Infectious Diseases Training in the 21st Century: A Glass Half Full or Half Empty?

Abstract

(See the Brief Report by Andrews et al. on pages 630–4.)

Infectious diseases (ID) emerged as a specialty in the mid-20th century during a period of great progress in antimicrobial drug discovery and vaccine development that advanced patient care and stimulated clinical and basic research. However, paradoxically, the very successes that led to the availability of life-saving antibiotics and vaccines may have decreased interest in the specialty. This is highlighted by one of the most infamous quotes in the history of biomedicine: “It is time to close the book on infectious diseases and declare the war against pestilence won,” which was falsely attributed to Dr. William H. Stewart, United States (US) Surgeon General from 1965 to 1969 [1]. Nonetheless, since any physician can prescribe or select antibiotics without specific training, it reinforces the view that ID expertise is not essential, which appears to be held in some circles of modern medicine.

The ID landscape changed in the early 1980s, with the onset of the human immunodeficiency virus (HIV) pandemic, its impact on global health and exposure of inequities, and a growing population of patients with malignancy, organ transplants, and inflammatory diseases whose lives depended on immunosuppressive drugs [2]. The infectious complications in these patients led to an explosion of new knowledge about host–microbe interactions and the need for new paradigms to treat and prevent infectious diseases in immunodeficient patients that galvanized unique training opportunities in HIV and transplant/immunocompromised patient ID. At the same time, the looming “silent pandemic” of antimicrobial resistance focused attention on the ominous prospect of losing critical antimicrobial agents and prompted the development of antimicrobial stewardship programs to preserve antibiotics that also created training opportunities in ID.

In the early 2000s, just as the care of patients with HIV and other immunodeficient states was incorporated into the ID toolbox, the field was faced with successive coronaviruses with pandemic potential, first severe acute respiratory syndrome coronavirus, then Middle East respiratory syndrome coronavirus, and then severe acute respiratory syndrome coronavirus 2, which exploded across the globe in late 2019, causing the coronavirus disease 2019 pandemic and >6 million deaths [3]. ID physicians around the world were called to action to manage the most catastrophic infectious disease to plague humanity since 1918. But that was not all. The pandemic coincided with the continuing HIV pandemic and a rise in infectious diseases stemming from climate change, health disparities, poverty, and increasing antimicrobial resistance. While these threats underscored the critical importance of ID care and research to global and public health, they also highlighted constraints on the ID workforce. There were not enough ID physicians in many areas or to care for vulnerable populations or those facing barriers to care due to social determinants of health. In addition, there was a growing imbalance between an increasingly complex workload and compensation [4].

Successive years of fellowship match data show that the percentage of ID positions filled has declined. Despite these discouraging results, the total number of ID trainees has increased over the past decade [5]. For example, the number of ID programs entered in the 2023 match, 175, and the number of positions offered, 441 [6], increased from 130 programs and 316 positions offered in 2013 [7]. Nonetheless, the 2023 appointment year ID position match fill rate of 73% (328 positions) was substantially lower than that of numerous other internal medicine subspecialties and the lowest for ID since 2016. This trend continued in the 2024 appointment year ID position match, in which 67% of (450) positions and 51% of (189) programs filled [8]. These data are concerning and unsettling because of the threat that an insufficient ID workforce poses for patient care, research, and public health. To gain insight into factors that might have underpinned the 2023 appointment year ID position match rate, Andrews and colleagues performed a de-identified survey, published in this issue of The Journal of Infectious Diseases, of adult ID fellowship program directors that collected perceptions about factors that may have affected the match rate.

The results of the survey are important, thought provoking, and hypothesis generating. Its main finding was that urban and large programs had the highest percentage of filling, and that while unique training opportunities and internal candidates were perceived as important, program location was perceived to be the main factor determining program filling. In support of this, among the respondents, 62% of urban, but only 46% of suburban and 30% of rural programs filled. Notably, this parallels the shortage of ID physicians in the US, which is most dire in rural areas [9]. The survey also found that the fill rate of large (mean >10 fellows) programs was 73%, which was substantially higher than that of medium (5–10 fellows), 66%, and small (<5 fellows), 44%, programs. These data raise questions that highlight important limitations of the survey, namely, that neither the number of positions offered per program and the number that filled, nor the number of positions offered in different geographic regions and the number that filled, nor the number of positions offered by program size and the number that filled, was analyzed. In addition, most respondents identified their location as urban (71%) or suburban (21%), with only 9% rural, but the extent to which this reflected matching in their programs was not reported.

Drivers of interest in ID subspecialty training among potential applicants are likely complex. However, the survey results underscore the necessity for critical analysis of the number of training positions offered; the number of ID physicians needed to provide state-of-the-art ID care in urban, suburban, and rural areas; and how the decisions of potential applicants are influenced by program location and size. Importantly, many US citizens live in areas that lack ID physicians [9]. Therefore, the survey results showing lower match rates in rural and suburban locations call for more granular data on how many positions are available in each type of location, how many filled, and the type and availability of unique opportunities and programs by program location and size. The factors that lead prospective trainees to select urban rather than suburban and rural locations are important and deserving of rigorous analysis. Attention must also be paid to the potential role that foreign medical graduates may play in reducing gaps in the ID workforce and why fewer foreign medical graduates (64 [21%]) matched in ID for appointment year 2024 than 2023 (78 [24%]), when the number of foreign medical graduates matching in all internal medical specialties was similar: 1381 (26.7%) for appointment year 2023, and 1393 (26.2%) for 2024 [6, 8].

The survey also showed that unique training opportunities, such as specialized tracks (transplant, critical care, and research opportunities), were perceived to be a top factor positively affecting ID program filling. However, the survey was not designed to link the specific nature or availability of specialized tracks to program location or size. In addition, it did not query respondents about their perceptions of the importance of the type of healthcare setting (academic, nonacademic center, specialty hospital, community hospital, etc), or the availability of externally funded research training funding (National Institutes of Health, Centers for Disease Control and Prevention, etc), or degree programs (MS in clinical research, MPH, MBA), in attracting prospective trainees. These survey gaps require investigation.

The issue of compensation deserves comment since ID compensation is the lowest among internal medical subspecialties and is considered a disincentive for prospective trainees to enter the field [10, 11]. Insufficient research funding is also a disincentive for those who aspire to careers in clinical, translational, or bench research and a major threat to the ID physician-scientist/clinician-investigator pipeline [12, 13]. Notably, growth of allied fields, including epidemiology, public and global health, health disparities, social science, environmental science, microbiome, and even other medical subspecialties that also focus on these areas, has broadened the options for those who wish to join the effort to treat and prevent ID. The need to increase compensation and meet the need for larger ID clinician and researcher workforces is a major priority area for the Infectious Diseases Society of America [4, 14–16]. Although compensation was not directly assessed by the survey, financial considerations are likely to affect how prospective applicants choose a discipline and location in which to train. Therefore, it is imperative to determine how compensation influences interest in ID among match applicants who did and did not apply in ID. These voices are needed to understand how the field is seen by prospective trainees and how compensation and the factors identified in the Andrews et al survey influence career choices.

The roadmap to attract prospective trainees requires strategies to leverage the importance that early [17] and ongoing exposure to ID [15] plays in stimulating interest in the field. This is highlighted by compelling data, published in 2016, showing that the decision to train in ID is often made in medical school [17]. Therefore, a concerted effort to increase medical student exposure to ID should be a central part of the interventions to increase applicant interest in ID proposed by Andrews and colleagues. In addition, the ID field must endeavor to meet the needs of a diverse potential application pool with opportunities to study problems of the current era, such as climate change, health disparities, pandemic preparedness, and transdisciplinary efforts to improve the state of the environment and the health of humans and animals (also termed “One Health”) [18–23]. Just as the discoveries of the inaugural antimicrobial therapy era ushered in an era with training opportunities in host–microbe interaction, treatment and prevention of HIV, the care of immunodeficient patients, and antibiotic stewardship, the current era calls for more variety in ID training opportunities to meet prospective applicants where they are, while matching their interests with the needs of and resources at diverse training sites.

The specialty of ID is a vibrant, expansive, and constantly changing field. When the world changes, ID must change, and this in turn leads to new opportunities for growth, job satisfaction, and fair compensation. Despite the worrisome trends detailed in the Andrews et al survey and the 2024 appointment year ID match, we have a golden opportunity to reimagine ID training. We must seek creative ways to develop new training models that leverage the importance of ID to academic medicine, public health, and the care of vulnerable populations to meet the needs of diverse locations and healthcare settings. The Andrews et al survey provides a starting point to dissect the current situation in an evidence-based manner, incorporating social science to address the questions raised by the survey. A tailored strategic plan should follow that allocates resources to ensure diverse training opportunities that maximize the potential and aspirations of prospective trainees and consider local, regional, and societal needs, while providing mentorship and clinical, educational, and research training aimed at future employment and career satisfaction. There is much work to be done, optimistically, we submit that the glass is half full!

Notes

Financial support. C. A. A. was supported in part by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (grant number K24 AI 121296-06).

References

Author notes