December 19th, 2015

Part 2, Now The Good News: Why ID Will Survive as a Specialty

it's full!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.

    Yes, universal!

  • 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 IQ_test_graphcertification 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!


9 Responses to “Part 2, Now The Good News: Why ID Will Survive as a Specialty”

  1. Loretta S says:

    Great post, Paul! Should be required reading for anyone considering whether ID is the right specialty for them. Love the quote about always having wanted to don a hazmat suit. LOL And I still sometimes (OK, often!) think how cool it would be to work in ID.

  2. Leonardo A says:

    One think that I believe helps is how, in the end, we are fighting to save mankind.

    It’s very unlikely that humanity would suddenly be wiped out due to a mass acute myocardial infarction, or due to everyone suddenly developing diabetic ketoacidosis. But infectious diseases have potential to cause a real “end of the world” scenario, and we are at the forefront of stopping something like that from happening.

    This is something the media acknowledges; maybe not often, but in 1971 the movie “The Andromeda Strain” was already talking about an infectious disease that could wipe out all human life.

    We are unique in that our medicina has a bit of art, a bit of sciente and a bit of a war, and I think we will always attract people who vaue and acknowledge this role even in the absence of very high salaries.

  3. KB says:

    One more point if I may add: ID is the only specialty where what you do for one patient can influence the health of a whole population. It is hard to convince me that doing a PCI on patient X can influence an unrelated patient Y’s health. But this is the case if you are talking about treating TB in patient X, or placing him in isolation for CDiff or deciding not to give him antibiotics for an asymptomatic bacteruria.

  4. Robert Güerri-Fernandez says:

    Thanks for give us some hope… I’ve just begun (5 years ago) my professional career in ID and I was so happy… Until I read your first post… This second one make things more clear 😉

  5. Mike A says:

    Paul this is a great post.

    We need to promote what makes ID a fantastic career choice using the points you bring up and more. Forget about the money (which is still a good living when you compare other professions out there), it is the above examples that make a career in ID so great.

    We, as a profession, need to move beyond the money issue and start promoting our field for how great it is.

  6. Charles L Carter says:

    As a general internist/ now hospitalist I find your self-aggrandizement unseemly.
    If, as I don’t doubt, general internists love their specialty less than you then it’s at least in part due to the documentation and regulatory burden which PCP’s and hospitalists bear the brunt of.
    As the US tries to improve its health statistics to that of other developed countries, recall that the generalist- specialist split is the reverse of ours.
    Regardless what I know if ID is often fascinating. I do not doubt it’s a very fulfilling field.
    But today’s post begins “Fix the money problem…”. This is not a new problem nor is it exclusive to ID. Yes the solution is political and involves the AMA. But for cognitive specialties to act separately diminishes chances of success.
    Lastly I’ve worked with quite a number of different ID specialists. Their practice patterns vary a great deal. Each is knowledgeable but some visit every patient to discharge, others sign off when a course of treatment is identified. Some provide concise opinion and plan daily, others reiterate a summary of what I already know. Occasionally one new to practice unnecessarily pursues rare diseases on a substantial plurality of patients. Some change antibiotics on every new consult, others infrequently when there is a clear reason.

  7. Paul – Thank you for another thoughtful and well-written post. I whole-heartedly agree that ID is exhilarating and it should easily attract students and residents. It may be that numerous students and residents initially enthusiastic about ID (for all the reason you laid out) become disinterested once they find out about our lower reimbursement. However, I think we need to give serious consideration to the idea that we are not doing a good job selling our field to students and residents in the first place. To successfully sell a product you need both exposure to potential buyers and good salesmanship. This leads me to ask three questions:

    1. Are students/residents having adequate exposure to all the cool parts of Microbiology/ID as you described?
    2. Are students/residents having adequate exposure to ID physicians for positive role modeling to occur?
    3. When ID physicians have direct exposure to students/residents are they effective role models/teachers as to attract new members?

    We need to gather more data over the coming years to better understand this but two recent ID Week abstracts suggest that improving our sell to medical students may be beneficial. Bonura et al revealed that most IM residents interested in ID became interested during medical school and found their pre-clinical medical student micro courses as a very positive experience. Friedman et al revealed that microbiologists predominant as pre-clinical medical student microbiology course directors and micro curriculum are facing dwindling teaching hours overall, challenges integrating micro into other curriculum, and struggles balancing basic and clinical science content.

    I think we need to find more ways for students/residents to be exposed to our stimulating content and for these learners to work with ID docs in our varied roles. Ideally we need to be speaking at medicine noon-conference and morning reports, attending on the medicine wards, and find ways to give the extra “chalk-talk” while on a busy ID consult service.

    However, most ID divisions across the country are small and their physicians are stretched. Therefore, ID physicians cannot be asked to do more on top of already demanding schedules. They need to be supported by leadership (locally and nationally) for this teaching time and provided faculty development to enhance their teaching skills. Yes, reimbursement is an important piece to our recruitment problem but it is only one piece. We should not overlook the importance of brainstorming new ways we can gain exposure to students/residents and ways we can be more effective role models/teachers.

    Bonura et al:
    Friedman et al:

  8. Nick says:

    As a Hospitalist I only consult ID only after the diagnosis is clinched to minimize indiscriminate testing. In fact I think the way to go is to have an ID/Hospitalist track during residency

  9. David says:

    I guess I am one of the few internal medicine residents who decided to go into ID. I matched into my first choice in a city to which I am excited to move. I have to say though, that since matching I have definitely questioned my decision. I see my friends getting jobs as hospitalists getting paid $200K or more, working 10-14 days per month and doing essentially the exact same job I’ve been doing for 3 years as a resident. For me, the pay is not really an issue with ID, I more worry about lack of flexibility in lifestyle and work/life balance. My experience has been that there are fewer jobs opportunities in ID if I want to work a normal 40-45 hr work week. Many of my colleagues are doing primary care jobs working 60-80% full time in the hopes of avoiding burnout. This post helped me reaffirm my interest in ID however, so I thank you for that.

    I have been interested in being an ID or HIV doctor since junior year of college, so it wasn’t difficult for me to decide. I have done a few weeks of ID consults during residency over the years and each time it has only diminished my interest in ID… so I stopped doing ID rotations. In my experience at my specific residency program, the ID consult rotation is loathed and avoided. This is due to a very high volume of consults, predominantly orthopedic and surgical infection consults for “antibiotic choice and duration,” and no time for learning. These issues are amplified by the fact that the fellowship has not filled on occasion, more often than not the internal medicine residents run the ID consult service with an attending and no fellow on service. Everyone agrees ID is interesting and intellectually stimulating, but we’ve had about 1 resident per year only apply for fellowship.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.