The Infectious Diseases Specialist, At Risk of Extinction

Abstract

The 2023 Infectious Diseases (ID) fellowship match results raised concerns that the future of our specialty is in peril. Forty-four percent of ID fellowship programs did not fill their training positions in the Medicine Subspecialities Match of the National Resident Matching Program, the highest percentage since 2016 (when 58% of programs did not fill) [1]. In fact, ID fellowship training has been undersubscribed for many years, with the ratio of applicants to positions under 1.0 dating back to 2012 [1]. While there was a modest increase in the number of applicants to ID fellowships attributable to the coronavirus disease 2019 (COVID-19) pandemic in 2021–2022, the 2023 match results indicate that the increase was short lived and may not lead to sustained growth in residents seeking ID specialty training.

Further complicating the situation, the number of ID training programs and positions has grown over the past 10 years. Since 2013, the number of ID fellowship programs has increased from 134 to 175, with the number of training positions growing from 334 to 441. Yet, the number of applicants continues to lag behind this expansion of training positions. In comparison, over the past 5 years, there have been greater increases in the number of positions in other medicine subspecialty fellowships such as cardiology and gastroenterology; however, the number of applicants in these specialties continues to exceed the pace of that growth (Figure 1) [1]. Despite the COVID-19 pandemic, recent mpox outbreak, emergence of multidrug resistant pathogens, the continued fight against human immunodeficiency virus (HIV), and other national and global health challenges related to infectious diseases, ID continues to struggle in the match and a troubling proportion of ID training programs went unfilled this year. We need to quickly identify solutions to combat this critical workforce shortage.

Figure 1.

Infectious diseases, cardiology, gastroenterology fellowship positions and applicants, 2019–2023 [1]. Abbreviations: Cards, cardiology; GI, gastroenterology; ID, infectious diseases.

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Multiple factors contribute to low interest in ID, including low salaries (relative to other fellowship-trained specialists and hospitalists), inadequate exposure to the specialty during medical school and residency training, and concerns over work/life balance. We believe that the comparatively low salaries for ID-trained specialists, particularly when medical student debt remains high for most residents, is the primary driver of disinterest in the specialty. In 2014, after 41% of ID training programs did not fill their training positions, Bonura et al conducted a national cross-sectional mixed-methods study of graduating internal medicine residents from US programs to identify reasons for choosing specialties other than ID [2]. Among 590 participants, 7% applied to ID, 61% were uninterested in ID, and 32% considered applying to ID but did not. Among this latter group, salary was identified as the most dissuading factor and increasing pay was considered the intervention that could most likely lead to higher interest in the specialty [2]. Given the current average US medical school graduate owes >$240 000 [3], expecting residents to choose a 2–3 year ID fellowship that will result in an average salary of $260 000 compared to average salaries of $490 000, $453 000, and $264 000 for careers in cardiology, gastroenterology, and internal medicine (which does not require fellowship training), respectively [4], is not realistic. Without significant increases in reimbursement for ID specialist services with concomitant increases in salary, this is a battle we will continue to lose.

Importantly, the Infectious Diseases Society of America (IDSA) has been working on multiple fronts to increase recruitment to ID, including addressing the salary gap. Since the 2023 match results, there has been reinvigorated discussion among society members and leadership as to the causes of declining interest in our field and potential solutions. Increasing early exposure to ID as a specialty is one priority. IDSA has multiple mechanisms to engage medical students and supports ID interest groups at medical schools. While these interventions have increased the numbers of medical students participating in ID-related activities, long-term successes in recruitment have not yet been realized. Additional research is needed to determine what factors, such as compensation after fellowship training, influence career decisions among medical students who demonstrated early interest in ID yet ultimately choose other careers.

To address the financial disparities, IDSA spearheaded congressional lobbying efforts that recently led to the successful passage of the BIO Preparedness Workforce Pilot Program [5]. When and if this program is funded by congress, it will provide loan repayment to those who choose to work in infectious diseases in areas with the greatest need. This will be an important step in recruiting trainees into ID, helping to fill the workforce gap reflected by the fact that 80% of US counties do not have an ID physician [6]. Additional efforts include the IDSA Physician Compensation Initiative, which consists of specific webinars and tools including the Compensation Negotiation Playbook and the Value-Based Arrangements Guide to help ID physicians advocate for their value in different practice settings [7]. This initiative identifies ways ID physicians bring value to health care systems, including patient care, antimicrobial/diagnostic stewardship, infection control, public health response, and others. ID physicians have been shown to have significant impact in saving health system dollars through reducing monetary penalties for health care-associated infections, hospital length of stay, unnecessary antibiotic costs and days of therapy, and mortality with infections such as Staphylococcus aureus bacteremia [8, 9]. However, despite this value, ID physician compensation is still based on work relative value unit (wRVU) reimbursement rates that disproportionately undervalue nonprocedural consultations [10]. Thus, we believe that additional coordinated efforts addressing wRVU reimbursement and the value of nonpatient care activities to bolster the salaries of ID physicians nationwide is needed.

Given the persistent deficiency in the number of applicants to ID fellowships, despite efforts to reverse these trends, we argue that a temporary moratorium on expanding the number of ID training positions in the US needs to be considered. Freezing the number of positions will help equalize supply and demand between training programs and trainees in the near term, while efforts continue to address the root causes for the low interest in ID specialty training. To achieve a supply and demand balance in the long term, a comprehensive workforce study should be completed by IDSA to estimate the appropriate size of the workforce that is needed to meet current and future demands. In turn, the results of this study could inform recruitment efforts and the optimal training capacity of fellowship programs.

It is important to recognize that any manipulation in the number of training positions could potentially exacerbate disparities in the geographic distribution of ID specialists, which already presents a challenge for many rural parts of this country. There is clearly a need to increase the number of ID physicians in rural communities, which are disproportionately impacted by the infectious consequences of substance use and other health disparities. Aggressively incentivizing medical students and residents from these areas to enter ID training could help retain these specialists in highly impacted areas once training is completed.

The results of the ID fellowship match over the past decade threaten the existence of our specialty. Despite multiyear and multifaceted efforts to reverse this course that have now taken on a new urgency, we continue to struggle even in the face of unprecedented demand for ID expertise, as exemplified by the COVID-19 pandemic. Unfortunately, as the number of applicants declines, the stress and workload on the existing ID workforce is magnified, which leads to higher burnout rates and less job satisfaction, thus creating a vicious cycle that negatively influences recruitment. Historically, job satisfaction among ID specialists has been high, a recent 2022 survey found that 94% of us would choose ID again [4]. In our opinion, ID is a highly rewarding career that has opportunities for patient care, research (clinical, translational, basic science), education, infection prevention, antimicrobial stewardship, public health, and global health.

There is no simple solution to this dilemma. However, we argue that there are crucial elements to be considered, including increasing salaries for ID specialists, offering other financial incentives such as loan repayment programs, providing layered financial incentives to ID specialists in geographic locations that do not have access to ID expertise, and conducting a workforce analysis to guide recruitment efforts. Creating a balance between the number of training positions and those seeking training will help to enhance and grow the ID workforce over time by filling training programs with fellows who are motivated and who aspire to a career in ID. This equilibrium will eliminate the perpetual experience of coming up short in the match, which has negative consequences for those of us in ID medical education and which further contributes to a negative perception of our field among trainees. These interventions will in time lead to stabilization and growth of the ID workforce, which is critical to the public health of this nation and beyond.

Notes

Financial support. No financial support was received for this work.

References

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