‘Negative Fauci effect’? ID reckons with disappointing Match Day
As the COVID-19 pandemic grew, so did the feeling that the field of ID might begin to attract more physicians, drawn by the important and rewarding work that was so suddenly in the public eye.
A disappointing Match Day, however, suggests that the perceived drawbacks to a career in ID — for example, lower compensation and one of the highest rates of reported burnout — persist.
Source: Darcy A. Wooten, MD, MS
Darcy A. Wooten, MD, MS, associate professor of medicine and director of the ID fellowship training program at the University of California, San Diego, said these issues exist even though most physicians in the traditionally underserved field love what they do.
“We do hard work in ID that is often underfunded and underappreciated by the health care system, but many value the substantial meaning that comes with caring for a vulnerable patient or finding strategies to curb a pandemic,” said Wooten, an Infectious Disease News Editorial Board Member.
Between curbside consults, overseeing efforts to control the spread of SARS-CoV-2 and receiving threats from a public that questions their expertise, even the happiest ID clinician may feel burned out.
“The quality of life for many of us in the trenches and on the frontlines — war analogies are intentional here — has not been high for the past several years,” Wooten said.
Carlos del Rio, MD, president of the Infectious Diseases Society of America and an Infectious Disease News Editorial Board Member, said the pandemic and the stress it has put on ID professionals may actually have caused a “negative Fauci effect” — the inverse of the phenomenon named for Anthony S. Fauci, MD, that led to a surge in U.S. college students pursuing medicine as a career during the pandemic.
We spoke with Wooten, del Rio and three other Infectious Disease News Editorial Board Members about the match and ID recruitment overall.
‘Outstanding applicants’
According to the National Resident Matching Program, 44% of the 178 participating ID fellowship programs went unfilled in the latest match, up from the 30% of 172 programs that went unfilled in the previous match.
“There were many outstanding applicants this year — I thought in general the group of applicants was stronger than in previous years,” said Elizabeth Connick, MD, professor of medicine and chief of infectious diseases at the University of Arizona College of Medicine Tucson and director of the ID fellowship program there.
She noted, however, that for a program like the one at Arizona, it is normal to recruit beyond the annual match because of the number of ID fellowship applicants seeking positions on one of the coasts.
“Similar to other programs not located on the East or West Coast, our program frequently does not fill all its slots. We have usually been able to successfully recruit outstanding people outside of the match,” Connick said.
Wooten said the University of California, San Diego, failed to fill its fellowship program during the match for the first time in 15 years — at least partially because it was only able to advertise four positions while waiting on approval for an expected fifth — but was impressed with the large number of candidates who applied to the program.
Wooten said the program was “lucky” to fill its fifth position after the match, but that amid low program fill rates across the country, “including very prestigious programs in highly desirable places to live, we are definitely adjusting and modifying our strategies for recruitment next year.”
‘Money isn’t everything, but ...’
Among the most cited reasons for recruitment difficulties is ID’s rank among the lowest paying specialties — which makes it harder for ID physicians to pay back school loans — and the challenges of the specialty itself.
“Money isn’t everything, but it does matter,” Wooten said. “This is even more true for trainees who do not come from backgrounds of wealth and privilege. So, while we can continue to make small tweaks here and there to recruit people to the field of ID — including things like mentoring pre-med and medical students, engaging trainees in critical areas of ID research, expanding opportunities for students and residents to address health disparities through ID work, etc. — unless we have a dramatic restructuring of how compensation works in health care, I think we can expect to see more match years like 2022.”
ID is one of the lowest compensated specialties in medicine because the health care system is skewed toward procedures, and compared with other fields, there are far fewer procedures in ID, according to Gitanjali Pai, MD, AAHIVS, FIDSA, an ID physician at Memorial Hospital and Physicians’ Clinic in Stilwell, Oklahoma, and chief medical officer for the Oklahoma State Department of Health.
Pai described ID as “far more cerebral” than other specialties because the patients — and their care — tend to be more complex.
“A lot of effort and manpower can be required for this complex subset of patients who require ID consults, as it can take a while to gather all the relevant information and results before we even start to synthesize the data,” Pai said.
Amanda Jezek, senior vice president for public policy and government relations at the IDSA, told Healio | Infectious Disease News that Medicare evaluation and management codes “historically, significantly undervalued” ID physicians and work.
“We are actively advocating with CMS to increase the value of these codes,” Jezek said. “They really tend not to capture the value of the work ID physicians do, and we’re trying to improve that.”
Jezek said at the height of the early pandemic, many ID doctors were working more than 20 extra hours per week — and some even more — typically with no additional compensation. ID physicians also occupy leadership roles, sit on boards and committees that oversee vital health care functions and contribute on-the-spot consultations for other doctors’ patients, she said.
“Many feel devalued because the system rewards those who do procedures that generate revenue over the time ID physicians spend thinking about challenging cases and communicating with patients, families and other health care providers,” Wooten said.
Unlike many specialties, which face cuts, ID physicians are expected to receive a 4% overall increase in payments under CMS’s 2023 Medicare Physician Fee Schedule final rule. Still, the IDSA lobbied for a larger increase, Jezek said, and del Rio called the fee schedule a “serious setback,” saying in a statement issued by IDSA that it “continues the long-standing practice of gravely undervaluing the contributions of infectious diseases physicians” at a time when having enough ID physicians is an essential priority for public health.
“Outbreaks of infectious diseases are emergencies that jeopardize public health and patient safety,” he said. “The U.S. population has seen this up close for nearly 3 years in ways not experienced in decades. One clear takeaway from the pandemic is that America needs more infectious diseases physicians to adequately meet the country’s needs.”
Jezek said it is common to hear medical students and residents talk about ID as an exciting and interesting field, but also that “they can’t make the finances work because not only is ID underpaid compared to other specialties, they’re coming out of school with debt.”
The average medical school student graduates with around $200,000 in debt, according to several studies. An IDSA survey showed the median salary of an ID physician involved with patient care was $215,000 per year in 2017.
The IDSA led a successful advocacy effort to enact the new federal BIO-Preparedness Workforce Pilot Program in the PREVENT Pandemics Act, which Congress approved and President Joe Biden signed into law on Dec. 29 as part of a federal omnibus spending bill, Jezek said. The program is designed to incentivize young professionals to work in ID by providing them with loan repayment. IDSA is now lobbying for Congress to fund the program so it can be implemented in 2024.
Although there are medical school loan repayment programs, Jezek said the IDSA had to show members of Congress that that these programs often ignored ID. The pandemic, she said, “kind of shined a brighter light” on the need for ID physicians.
“The new pilot helps pay off loans for people working in health professional shortage areas or federal clinics, like VA clinics or Ryan White clinics,” Jezek said. “We think this will — once we’re able to get the program up and running — help more physicians choose ID.”
Ultimately, Pai said deciding on a specialty often comes down to feeling valued.
“I tell people that compensation is important, but it’s not the only factor,” del Rio said. “Nephrology has much better compensation than infectious disease, and they still have trouble attracting people. [Applicants] see the hours. During the pandemic, my ID doctor friends were there 24/7 — ID doctors don’t work shifts. I think there’s a work/life balance issue.”
Pandemic tested limits
One thing that throws off the work/life balance is curbside consults, which Pai said are “the result of a never-ending vicious cycle.”
According to the American Association of Medical Colleges, as of 2021, there were 9,913 ID doctors in the United States, working out to 32,994 people per physician.
ID physicians regularly consulting on other doctors’ patients and at increasing numbers since the pandemic may be hurting recruitment, Pai said.
“Curbsides can potentially cumulatively take up a significant amount of time, and in the ID specialty, curbside consultation is less likely to result in an actual referral than other specialties,” Pai said, adding that it “certainly” can impact work/life balance.
“For the long run — in the context of curbside consults, and to ensure sustainability — all roads lead to bolstering the ID workforce, and there may not be a shortcut to that,” Pai said.
ID physicians have helped parse an avalanche of information, mandates, recommendations and study findings during the pandemic, adding to the burden.
“The field of ID was severely tested to the limits during the pandemic, especially in the context of work/life balance,” Pai said. “Most if not all of us in the field have been burned out in the process.”
Additionally, ID physicians and public health officials have been heavily criticized and even threatened because of their public support for vaccines and other COVID-19 mitigation measures, which also may be having an impact on recruitment, del Rio said.
“Think about how ID doctors have been subject to threats and attacks,” he said. “That’s a deterrent, quite frankly.”
‘Truly in everyone’s best interest’
Keith S. Kaye, MD, MPH, chief of allergy, immunology and infectious diseases at Rutgers Robert Wood Johnson Medical School, said ID physicians “need to lead the charge” amid increasing health threats, from antibiotic resistance to new and re- emerging pathogens.
Although the pandemic may have showed the need for ID doctors, experts said concerns about the overall cost of health care dominate conversations about medicine. Jezek noted that ID physicians help patients with serious conditions and infections get out of the hospital faster — which results in lower health care costs.
“We know that when stewardship is implemented, care is better, costs go down, and investing in [ID] is a really good deal for the federal government,” she said.
Infection control and stewardship may also provide “hard money support that can offset clinical duties and synergize well with research interests,” Kaye said.
Connick and Wooten both called ID the most interesting specialty because of its range, and Wooten and Kaye noted that ID physicians are well suited for hospital leadership because of the work they do.
“ID is one of the few specialties where you can truly be a triple threat — mix clinical, academic and quality improvement work together,” Kaye said. “Many of the leaders in quality and in hospital administration come from ID. Infection control and stewardship are great ways to foray into hospital administration and quality.”
Wooten said the work is worth it and that most people considering ID as a specialty are drawn to the field to help address health disparities among the most vulnerable patients and large health threats like COVID-19.
“Keeping the public healthy and safe during the next pandemic will fall on the shoulders of ID specialists and is all the more reason for why we need to make quick and sweeping changes in health care compensation,” Wooten said. “It’s truly in everyone’s best interest.”
- References:
- American Association of Medical Colleges. Number of people per active physician by specialty. https://www.aamc.org/data-reports/workforce/interactive-data/number-people-active-physician-specialty-2021. Accessed Jan. 23, 2023.
- Hussaini, S. Lancet Infect Dis. 2020;doi:10.1016/S1473-3099(20)30377-7.
- IDSA. 2023 Medicare Physician Fee Schedule Final Rule: Initial IDSA response. https://www.idsociety.org/contentassets/48727d3ea65f43c08529254bc4b3d34f/2023-medicare-physician-fee-schedule-final-rule-summary-for-idsa-members-final-1-1.pdf. Accessed Jan. 26, 2023.
- IDSA. Medicare physician fee schedule is a serious setback to a robust infectious diseases workforce. https://www.idsociety.org/news--publications-new/articles/2022/medicare-physician-fee-schedule-is-a-serious-setback-to-a-robust-infectious-diseases-workforce/, Published Nov. 9, 2022. Accessed Jan. 26, 2023.
- IDSA. Take action to strengthen the infectious diseases workforce to prepare for future pandemics and respond to current public health threats. https://www.idsociety.org/globalassets/hivma/policy-and-advocacy/bio-preparedness-workforce--prevent-one-pager.pdf. Published October 2022. Accessed Jan. 23, 2023.
- National Resident Matching Program. 2022 appointment year. https://www.nrmp.org/wp-content/uploads/2022/03/2022-SMS-Results-Data-FINAL.pdf. Accessed Jan. 26, 2023.
- National Resident Matching Program. Match results statistics, medicine and pediatric specialties – 2022. https://www.nrmp.org/wp-content/uploads/2022/11/Medicine-and-Peds-Specialties-MRS-Report.pdf. Accessed Jan. 26, 2023.
- Zahn M, et al. Clin Infect Dis. 2018;doi:10.1093/cid/ciy888.
- For more information:
- Elizabeth Connick, MD, can be reached at connick3e@arizona.edu.
- Carlos del Rio, MD, can be reached at cdelrio@emory.edu.
- Amanda Jezek, can be reached at ajezek@idsociety.org.
- Keith S. Kaye, MD, MPH, can be reached at kk1116@rwjms@rutgers.edu.
- Gitanjali Pai, MD, AAHIVS, FIDSA, can be reached at gpai@stilwellmemorial.com.
- Darcy A. Wooten, MD, MS, can be reached at dawooten@health.ucsd.edu.
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