Who Wants to Be an Infectious Disease Specialist?

Just 56% of infectious disease fellowship programs filled their 2023 slots, according to new data released by the National Resident Matching Program. Infectious disease (ID) fellowships had seen a jump in applications in the previous 2 years, but these new numbers may suggest a backward slide in a specialty that for many years has struggled to recruit residents.

This latest match rate in ID fellowships is lower than those of the previous 5 years. There are unfilled positions across the country, including in healthcare hotspots. In Boston, all three slots at Boston Medical Center (BMC) ID fellowship program are currently empty.

“For our program, going unfilled is a pretty rare event,” said Daniel Bourque, MD, an assistant professor of infectious disease at Boston University and director of the program. “For a program in the city of Boston that’s at a large tertiary care center, that definitely was a big surprise.”

Many other ID fellowships have joined BMC in posting about their vacancies on social media, looking for residents who may not have matched in other fellowships and for physicians who initially decided not to pursue additional training but are now reconsidering.

“If you are interested in a career in this exciting field, in the amazing city of Seattle, with incredible and friendly colleagues, please contact us,” the University of Washington’s ID fellowship program tweeted. Tulane University, Creighton University, University of Connecticut, Washington University in St. Louis, and University of Colorado also advertised their unfilled positions.

Other ID doctors commiserated with the disappointing match year. “I made a new riddle after yesterday’s match results: In the hospital, everyone needs me. Yet, no one wants to be me. What am I? An ID doctor,” tweeted Nathan Nolan, MD, MPH, an infectious disease specialist at the Veteran’s Health Administration in St. Louis.

Infectious Disease Positions Continue to Grow

One contributor to this downturn could be the growing number of infectious disease programs offered, whereas the number of applicants has generally remained stable. In 2018, there were 394 slots at 151 infectious disease fellowship programs offered. For the 2023 match year, there were 441 slots at 175 programs.

At the same time, there has not been a notable rise in applicants. From match years 2018 to 2020, about 320 applicants applied for ID fellowship positions each year. There was a rise in in interest in first 2 years of the pandemic, with 404 and 387 applicants in the 2021 and 2022 match years, respectively. The most recent round suggests a return to prepandemic numbers, with 330 residents applying to ID programs.

“I think it’s fair to question whether, as a field, we should be increasing training programs and spots at this point, and if it’s better to focus on ways to increase interest and demand,” said Daniel Diekema, MD, an ID physician at Maine Medical Center in Portland. “Otherwise, we’re just going to look worse and worse every year,” he added, and the work that goes into creating these training opportunities will not have a return on investment.

More Training, Less Pay

The fellowship recruitment issues combined with an already short supply of infectious disease specialists can be traced back to comparatively worse pay compared with other subspecialties, experts say. Infectious disease was the fifth lowest paid specialty in the 2022 Medscape Physician Compensation Report — ranking only above primary care specialties and diabetes and endocrinology.

Pursuing this subspeciality in medicine may not translate to higher pay, Diekema noted. For example, a physician who completes an internal medicine residency and then a 2–to-3-year infectious disease fellowship can make less than a physician who pursues hospital medicine directly after completing the same residency.

“You’re in a situation where you’re doing additional training to reduce your income earning potential, and that’s a very hard sales pitch to make,” he said. It’s become more difficult as student loan debts continue to increase, he added.

Because infectious disease is a cognitive specialty and does not perform procedures, it is at a disadvantage in a typical fee-for-service pay model. ID physicians also advise on hospital policies for testing and personal protective equipment, which is not always compensated, said Wendy Armstrong, MD, a professor of infectious diseases at Emory University School of Medicine in Atlanta.

A Reflection of Pandemic Burnout?

Experts also wonder if the past 2 years of the pandemic and the notable burnout in ID and other in-demand specialties may have dissuaded applicants from pursuing the ID career path.

“This residency class is the class that started their training in June or July of 2020 and represent that residency class that has trained throughout the pandemic,” Bourque said. “Does [this low match rate] reflect a negative outlook on the field of ID because of COVID? Is it a reflection of trainee burnout in the setting of the pandemic?”

Diekema wonders if increased public scrutiny and politicization of the field may have discouraged residents. “The vilification of public health and [of] infectious disease experts like Dr Fauci by significant portions of our society can be demoralizing,” he said. “People might say, ‘Why would I want to put myself through that?’ “

But Armstrong doubts this is the case. “I’ve never had a resident tell me that was on their radar screen,” she said, noting that while there had been recent improvements in applicants, lower match numbers for ID fellowships have been a long-standing issue.

Rethinking Reimbursement

Experts agree that pay issues need to be addressed to make ID a more attractive specialty. Moving away from traditional payment plans to value-based models using quality measurements specific to infectious disease could be one way to quantify the value of ID specialists in care systems.

The Infectious Diseases Society of America (IDSA) recently met with the panel that sets compensation rates for Medicare to discuss ways to increase compensation for ID, said IDSA president Carlos del Rio, MD. He is also a professor of medicine at Emory University.

ID specialists need to be able to put a dollar value to the their policy work that’s not related to patient reimbursement, del Rio said. IDSA’s ongoing compensation initiative advocates for value-based care and provides salary negotiation tools for ID specialists, he added.

“Salaries shouldn’t simply be defined by what reimbursement is, and that’s true for other specialties,” such as hospital medicine and palliative care at many institutions, Armstrong said. “Infectious disease needs to be held at the same level of respect and value.”

But despite issues within the specialties, ID physicians remain passionate about their field.

“It is the most fascinating specialty I can ever imagine,” Armstrong said. Bourque agreed, noting the dynamic nature of specialty, with the emergence of new diseases like COVID-19 and reemergence of diseases like mpox, Zika, Ebola, and chikungunya in the past decade.

“There’s nothing about the field of infectious diseases that, in my mind, isn’t fascinating or rewarding enough to bring people in,” added Diekema. “The factors that are keeping people out are primarily economic factors and aspects of our healthcare system that need attention.”

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