Would increasing compensation have an effect on ID recruitment?

Issue: January 2016

Brian S. Schwartz, MD
Associate professor and program director
Infectious diseases fellowship
University of California, San Francisco

Evidence suggests that the lower median starting salary in ID compared with other specialties is a significant factor in recent fellowship recruitment trends. As fewer positions are filled each year through the National Resident Matching Program, many prominent voices have advocated increasing economic incentives for medical students and fellows entering the field.

Read comments from experts whom Infectious Disease News asked for their opinion on the challenge of increasing compensation and its potential impact on recruitment. We welcome you to share your own impressions of this topic by commenting online at Healio.com/ID.

As the program director of a large ID fellowship program, I am impressed each year by the outstanding residents applying to our field. I am inspired by the applicants’ intelligence, curiosity, determination and kindness. Our type of work attracts this phenotype, and I suspect that increased compensation would only attract more of the same.

Increasing compensation to ID physicians is needed and should be a high priority; however, there are other ways that we can enhance recruitment. During IDWeek 2015, Bonura and colleagues presented results of their survey on factors influencing residents’ choice of a career in ID. They reported that residents identified salary as an issue when considering ID as a career, but they also reported that early introduction to ID along with exposure to high-quality and enthusiastic ID/microbiology teaching in medical school were very influential factors. Should we not place equal effort into promoting our specialty to medical students and residents through stimulating learning experiences alongside enhancing compensation?

To reach our students and residents, we each need to:

take a local inventory to see if our student and resident curricula include ample exposure to all the intriguing facets of microbiology and infectious diseases;
identify if our learners have sufficient contact with ID physicians for positive role modeling to occur; and
be sure that ID physicians who teach our students and residents serve as effective role models and teachers when given the opportunity.

When we identify that our learners have insufficient exposure to ID, we should cultivate new and improved opportunities for teaching ID and role modeling ID physicians. We can reach out to preclinical medical student microbiology course directors and offer to participate in their courses as lecturers, small-group leaders, and help revise curricula. We can be regular attendees at medicine noon-conference and morning report. While attending on the ID consult service, in addition to providing great education to our students and residents, we can try to teach the students and residents caring for the patients on whom we are consulted. We can enhance our teaching efficacy by gaining a better understanding of what our students are learning throughout the medical student curriculum and by enrolling in faculty development workshops. Unfortunately, spare hours are rare, so such activities will require the support of division chiefs and invested national societies to help us buy the time to engage in these opportunities.

The residents we attract to our field are outstanding. An increase in compensation would not change the high quality of applicants, although it may increase applicant numbers. While increasing reimbursement is one potential way to aid in recruitment, we must give equal weight to finding ways to provide high-quality teaching and role modeling to students and residents, since these interventions likely help to attract trainees to our field.

Reference:
Bonura E, et al. Abstract 418. Presented at: IDWeek; Oct. 7-11, 2015; San Diego.

Disclosure: Schwartz reports no relevant financial disclosures.

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Michael B. Edmond, MD, MPH, MPA
Clinical professor of infectious diseases
University of Iowa

This year 60% of ID fellowship programs went unfilled and the cause is almost purely economic. Put yourself in the shoes of a 30-year-old third-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. On average, as a hospitalist, you will earn more each year than your ID colleagues while working fewer hours. Moreover, hospitalist positions offer predictable schedules and extended periods of time off. These disparities in income and lifestyle are impossible for many to overcome.

Unfortunately, most physician compensation plans reward volume not value, and that’s a losing proposition for ID physicians. You can’t evaluate a patient with fever of unknown origin in 20 minutes. There are no RVUs earned for spending 3 hours reviewing the medical records of a highly complex patient without a diagnosis who has already been evaluated by multiple specialists. In a previous job, an administrator chastised me for spending too much time with my patients. Although I knew that my work was important, that referring physicians were pleased and that my patients were grateful, I did not feel valued.

Several critical questions now face the field of infectious diseases:

How do we demonstrate the value we add?
How can compensation models be changed to fairly reward the work we do and acknowledge the additional training and skills we possess?
Should the ID fellowship be shortened to positively affect the cost-benefit calculus of additional training? Do trainees who plan to enter private practice need research training?
Could hybrid models of training be developed to lessen the economic impact on trainees? For example, could training be integrated with practice? Various models could be envisioned, such as alternating hospitalist attending duties with ID fellowship duties. This would increase the fellow’s salary, and, even if the total training duration were extended, may entice more residents to consider ID. Some would probably continue this model beyond training into employment.

The work of the ID doctor has never been glamorous, the pay has never been as good as many other specialties, and the hours have always been long. 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, it is unlikely that the downward trend of fewer trainees in ID will reverse.

Disclosure: Edmond reports no relevant financial disclosures.