opportunity and, probably, much more responsibility to be mentors to young internal medicine trainees,” Eickhoff said. “There are opportunities for practice physicians, but they are much less frequent. As it follows, practice doctors will have to go out of their way a bit to engage in mentoring situations.”
Eickhoff, Armstrong and other specialists suggested that when speaking to potential trainees, mentors should evoke the characteristics of ID that set it apart from other fields of medicine, such as its diversity, intense focus on patient care and constantly evolving challenges.
“I think one thing that is critical is to find learners at all levels and show them what we love about our specialty,” Armstrong said. “As there are more pressures for documentation, seeing more patients and everything else, sometimes we forget to tell people how much fun we’re having.” – by Dave Muoio
- References:
- Bonura E, et al. Abstract 418. Presented at: IDWeek; Oct. 7-11, 2015; San Diego.
- Chandrasekar P, et al. Clin Infect Dis. 2014; doi: 10.1093/cid/ciu656.
- National Resident Matching Program. NRMP Results and Data Specialties Matching Service, 2015 Appointment Year. http://www.nrmp.org/wp-content/uploads/2015/02/Results-and-Data-SMS-2015.pdf. Accessed December 15, 2015
- Profiles. Physician Database. The online database of graduating physicians. www.profilesdatabase.com. Accessed December 15, 2015.
- Schmitt S, et al. Clin Infect Dis. 2014; doi: 10.1093/cid/cit610.
- White House. National Action Plan for Combating Antibiotic-Resistant Bacteria. https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. Accessed December 15, 2015.
- For more information:
- Wendy S. Armstrong, MD, FACP, FIDSA, can be reached at wsarmst@emory.edu.
- Johan S. Bakken, MD, PhD, FACP, FIDSA, can be reached at jbakken1@d.umn.edu.
- Theodore C. Eickhoff, MD, can be reached at theodore.eickhoff@ucdenver.edu.
- Sanjay Revankar, MD, can be reached at srevankar@med.wayne.edu.
- William Schaffner, MD, can be reached at william.schaffner@vanderbilt.edu.
Disclosures: Revankar reports relationships with Astellas Pharma, Gilead Sciences and Merck. Armstrong, Bakken, Chandrasekar, Eickhoff, Schaffner and Schmitt report no relevant financial disclosures.