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Infectious disease fellowships not filled for new doctors: Gunshots

Despite its central role in the COVID pandemic, the specialty of infectious diseases has seen 44% of its training programs for doctors remain vacant.

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Thousands of doctors ready to continue their training celebrated the day of the specialty scholarship game on November 30, but one group lamented its results: infectious disease doctors. Despite its central role in the COVID pandemic, the infectious disease specialty saw 44% of its training programs unfilled.

“I’m disappointed,” says Dr. Carlos Del Rio, a professor at the Emory School of Medicine and president of the Infectious Diseases Society of America. “I love my field, I love what I do. And it’s upsetting to know that my field may not be as appealing to interns as I would like.”

At the University of Washington, which has one of the highest-ranked programs in the nation, administrators scrambled to find suitable candidates for two scholarship spots that were still open after the matching process. “It’s troubling,” says Dr. Paul Pottinger, director of the UW infectious disease training program, “Typically, we equip our eight slots on the first try.”

At Boston Medical Center, affiliated with Boston University, none of their three fellowship positions were filled in this year’s game – a “difficult” and unprecedented situation for Dr. Daniel Bourque, who leads their program scholarships: “There has been a decrease in the number of applicants this year, and this decrease seems to be a trend.”

Becoming an infectious disease specialist takes years of training. Typically, after four years of medical school, followed by several years of medical residency, an aspiring ID doctor applies for a fellowship program of at least two years. The field hit a low point in scholarship recruitment in 2016. Over the past five years, it has been somewhat stable, with around 65% to 70% of training programs filled.

But 2020 was the exception, when a flood of candidates produced a record match rate – a phenomenon dubbed the “Fauci Effect”. When infectious diseases dominated the news, “many of us saw it as a [sign of] has revived interest in identification” due to the pandemic, says Dr. Boghuma Titanji, an infectious disease physician at Emory University.

Although he has guided colleagues and the public through the COVID pandemic and recent mpox outbreak; despite their lifesaving work to prevent hard-to-treat infections from spreading in hospitals; despite high job satisfaction and a profession many described to NPR as “never boring”: New doctors don’t choose to specialize in infectious diseases.

It’s a decline that drives the best experts in the field to seek explanations.

Train more to be paid less

The most obvious reason is that the pay is low compared to other majors, says Titanji at Emory University, of which Tweet kicked off a heated discussion about the Match Day results. “We’re talking about a six-figure salary difference,” she says, citing a 2022 Medscape report that found infectious disease specialists earn an average of $260,000 a year, more than $100,000 less than the average person. average salary of all specialists.

In some cases, doctors specializing in infectious diseases earn less than they would have before the additional two to three years of training – for example, as a hospitalist, i.e. an internal medicine doctor who sees patients in the hospital. One can become a hospitalist – earning between $200,000 and $300,000 a year – after completing medical school and residency, with no additional specialty scholarship required. “I am paid less for working more hours than as a hospital worker” Dr. Hannah Nam, an infectious disease physician at UC Irvine, tweeted. “My student debt isn’t going anywhere. Don’t regret my choice, but don’t blame anyone for not choosing it either.”

Pay disparities are rooted in the way the US medical system is structured, say Titanji and others. “Much of the medical compensation system is based on performing highly reimbursed procedures or interventions,” says Titanji.

Infectious disease physicians, on the other hand, examine and interview patients and consult with their colleagues – “we think for a living,” says Pottinger of the University of Washington, “and because we don’t have operation to do, I think that’s where this legacy of reduced pay comes from.”

Although the salary is lower than in other specialties, “it’s still very good,” says Pottinger. “There is a lot of money in it, both in studies [settings] and in private practice, and our salary increases over time. »

Yet the prospect of taking additional training to take a pay cut dissuades many from choosing the field. “Medical education in the United States is incredibly expensive,” says Del Rio of Emory. “If you graduate with a lot of debt, you won’t go into a major that doesn’t pay as much as others.”

Long hours and public criticism

The relatively low salary is not the only problem, experts say. The field has long been understaffed, resulting in long hours – a problem supercharged by the pressure of the pandemic. “Any infectious disease doctor can tell you that the first year of the pandemic, I felt like I was on call 24/7 because everyone was calling you – and relying on the knowledge you had – to be able to answer that,” Titanji says.

The current class of physicians largely began their postgraduate residencies in the summer of 2020. All of their training took place during the COVID pandemic, notes Bourque of Boston Medical Center. The long hours and poor work-life balance they observed among ID physicians — and physicians leaving the field in droves due to burnout — may have reduced appeal. “Long hours and low wages are a terrible combination,” del Rio says.

The COVID spotlight also made ID doctors high-profile targets for bitter vitriol from people who disagreed with them. “Many of us, myself included, have been attacked in the media and elsewhere,” for sharing thoughts about COVID, del Rio says. Dr. Anthony Fauci, a top COVID adviser to President Donald Trump and President Biden, was a lightning rod for criticism — and even death threats. “People [considering the field] realize that there is a personal risk. When the nation’s chief infectious disease physician has to have bodyguards, it doesn’t necessarily make you think, “Oh, that’s a great profession,” del Rio says.

Loan forgiveness could help

Infectious diseases also had a recruiting problem before the pandemic: 2016 was a particularly disappointing year, recalls Marcelin of the University of Nebraska, who was then undergoing his specialized training. That year, 57% of programs were not filled. “A lot of the conversations that happened then are happening now,” Marcelin said.

This has spawned soul-searching for the field, with researchers trying to figure out how to attract more doctors. Financially, medical associations like the IDSA have lobbied Congress for student loan repayment programs, to reduce medical school debt for physicians who choose the field. They also advocate for higher reimbursement rates for the work doctors do. If the infectious disease pay gap narrows, “it may make it more attractive for interns to consider it as a career path,” Titanji says.

They have also stepped up their efforts to attract new candidates in the field of infectious diseases, with grants and mentorship programs. Yet over the past five years, “despite our recruiting and mentoring efforts, we have made minimal progress in reversing this trend,” IDSA leaders wrote to Congress earlier this year. In 2020, a research paper co-authored by Dr. Rochelle Walensky, then head of the division of infectious diseases at Massachusetts General Hospital and now director of the CDC, found that 80% of US counties lacked physicians who specialize in infectious diseases. infectious diseases – including most counties that were hard hit by COVID in the first year.

“What I’m learning is that the road is long,” says Marcelin of the University of Nebraska.

And the stakes are high, leaving the nation unprepared for disease outbreaks and health emergencies. “If we don’t have enough infectious disease doctors in the future, it will impact our ability to manage everything from recognizing and diagnosing a disease, to informing the public, and the creation of advice and the administration of appropriate treatments,” says Marcelin. Then there are the less visible impacts – outbreaks in hospitals that could have been avoided in consultation with ID doctors; deaths from infections with treatment-resistant bacteria and viruses that could have been stopped by doctors in ID.

That the COVID pandemic has yet to inspire more doctors to get into infectious diseases may not be the end, Bourque says, looking back at the galvanizing effect the HIV/AIDS crisis has had. in the field. “There was a moment when I felt like [infectious diseases] may be a dying subspecialty, then HIV/AIDS demonstrated the importance of the infectious disease specialist and really spawned a generation of physicians,” including Bourque, to make a career out of it. He says the effects of COVID are still being felt: “COVID has had a huge impact on human life, and it continues to have an impact. I believe it can and should inspire people to pursue careers in infectious disease.”

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