HIV and ID Observations

“The Vanishing Family Doctor,” by Mary B. Spahr, 1947.

Two decades ago, Dr. Atul Gawande wrote a memorable piece for The New Yorker about how doctors in the United States get paid. Providing a nice mix of self-reflection about his own experience and some skillful reporting, he described the challenging process of figuring out what he, a newly hired surgeon, should earn for a salary.

Why challenging?

Most people are squeamish about saying how much they earn, but in medicine the situation seems especially fraught. Doctors aren’t supposed to be in it for the money, and the more concerned a doctor seems to be about making money the more suspicious people become about the care being provided … Yet the health-care system, as I soon discovered, requires doctors to give inordinate attention to matters of payment and expenses.

Isn’t that the truth? After years of sacrifice — medical school (usually with debts), residency, subspecialty training — it’s time to get a job, and to get paid. So knowledge of what sort of things comprise a salary plays a big role in career planning, even for those toward the bottom of the physician payment scale.

Or maybe I should say especially for those of us at the bottom of the pay scale. You know — us.

I thought of Gawande’s piece because the other day, I was chatting with someone in hospital administration who is relatively new to issues of clinical reimbursement in ID. I thought she might benefit from a primer on how ID doctors earn their salary, particularly through patient care and related activities — hence this three-part* series on how we actually earn a living. I’m leaving out other potential sources of income (grant-funded research, administration, teaching, consulting, medicolegal work) because that’s a whole different topic, but these too can support or supplement a person’s salary.

(*Yes, three posts. The first draft was gargantuan, and one must respect the precious time of brilliant-but-busy readers!)

And caveat emptor, I’m an ID doctor at a US-based academic medical center, so some of my comments might be irrelevant, or not applicable, to practitioners in private practice, or those of you reading from countries with different medical systems — and little to no medical school debt. Because of this limitation, I reached out to Dr. Ron Nahass, Medical Director at ID Care, a large, multisite private practice in New Jersey, and Dr. Brad Spellberg, Chief Medical Officer at the Los Angeles General Medical Center, who provided very useful feedback before I posted this.

Here’s the start of the list — basic patient care. In Parts 2 and 3, I’ll cover some other common salary sources for consideration:

1. Consults on hospital inpatients. For most ID doctors, this is the primary source of their clinical income. The more consults, and the higher the complexity of the consults, the more revenue. It’s the same as with procedural-based clinicians and surgeons but, of course, much less remunerative. Still, the more you see, the more you earn.

Note that most ID doctors in academic medical centers are salaried, so the relationship is blunted or, ironically, not present at all. More consults just means you’re busier, not that you’re paid more. Incentive programs to salaried physicians can encourage ID doctors to see more patients, but these may be canceled out by accounting that shows we ID doctors are being paid more than we earn. Talk about a dispiriting message from an institution — Even though you’re really busy, you’re costing us money.

Given the above information, ID doctors have mixed feelings about “curbsides” — informal advice given to clinicians. On the one hand, we want to be collegial, improve the efficiency of care, and help. Salaried doctors may even view them as shortcuts to completing the day’s work more efficiently.

On the other hand, each curbside deprives ID doctors of income (especially in private practice), they take time, they are interruptions, the information could be relayed inaccurately, and there’s some medicolegal risk. There should be a system that supports the time and expertise required to formally advise other clinicians, but those that exist are mostly limited to outpatients, offer meager pay, or don’t exist at all. And yes, I’m obsessed with this topic!

2. Outpatient care. Outpatient care can reimburse at the same level as inpatient consults, but it’s arguably more difficult, both from the perspective of patient diversity and the infrastructure (support staff and real estate) needed to make it work financially. Unless you have someone helping with prior authorizations for unusual drugs (isavuconazole or omadacycline spring to mind first), scans (PET CTs for fevers of unknown origin), or tests (Karius, I’m looking at you), you will be quickly buried by non-physician work.

In addition, care is more likely to spill over into non-clinical hours as you follow up on tests and communicate with patients. For the vast majority of doctors, interactions with patients via telephone and electronically through patient portals reimburse nothing — despite the fact that these communications are a critical component of good patient care, and take time to do well.

In other words, there’s a reason that a high proportion of ID doctors greatly limit their outpatient hours, or in many cases, don’t do outpatient care at all. It’s hard clinically — and even harder to make it work financially!

3. Procedural activities. One of the primary reasons ID doctors choose the specialty is because of the cognitive nature of the work. As a result, most of us do few if any procedures, which suits me just fine — though, of course, it sometimes is frustrating to hear that a dermatology visit with a skin biopsy that last minutes reimburses as much as an hour-long outpatient ID consult on a fever of unknown origin.

Here’s a memorable example from Gawande’s New Yorker piece:

In the mid-eighties, doctors who spent an hour making a complex and lifesaving diagnosis were paid forty dollars; for spending an hour doing a colonoscopy and excising a polyp, they received more than six hundred dollars.

Amazingly (at least to me), a small proportion of ID doctors have training in certain outpatient procedures, and do them regularly — skin biopsies, wound management (debridement and cauterization), simple dermatologic procedures, high-resolution anoscopy. One of them is a close colleague of mine, and she told me she always loved doing procedures during her medical residency. Not your typical ID doctor!

Before wrapping up this category, I must share an important (and depressing) fact about ID in a mostly fee-for-service world. Quoting Brad here, offering perspective from hospital administration:

In a fee-for-service world, ID is always going to be a loss-leader. ID does not bring in business to hospitals. Surgeons and proceduralists do. That’s where the money is in a fee-for-service world. The role of ID therefore is to support the surgeons and proceduralists. Even in internal medicine, ID is in a supportive role, supporting the hospitalists. People often talk about how ID improves outcomes and care. But those things just aren’t paid for. The pay in a fee-for-service world is for the surgery, procedure, or admission to the hospital.

Oh well. Brad has eloquently written about this problem in ID, and the challenges are especially acute in large academic medical centers, where ID divisions frequently run budget deficits and rely on more flush clinical services for subsidies.

Maybe we should we all get fleece vests to wear at the hospital, emblazoned with the text:

ID:  Proud Loss Leader

Sigh. So in Part 2, I’ll cover how ID doctors support hospitals, sometimes get paid for it, and sometimes… don’t.

Hope this is interesting. As a compensation for going on this journey with me, I’ll finish each one with a remarkable dog video, so at least you’ll have that.