Pediatric ID compensation ‘just too low’

Pediatric infectious disease specialists are the lowest paid physicians compared with all other medical specialties, according to a recent report.

Most recent data from the National Resident Matching Program (NRMP) show that less than half of available pediatric ID fellowship positions across the nation were filled.

Unless something is done, experts agree that the shortage of pediatric ID specialists in the face of a growing demand for their expertise could have serious implications for patient care.

Paul W. Spearman, MD, director of infectious diseases at Cincinnati Children’s Hospital Medical Center and president of the Pediatric Infectious Diseases Society, reflected on the low compensation issue for pediatric ID specialists.

“I think our overall career field is losing outstanding applicants, and low numbers of matching fellows into our fellowship programs reflects to a significant degree the fact that the compensation is just too low,” Spearman told Infectious Diseases in Children in an interview. “When we look at all subspecialties, we generally rank at the bottom.”

Infectious Diseases in Children spoke with leading ID and pediatric ID specialists about the problems stemming from low compensation and what medical organizations like PIDS and the Infectious Diseases Society of America are doing to improve salaries and bring more people to the field.

‘Not a record to be proud of’

A recent survey published in the Doximity 2018 Physician Compensation Report showed that pediatric ID physicians received an average annual salary of $191,735. Pediatrics was also among the bottom five specialties, with an average annual salary of $221,900, just above pediatric endocrinology with an average annual compensation of $214,911.

By comparison, specialties with the highest annual compensations included neurosurgery at $662,755, thoracic surgery at $602,745 and orthopedic surgery at $537,568, according to the report.

Spearman noted that adult ID programs in general are matching fellows better than pediatric ID programs. ID physicians’ average annual salary is $265,000, which still puts it in the list of 20 specialties with the lowest average annual salaries in the report.

According to NRMP data, there were 79 pediatric ID fellowships available in 2018, and only 37 were filled. Spearman said financial decisions are an important part of the reason that qualified candidates may lose interest in pursuing pediatric ID fellowship training.

“This year was a bit lower than our average,” he said. “We have had low years before, but this is really a disturbing trend. Basically, we filled about 47% of our positions. And that’s not a record to be proud of.”

Spearman said he does not know how pediatric ID became a relatively low-paid specialty.

“When we talk to pediatric department chairs, their answer has been that it is a supply and demand thing — if you can increase the demand, and the supply is limited, your salaries will go up.”

This, he said, is “not a very satisfying answer.”

Kari A. Simonsen, MD, division chief of pediatric infectious diseases at the University of Nebraska Medical Center, explained that physician reimbursement for procedures in the United States has driven opportunities for procedure-based specialties while limiting opportunities for those in cognitive specialties.

“All of us practicing in the field of pediatric infectious diseases and other cognitive subspecialties really are acutely aware of current and potentially worsening physician shortages in these areas, because fewer and fewer students and trainees are choosing to go into these cognitive-based specialties,” Simonsen said.

Infectious Diseases in Children Editorial Board member C. Buddy Creech, MD, MPH, associate professor of pediatrics in the division of pediatric infectious diseases and director of the Vanderbilt Vaccine Research Program, agreed with Simonsen, adding that pediatric ID specialists do not have a procedure code that they typically bill for.

“Historically, procedural codes have often brought higher compensation,” he said.

In the 2017 PIDS Needs Assessment Survey, members answered the question, “What is the most important challenge facing the field of pediatric infectious diseases at this time?”

The top responses were noncompetitive salaries, poor awareness of the value of ID consultation, and the lack of desirable jobs and the lack of research funding, which tied for third place.

Student loan debt is also a big issue for many students as they graduate from medical school.

“I think the issue of compensation does weigh heavily on the minds of residents as they are deciding how to pay back their medical school debt,” Spearman said. “Maybe they see three or four nice career opportunities that they can go into. When they see that, look at their debt, and see that our compensation level is the lowest, that certainly is influencing their decisions.”

Andrej Spec, MD, MSCI, an assistant professor in the division of infectious diseases at Washington University School of Medicine in St. Louis, said student debt is a significant problem for the field of ID in general.

“It is a very common story for a medical student or resident to ask, ‘How do I get into infectious disease?’” he said. “We chat for an hour, and they are super excited. Then they go online and figure what the compensation will be, and they run a budget and they say, ‘I am going to struggle to pay my loans back.’ Then they go into another field.”

Spec mentioned the growing body of evidence showing how beneficial ID consultation is to patient outcomes — lowering mortality, reducing costs and shortening patients’ length of stay, for example.

“We literally keep people from dying,” he said. “People are interested in our field. People in the field find it exceedingly rewarding. We are constantly ranked as some of the best mentors and teachers, and yet our field as a whole struggles to recruit. When asked why, ‘loans, children, putting children through college’ — things like that.”

Advocating for better compensation

The task of advocating for improvements in compensation in the specialty of pediatric ID has fallen to PIDS, and to a larger extent, IDSA, whose members include both adult and pediatric ID specialists.

“PIDS itself is not a large enough organization that we can do very active lobbying, but we can get help from other organizations, so we do try to lobby on behalf of appropriate physician compensation, fair compensation, together with IDSA,” Spearman said. “We provide a lot of resources for programs through PIDS that can help to enhance the visibility of pediatric ID among residents and among students. But the hardest thing to directly address is the level of compensation.”

Creech, who is secretary-treasurer of PIDS and a member of IDSA, said the latter organization has a large government affairs presence in Washington, D.C.

“What that means is when there is important legislation being considered, or there are policies that are being announced that are up for public comment, IDSA tries to leverage its lobbying forces and its subject matter experts to inform that,” he said.

For example, Creech said IDSA has been lobbying Congress to “rethink our compensation codes so that there is a bit more parity between proceduralists and the nonproceduralists.”

Simonsen mentioned that in the fall of 2017, then-IDSA President William G. Powderly, MD, FIDSA, spoke at the House Energy and Commerce Committee hearing about the critical role of ID specialists’ expertise in responding to viral outbreaks and emerging infectious diseases, such as managing drug-resistant infections and helping to stem the tide of drug resistance through antimicrobial stewardship.

“These are the domain of the ID physician,” Simonsen said. “One epidemic at the forefront — the opioid epidemic in the U.S. — has brought those viral pathogens back to center stage, particularly in our rural and underserved areas of the country.”

Creech said another way that IDSA and PIDS are bringing attention to the field is by demonstrating the value of the specialty through qualitative and quantitative studies.

For example, in a study funded by PIDS and published in Hospital Pediatrics, Julia E. Szymczak, PhD, assistant professor of epidemiology at the University of Pennsylvania Perelman School of Medicine, and colleagues examined how physicians and administrators perceived the value of pediatric ID specialists. They concluded that “pediatric cognitive specialties contribute value in multiple ways to the health care delivery system,” but that “many of these domains are difficult to capture by using current metrics, which may lead administrators to overlook valuable work and to under-allocate resources.”

Catching the bug early

Another strategy in which PIDS and IDSA are cooperating is to recruit people as early in their career as possible “so that we can get people to catch the bug,” as Creech put it. To that end, both organizations are making concerted recruitment efforts at IDWeek.

The meeting is “a springboard” for young people to network with others in the field, Creech said. He noted that travel grants and funding are available to students who are interested in ID, along with numerous opportunities for mentorship. He added that while PIDS and IDSA are separate organizations, “we share a mission and we share desires to see young folks come into the field.”

Spearman emphasized that medical schools together with local pediatric ID programs should offer students more exposure to the field of pediatric ID.

“For instance, at my institution, we are starting an infectious disease interest group for medical students,” he said. “We will have presentations and some lunch meetings to go over what do we do as pediatric infectious disease specialists. We can get across the excitement and the passion for the field. I encourage all of our programs around the country to hold these interest groups.”

There are also financial incentives for recruiting people into the field earlier.

“For instance, I participated in the NIH loan repayment plan,” Creech said. “NIH loan repayment is a remarkable benefit for those of us conducting research, and it was an enormous benefit for me. So, the advantage of identifying people early on is we can find those ways to offset the earning difference they would make if they went into a procedural subspecialty.”

Creech noted that the NIH loan repayment program pays up to $140,000 of student loans for physicians doing clinical research or pediatric research, but it is not ID specific.

Jasmine R. Marcelin, MD, assistant professor of infectious diseases and associate medical director of the antimicrobial stewardship program at the University of Nebraska Medical Center, said “aggressive recruitment” during medical school and even pre-med is important, but she stressed that it “is also important to have women and minority ID leaders visible, so that young hopefuls can see themselves in these roles someday.”

Marcelin, who recently wrote a commentary in Open Forum Infectious Diseases about the disparities in compensation for women and minorities in the field, said that because ID physicians are “the primary specialty caring for persons living with HIV — a disease that disproportionately affects minorities, including sexual/gender minorities — it should be a priority to recruit more minorities into our specialty.”

Creech said PIDS and IDSA are “committed to making our workforce look like the patients we serve.”

Pediatrics and obstetrics/gynecology are two specialties in which women are in the majority. Women account for 60% of the physicians practicing in those fields, Simonsen said.

The future of pediatric ID

Spearman warned that a shortage of pediatric ID specialists in the United States could “impact the care of complex hospitalized patients, with complex infections.” It could affect the care of the transplant population, immunocompromised patients, the treatment of post-surgical infections, and “many of the more complex cases” that pediatric ID specialists are often tasked with treating, and “not just with the choice of antibiotics but with other interventions as well, including the use of appropriate diagnostic procedures,” he said.

Antibiotic stewardship and infection prevention and control programs in hospitals would also suffer without enough pediatric ID specialists, Spearman said.

Simonsen sees an increase in wait times, particularly in the outpatient setting, if the shortage of matched applicants continues.

Additionally, fewer pediatric ID physicians joining the workforce means more clinical work for those currently in the field. This increase in clinical workload could have “a downstream impact on the pool of physicians who go into careers as physician scientists or those who become career educators who train the workforce for the future,” Simonsen said.

Simonsen noted that most pediatric ID physicians practice in academic medical centers where they hold teaching appointments, conduct research and serve in administrative and directorship roles, in addition to caring for patients. A salary can be pieced together through “many elements,” she said — including managing a hospital-based program for antimicrobial stewardship, for example, or though funding for research.

Another drawback is the way pediatric ID specialists’ compensatory value is measured within the health care system, Simonsen noted.

“Much of what we do results in cost savings,” Simonsen said. “Rather than something that is counted, like a procedure or a visit, we are working behind the scenes.”

She added that pediatric ID specialists have not developed a standard to measure the value of that kind of work.

“If we have better matrix and benchmarking around organizationally funded positions, such as directorships of programs in a hospital system, that would help raise the visibility of pediatric infectious disease physicians.” Simonsen said.

This would, in turn, encourage more trainees to enter the field and provide better salary benchmarks to use nationally.

“Those of us who chose pediatric infectious disease did so because we love to think about complex problems, we love taking care of children and we love investigation, research and teaching the next generation,” she said. “Finding ways to better imbed that skill set across our organizations would be of tremendous value to U.S. health care and protect the field, helping to grow the workforce.” – by Bruce Thiel

• References:
• Doximity 2018 physician compensation report. Doximity blog. Posted March 27, 2018. https://blog.doximity.com/articles/doximity-2018-physician-compensation-report. Accessed February 24, 2019.
• Marcelin JR et al. Open Forum Infect Dis. 2019;doi:10.1093/ofid/ofz042.
• Medscape. Women physicians in specialties. https://www.medscape.com/slideshow/2018-compensation-overview-6009667#16. Accessed February 24, 2019.
• Schmitt S, et al. Clin Infect Dis. 2018;doi:10.1093/cid/ciy494.
• Szymczak, J et al. Hosp Peds. 2018;doi:10.1542/hepeds.2017-0240.

• For more information:
• C. Buddy Creech, MD, can be reached at buddy.creech@vanderbilt.edu.
• Kari A. Simonsen, MD, can be reached at kasimonsen@unmc.edu.
• Paul W. Spearman, MD, can be reached at paul.spearman@cchmc.org.
• Andrej Spec, MD, MSCI, can be reached at andrej.spec@wustl.edu.
• Jasmine R. Marcelin, MD, can be reached at jasmine.marcelin@unmc.edu.

Disclosures: Creech, Marceln, Simonsen, Spec and Spearman report no relevant financial disclosures.