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Graduating residents say exposure, salary influence ID career decisions
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A recently published survey investigating the decline of infectious disease fellowship applicants identified medical school curricula, mentorship, exposure to infectious diseases and compensation as the primary factors influencing career decisions of graduating internal medicine residents.
Furthermore, a separate study surveying Infectious Diseases Society of America (IDSA) members also found wide salary variance between practice type, as well as substantial disparity between ID practitioners of different genders among most settings.
Wendy S. Armstrong
Benefits of early interventions, exposures
“The steady downtrend in applicants to ID has led to speculation that low remuneration, poor ID exposure during training and work-life balance represent prominent factors,” Erin M. Bonura, MD, assistant professor of medicine at Oregon Health and Science University; Wendy S. Armstrong, MD, FIDSA, professor of medicine and program director of the ID fellowship program at Emory University; and colleagues wrote. “However, published data examining these hypotheses are lacking. A clear understanding of the factors behind this trend and how they fit into career decision-making constructs is essential.”
The researchers conducted a study of internal medicine residents graduating from United States Accreditation Council for Graduate Medical Education programs during the spring and fall of 2014. Twenty residents and five program directors from eight internal medicine residence training programs were interviewed using a standard script to identify potential themes influencing graduate interest. These responses guided development of a web-based questionnaire, which was distributed to a two-stage design cohort drawn from 160 residency programs. The researchers categorized survey participants into three groups based on their interest in ID (applied or intended to apply to ID; interested in ID but did not apply; never interested in ID), and conducted the analysis with post-stratification weights.
Bonura, Armstrong and colleagues received survey responses from 590 internal medicine residents, for a total response rate of 27% to 30%. Of these, 42 had applied or planned to apply to ID for fellowship training, 188 were interested but did not apply, and 360 were uninterested.
Approximately 63% of participants graduated from medical schools employing traditional curricular structures focusing on specific concepts. While 80% reported learning ID through didactics and memorization, participants who learned ID through case-based and nonmemorization approaches were more likely to pursue a career in ID (relative RR, 3.7-3.89). Respondents who applied to ID fellowships more often rated their medical school curricula as “very good,” and more frequently rotated in ID.
Mentorship, scholarship and conference attendance were reported to positively influence residents’ choice of career, regardless of chosen field. Participants who applied or intended to apply to ID more frequently reported ID mentorship, ID scholarship and ID conference attendance than those who were interested but did not apply. When asked to rate the factors that dissuaded them from selecting ID, the latter group reported compensation as their major detraction. In addition, graduating residents from all three interest categories said increasing ID physician salary would be the most effective intervention to improve recruitment, and 45% of those interested in ID who chose another specialty reported they would have pursued ID if the salary was equal to their chosen career.
These findings shared similar themes with other surveys examining internal medicine career trends, the researchers wrote. Because many respondents reported ID-related influences beginning in and before medical school, interventions targeting early experiences — along with those increasing exposure and compensation — could increase interest in ID.
“Given our results, a high-quality microbiology curriculum and exposure to ID in medical school are intervention points that may be necessary to spark an interest in ID during the first engagement phase,” they wrote. “In the second engagement phase, in order to maintain and recruit more interest in ID, exposure to the broad field of ID, mentorship/scholarship efforts and improving salary represent high yield target areas.”
Salaries vary across settings, genders
Recruitment concerns also prompted Jethro Trees Ritter, DO, FIDSA, ID specialist at Central Coast Infectious Disease Consultants, San Luis Obispo, California, and colleagues on the IDSA Clinical Affairs Committee to investigate compensation reports among ID specialists. From July 15 to Aug. 22, 2015, they distributed email surveys to 8,302 physician IDSA members, associates and fellows, and specifically analyzed responses from those who identified patient care as their primary responsibility.
The researchers received 1,878 replies, for a 22% overall response rate. Two-fifths of the respondents were women, and the average age and time in practice was 50 years and 16 years, respectively. Two-thirds identified patient care as their primary responsibility, and 48% were employed in a hospital or clinic.
According to Ritter and colleagues, compensation across the survey sample ranged from $50,000 to $1.4 million.
Among specialists within the patient care segment, those who were in solo practice or were the owner/partner of private practices were better compensated than specialists employed at hospitals, clinics or academic medical centers ($277,611 vs. $241,319). Consistent with most income studies across specialties, significant gender disparities were noted throughout the sample, they wrote, with men reportedly receiving higher salaries among nearly all patient care sub-segments. Compensation was lowest among those employed at academic medical centers, although income parity across genders was greatest in these settings.
Ritter and colleagues said the findings contrast those reported by other widely publicized surveys that have reinforced perceptions about lower compensation in ID.
“The sources of income reported by the IDSA survey respondents continue to point toward a varied and rewarding life and practice mix for ID professionals,” the researchers wrote. “We are confident that the future for ID specialists grows ever brighter and we need to attract intellectually curious and motivated individuals to join our specialty, with an understanding that they can enjoy productive, fulfilling careers that are as financially competitive as other specialties.” – by Dave Muoio
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Keith S. Kaye, MD, MPH
There is a rapidly growing need for ID specialists, particularly in hospital settings, due to growing recognition of the importance and challenges associated with antimicrobial resistance, infection prevention and antimicrobial stewardship. It is perplexing that there continues to be a growing shortage of ID specialists and a concerning drop off in the number of ID fellows. Bonura and colleagues discuss several variables associated with this dearth of ID expertise, but the three that I want to discuss are medical school curriculum, mentorship and salary.
The findings that exposure to infectious diseases through case-based and nonmemorization during medical school was associated with an increased likelihood of considering ID as a career is noteworthy. Medical schools will need to reconsider how they teach ID in order to stimulate more interest in the field. Surely case-based learning is much more stimulating that learning ID by memorizing pathogens and antibiotic classes.
Mentorship is critically important and sites that had strong ID leadership produced medical students more likely to go into ID. Thus, utilizing strong ID mentors early in medical training and education is vital to critically influencing students and residents to seriously consider ID as a specialty.
Finally, the biggest deterrent to going in to ID is the low salary. This a major problem that does not seem to have a viable solution. ID makes profitable medical and surgical events possible, including transplant, surgery and trauma management. The current reimbursement structure for physicians rewards them for performing procedures and seeing a large volume of patients. These are often not strengths of the ID specialty.
ID needs to cultivate the growing importance, value and role of ID specialists in hospital-based roles such as quality assurance, infection prevention and stewardship. These are areas that are growing in fiscal importance due to CMS metrics and reimbursement processes.
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