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September 27th, 2013

Yes! An Economic Justification for ID Specialists

16839354_blogWe’re currently in the middle of fellowship interview season, and I overheard the following conversation between two of my colleagues as they contemplated their upcoming interviewees:

ID Doctor #1:  He seems like a great candidate — wants to study hospital and community epidemiology of highly drug-resistant bacterial infections, and has already made major contributions to his hospital’s quality assurance program.
ID Doctor #2: Listen to this applicant:  She’s been working in [insert resource-limited country here] since junior year in college, even continuing to go there part-time during her residency. She apparently started an HIV screening program in rural healthcare settings that has reduced perinatal HIV infections by 50%!
ID Doctor #1:  My next interviewee has his PhD in yeast genetics. I can’t understand his work, but he has three first-author papers in [insert three highly prestigious basic science publications here], and he won the “Top Clinical Resident” at his program last year, proving he’s not just a science drone.
ID Doctor #2:  He sounds terrific. But should we ask these young doctors the really tough question about ID fellowship: Will they be willing to work hard in a medical specialty that pays so poorly?

Look, I get it. We just don’t — and can’t — do the obvious things that bring revenues to U.S. medical providers. First, we do essentially no procedures. Second, the very nature of our patient population makes it impossible to churn through high volumes of clinical visits, either in the inpatient or outpatient setting. And third, for those ID doctors who focus on HIV, the demographics of the patients will almost invariably skew toward the indigent.

Now all of this makes us ID doctors, sniff, feel relatively underappreciated, at least from a financial perspective. You should see the red carpet (salaries, office space, advertising, yachts — OK, not yachts) rolled out for our interventional radiologists who treat varicose veins. Meanwhile, we struggle to find funding for the food at our weekly educational conferences.

Is that fair? Of course not.

But what we ID doctors do must have some value, right? Otherwise why does the demand for ID consults seem infinite, increasing all the time? Does our expertise in management of highly complex medical and surgical patients improve patient outcomes and — gasp — even reduce costs?

“Yes!” says this in-press paper in Clinical Infectious Diseases.

The final corrected proof is not yet available, but set aside your “let’s wait for the final published paper” tendencies, and contemplate these incredible findings about those who get ID consults versus those who don’t:

  • They had a significantly lower mortality. Is there a more important clinical endpoint? Impossible, kind of like trying to beat 5 Aces in poker.
  • They had a significantly lower length of stay in the ICU. We all know that the more days in the ICU, the greater likelihood of badness (a medical condition to avoid) and the higher the cost.
  • They had a significantly lower rate of readmissions. Quality assurance gurus love readmissions data.

What’s more, “Patients receiving ID intervention within 2 days of admission had significantly lower 30 day mortality, 30 day readmission, hospital and ICU length of stay, and Medicare charges and payments compared to patients receiving later ID interventions”. I quoted it in its entirety, because how can you improve on that? Better quality and lower costs? Sounds like just what the doctor ordered for our troubled healthcare system.

There’s some potential bias here, since many of the authors are of course ID doctors themselves; plus, we ID docs love Clinical Infectious Diseases; it’s a journal that speaks right to us. But these concerns notwithstanding, I’m hoping this important study will catch the attention of non-ID providers, hospital administrators, and healthcare economists, and that they will subsequently realize that not everything can be measured in RVUs/hour. Maybe they’ll even send some of that varicose vein-procedural revenue our way so we can have sandwiches at our case conference.

Meanwhile, time to continue interviewing these promising young pre-ID doctors for the best specialty in the world.

12 Responses to “Yes! An Economic Justification for ID Specialists”

  1. ID MD says:

    I sent your summary to our Chief of Medicine — she said she’d argue for MANDATORY ID consults on all patients at the time of admission with certain diagnosis based on the evidence.

  2. Loretta S says:

    I hope the bean-counters sit up and take note! (And give you some sandwich money.) I recently sent a patient with daily fevers and 6 weeks of abdominal pain to the ER when her pain became unbearable. She had been worked up extensively by outpatient GI for the pain and had had multiple ER visits, with no Dx (and no ID consult). I purposely told her to go to the ER at [insert name of large academic hospital in City Across the Bridge] so that she *would* get an ID consult. I dunno, seemed pretty obvious to me that she needed one.

    Paul, this may sound odd, but I often feel guilty when I send my patients for an outpatient ID consult. I get back these *amazing* consult notes and I know the doc spent gobs of time on the case — and all he or she gets is a 99204 CPT code. No procedures = no add-ons to the bill. I work in primary care and we are always complaining about this, but ID docs *really* have that problem. Perhaps ID can invent some procedures they can bill for. :)

  3. Jim Recht says:

    I read and very much appreciated the thoughts you express here. Ever since medical school, I’ve thought of my colleagues in ID as the coolest/smartest kids on the block. So it’s heartening to see that there’s indeed real evidence out there — one can only hope the accounting people will pay heed. Power to the non-procedure performers!

  4. PCP MD says:

    I would only ask that with all these additional ID consults that the ID docs remember that it is ok to say, “yep, you picked the right antibiotics.” You don’t need to switch the medication every time just to justify your consultation.

  5. Chuck says:

    Underpaid and under appreciated? Welcome to the world of family medicine. Whine, whine.

  6. DocRock says:

    This is just one more bit of evidence of the inefficiency and irrationality of our health care system. Of course there should be more ID consults and these experts should be paid better (though I will say in my hospital it sometimes seems that every inpatient gets an ID consult, even for simple/straightforward entities like cellulitis)! We face the same issues in geriatric and palliative medicine, where the unreimbursed family conference is our “procedure.” Yet there is very good evidence that consultations in both of these specialties improve patient outcomes and satisfaction and lower costs. Only when care is delivered through ACOs will the value of low RVU specialties be recognized (hopefully!).

  7. Internist says:

    I’m a primary care internist who married an ID doc. I’ve always had the higher salary, and I was the one who got a cash signing bonus so we could buy our house. My retirement fund will be our major nest egg, not only because he has earned less but also because he started saving later, after completing his clinical fellowship and research years. ID docs aren’t whining when they express a need for financial support and professional recognition. Doomsday movies show the world overcome by a new virus that requires the agile minds of ID specialists to rescue us all from a terrible infectious fate – I can’t recall any movies where the world was saved by an interventional radiologist or a cosmetic dermatologist. Why shouldn’t ID ask for a little more demonstrated respect outside of Hollywood??

  8. JDB says:

    ID specialists are THE most meticulous, detail-oriented physicians in medicine. They pay attention to all organ systems, not just the heart, not just the GI tract. They pay attention. The findings in the forthcoming CID article thus aren’t at all surprising.

  9. DA says:

    In residency when we came on service and picked up a really complicated patient we got an ID consult (even if they weren’t really infected) because they were the only ones smart enough to figure out weeks of complicated notes and labs and distill it into a readable summary

  10. CB says:

    I’m prejudiced by both being an ID resident and from a country where socialised medicine is embraced as the cornerstone of health care (Australia).

    As ID doc’s, we don’t just provide consults for infections (or when no one else can work out what’s going on)… but we also run antibiotic stewardship programs, co-ordinate infection control as well as being a general debriefing service to residents everywhere in the form of the “corridor-consult” (See also Fox et al. CID 1996). Conversely we’re not always the most popular when we arrive uninvited in staph sepsis or try and stop the unnecessary surgical prophylaxis. Its not easy being ID (but we get the best cases so none of us would swap it for the world).

    In effect, we’re public-health physicians at the hospital level and as such there is innate market failure. Much of what we do is always going to be difficult to measure by the bean counters. Happily in Australia, employed as hospital specialist in a public hospital, I would be recognised for my experience not how much revenue I bring in.

    Maybe there is another way within the US system where the infectious diseases physician can be properly recognised?

  11. PH says:

    This income discrepancy affects the field of medicine as a whole, not just ID. Those specialities that require the most brain power receive the least compensation. Those that use their arms more (procedure-oriented) receive more compensation. Interventional cardiology and radiology, GI, orthopedics = more pay. ID, endocrinology, family medicine, internal medicine = less pay. Brain power is cheap.

  12. Bojana Beovic says:

    Interesting reading! The problem is global: in Europe, and in Slovenia, a small Balkan country much different from USA: the most complicated problems are seen by ID, but little appreciation from other colleagues. I often feel quite frustrated because of low level of medical knowledge of many very self-confident colleagues such as othopaedic surgeons etc, Even the patients appreciate the surgeons or haemotalogists much better not knowing that their live was saved because of ID intervention. But who cares: our job is extremelly interesting, full of chalenging cases and intellectual satisfaction, isn’t it?!

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

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