An ongoing dialogue on HIV/AIDS, infectious diseases,
December 12th, 2015
The 2015 ID Fellowship Match “Historic Bad”: Part 1, Debating the Cause
This year’s ID fellowship match has just taken place, and the results were, ahem, not pretty. Part 1 will cover why we’re in this situation; in Part 2, I’ll offer some reasons for optimism, and even some solutions.
According to data provided by NRMP, 117 of the 335 ID fellowship positions were unfilled. Dan Diekema from U of Iowa, who has written frequently on the issue of the ID match, quickly calculated that over
80% 80 programs had at least one unfilled spot.
[That was an important edit — please see Dan’s comments below.]
When I cited this alarming figure, it generated a spirited email exchange about the ID match with Emory’s Wendy Armstrong, the source of the “historic bad” quote in the title. Wendy is also IDSA Chair of the Task Force for Recruitment to ID, so has thought a lot about this issue.
She acknowledged the trend is worrisome:
The bulk of our exchange, however, was about the reasons for this alarming trend.
Her view: It’s multifactorial: Limited ID teaching in medical school, with declining numbers of dedicated microbiology/ID courses. A significant proportion of preclinical curricula are led by microbiologists alone. ID faculty have less exposure to medical students in the hospital. There are fewer clinical electives for residents. There are fewer ID clinicians acting as attendings on medical services. It’s the money.
My view: It’s the money. At least, it’s mostly the money.
Yes, the factors listed by Wendy are part of it. But since several apply to other medical subspecialties — how many cardiologists or gastroenterologists attend on general medical services? — I’m not sure they are playing much of a role.
Why is the money issue important, and why is it particularly bad for ID? A few thoughts:
- Debt. Undergraduate medical education in this country is expensive, and a substantial number of doctors in training have significant medical school debt. They look at the 2-3 years of extra training required to become an ID specialist — followed by a lower salary — and cross ID off their list. Or at the very least, strongly consider other options if they are undecided. Or, as put succinctly here:
- The volume/procedure deficit. So long as clinicians are reimbursed primarily based on volume and procedures, ID specialists will be at a disadvantage. Medical complexity and our drive to get the details just right limit the volume part of the equation — you just can’t rush most ID consults, it would be like trying to write a guide to the Louvre after visiting for 30 minutes — and we are not trained to do procedures.
- The “lifestyle” issue. The revenue disadvantage from not doing procedures is shared with other cognitive specialists, of course, but few have so much of their work focused on hospitalized patients. Importantly, nephrology is the other major specialty with declining numbers of applicants, and I don’t think it’s a coincidence that nephrology also has plenty of hospital work. Hospital-based specialties require extensive weekend and evening call for urgent cases — cases you have to come in and see, not manage from home. Here’s a comment on my wife’s primary care listserv discussing the 2015 ID match:
ID doctors are always the ones at the hospital late at night working at our hospital. And not compensated for it they way they should be. Many are of retirement age. Only a few younger guys.
Could it be that potential applicants see ID doctors staying late in the hospital, coming in during the weekends and holidays, and wonder — why should I do that and get paid so (comparatively) poorly? The contrast with cardiology, gastroenterology, and intensivist doctors from a reimbursement perspective is obvious.
- Primary care subsidies. Primary care providers are also on the low end of the salary scale, but they rarely do extra years of training after residency. Furthermore, primary care practices may be subsidized, both explicitly through the ACA and as a way of large healthcare systems increasing the number of “covered lives”. Again, from the listserv:
I worked in HIV clinic in urban city in NJ and couldn’t believe what a new grad starts at…one did his fellowship at our hospital and was offered $85k in a private practice and the other was offered $110 as a assistant director so a lot of administrative, teaching, and research in addition to seeing patients. He had to moonlight in the prison system just to make his student loan payment!
Certainly here in Boston, and anecdotally elsewhere, PCPs start at a significantly higher salary than ID doctors.
- The rise in hospitalist positions. The winners in this race to a “real salary” in Internal Medicine? It’s the hospitalists, whose salaries generally exceed those of many ID doctors who have been in practice for years. It’s no wonder that many ID applicants today have spent at least a year after residency as a hospitalist, essentially extending their residency in terms of clinical activity, but now getting paid a whole lot more. How many of these hospitalists once considered ID training, but decided ultimately it wasn’t worth it? Longer hours for less pay, no thanks!
- Biology. In my highly unscientific poll of friends and colleagues, the period at the end of residency is the most common time for doctors to start thinking seriously about starting a family — or, in some cases, actually having babies. Such a major change certainly brings the debt, salary, and lifestyle issues cited above into stark focus.
Reading the above, you might think I’m pessimistic about the future of our speciality, but — call me crazy — in fact the opposite is true. Having one dominant cause to the problem is in many ways easier than a highly complex, multifactorial situation. Fix the money problem, and the interest in ID will rebound nicely.
In Part 2, I’ll try to justify my optimism.
Here’s a relevant 80s classic: