An ongoing dialogue on HIV/AIDS, infectious diseases,
December 19th, 2015
Part 2, Now The Good News: Why ID Will Survive as a Specialty
Part 1 of this post, which highlighted the primary reason for declining applications to ID fellowship programs, could come across as something of a downer.
“Moping about it won’t get us anywhere,” someone said to me, and it’s true nobody likes a whiner. But my point was to acknowledge the issue, and find a way forward. It wasn’t a whine, it was an analysis.
And I concluded with the following:
Fix the money problem, and the interest in ID will rebound nicely.
So why am still optimistic about the future of ID as a specialty? Many reasons.
- We still attract lots of the top medical residents to ID. Chief Medical Resident-types. Outstanding researchers. Residents who want to make a difference in the world. Residents who are are not motivated primarily by the money — which for ID may not be in derm-ophtho-cards-GI-radiology territory, but it’s not that bad, c’mon. Our residents who match in ID know that the best cases in the hospital and in clinic are often ID cases — where history, physical, lab findings, and therapeutics all line up for a fascinating story — and these cases are frequently featured in morning reports, CPCs, grand rounds, and other teaching venues. They also know that the research, policy, and public health opportunities in ID are almost limitless. Finally, they know about the reputation of ID doctors in the hospital and beyond. Read on.
- ID doctors are often considered the best overall clinicians out there. Ok, ok, I’m biased. But how often have you heard someone say that if they really want to know what’s going on with a complex patient, they first read the ID note? And how about this comment from Loretta S, a PCP (and one of my favorite readers): “I know the ID doc is going to have to spend countless hours reviewing the patient’s history, reviewing old labs, ordering and interpreting new labs and just generally doing deep thinking … The patients are often those for whom we in primary care are out of ideas, and we hope ID can somehow puzzle things out. And then, on top of everything, this amazing, detailed consult note comes back and I learn something new. All of which makes me, a nerd, sometimes wish I worked in ID!” Thank you Loretta. I remember during my fellowship, the Chief Resident in surgery was watching us evaluate a post-op patient with unexplained fever, and said: “Please save him, because if you guys can’t, no one can.” Thank you. (For the record, we did. It was a pulmonary embolism.)
- The field has incredible, unmatched diversity. This is a partial list of what ID has to offer: 1) “Every organ system” involved, as ID fellow applicants frequently (and accurately) point out. As a result, we see patients from every specialty, both medical and surgical — they all need us. 2) Hospital-based and outpatient-based problems, you can choose either one or both. 3) Epidemiology and public health. 4) Infection control and antibiotic stewardship. 5) The rapidly expanding world of ID diagnostics. 6) Transformative advances in therapeutics (HIV and HCV two dramatic examples, perhaps unparalleled in all of medicine). 7) The role of the microbiome, in sickness and health. 8) Infections in transplant recipients and other immunocompromised hosts. 9) Tropical and travel medicine. 10) Sexually transmitted infections. 10) Emerging infectious diseases — 10 years ago, who ever heard of Chikungunya? Or 2 years ago, Zika virus? 11) Device-related infections. 12) Tuberculosis and other mycobacterial infections. 13) Infectious complications of pregnancy. 14) Malaria and other parasitic disease. 15) ID in critical care/sepsis. 16) Immunizations and other preventive strategies … I could go on and on and on, you get the idea. In a wonderful piece about ID doctors published a few years ago, there’s this great quote from Dr. Jerome Levine, an ID doctor in New Jersey:
“Never once in all my 28 years of practice have I ever been bored,” says Levine, echoing a refrain just about universal among his colleagues.
- Care that includes ID doctors improves outcome. Maybe it’s our meticulous attention to detail. Maybe it’s our involvement with literally all the hospital services and specialties (see above). Maybe it’s because we take the best histories. Or maybe it’s just because we’re just so darned smart — there’s a minimum IQ requirement for ID certification of 140 — 130 won’t cut it, sorry. (If you’re so smart, why didn’t you go into Dermatology, you might be wondering. Fair enough.) Whatever the reasons, many studies have linked care by an ID specialist to better outcomes. My personal favorite is this one — title says it all: Infectious Diseases Specialty Intervention Is Associated With Decreased Mortality and Lower Healthcare Costs. Talk about a win-win situation. Is there anyone out there who, after hearing that a family member or friend were hospitalized with staph bacteremia, or fever after travel to Malaysia, or spinal osteomyelitis, or bacterial endocarditis, or meningitis/encephalitis, or infection while on rituximab, or newly diagnosed AIDS, would not want an ID doctor involved? ID consultation should be mandatory in all of these cases, for everyone’s benefit.
- Outbreak control = need for ID doctors. One of my colleagues put it perfectly after helping lead our hospital’s preparation for Ebola last year: “I always dreamed I would have to don a hazmat suit one day.” This is what he wants to do! Whether it’s norovirus infection from a fast food restaurant, listeria in cantaloupes, viral respiratory infections from camels, or Ebola virus disease in Western Africa and beyond, we are front and center in the response to every outbreak — a critical public health role locally, nationally, and internationally.
The above are all reasons — may I be so bold as to say excellent reasons? — why ID has a bright future. And included up there is what I think is an escape from the dollars mess, which is the concluding sentence in the paper cited on the association between ID care and favorable outcomes (bolding is mine):
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.
It’s up to us to demonstrate that our care improves outcomes and lowers costs, and leverage these data to improve payment for what we do. Ron Nahass, who runs one of the largest ID practices in the country, articulated several approaches in a must-read paper published last year; Eli Perencevich says we should have representation at AMA’s Relative Value Update Committee, which makes tons of sense. I hate to say this in an upcoming election year, but let the lobbying start!
ID is a dynamic, exciting field, and most of us love what we do. When asked if we’d choose our specialty again, we say “Yes!” at a rate way higher than General Internal Medicine, for those weighing a hospitalist position or primary care vs ID.
Yes, ID will survive.
Happy Holidays — and take it away, Wall of Sound!