The COVID-19 pandemic has turned the spotlight on infectious disease doctors. They've acted as public health messengers, conveying the importance of interventions such as masking, social distancing, and vaccination, and answering questions about viral evolution and transmission. They've established infection protocols to keep medical teams afloat during the public health emergency.
While that has made their role more visible to the public, the specialty has struggled to attract new clinicians for years.
Interest in the infectious disease specialty among medical trainees has long been waning, as several fellowship training programs in the U.S. haven't filled all their positions over the last decade. Unlike other subspecialties in internal medicine, infectious disease doctors earn a relatively lower salary and perform fewer procedures – factors that may discourage new physicians from pursuing the specialty, experts said.
As the critical role that infectious disease doctors play in the health system is increasingly recognized, clinicians in the field are concerned that the U.S. isn't training enough new doctors to fill the ranks.
A Decade of Waning Interest
Infectious disease fellowships have had significantly lower match rates in recent years compared with other subspecialties, according to data from the National Resident Matching Program.
In this year's most recent fellowship match (which filled positions for 2022), infectious disease filled 82% of all available positions.
While last year's 2021 match cycle saw an uptick in medical trainees pursuing the infectious disease specialty -- filling 88% of all positions -- prior to that the fill rate for infectious disease fellowships consistently hovered around 80%.
"For about the last 10 years, our fellowship match has not filled," said Daniel McQuillen, MD, president of the Infectious Diseases Society of America. Low fill rates in infectious disease fellowships across the last decade have been pretty poor at times, he added, with up to 25% of programs leaving the match with empty slots.
Compared to specialties like cardiology, pulmonary disease and critical care medicine, and gastroenterology -- which fill almost 100% of open positions and practically have applicants fighting for a spot -- fill rates for infectious diseases are significantly lower, McQuillen added.
As training positions continue to go unfilled, research has also shown a shortage of infectious disease physicians. Approximately 80% of all counties in the U.S. did not have a single infectious disease doctor in 2017, according to a study published in the Annals of Internal Medicine last year. The same study noted that two-thirds of the counties with the highest incidence of COVID-19 did not have any ID physician coverage. Similar shortages have been observed among HIV providers.
"I think there is a shortage, and the only way that we can handle that shortage is by training more people," said Wendy Armstrong, MD, of Emory University School of Medicine. While the shortage of ID doctors is not getting worse, it is consistent, Armstrong said -- which is concerning during a time when the specialty faces more demands.
Due to the visibility of infectious disease doctors like Anthony Fauci, MD, or Rochelle Walensky, MD, MPH, during the COVID crisis, the public has a greater awareness about the need for these clinicians to mitigate the threat of future pandemics and bolster public health infrastructure.
In addition, increased antimicrobial resistance has created more jobs within the specialty, Armstrong stated, because the government has required hospitals to promote antimicrobial stewardship – and ID docs are trained to do just that.
"I think more people are recognizing the important role that ID doctors play in maintaining health and safety through a lot of different avenues," Armstrong said. "And then, there aren't enough ID doctors."
Low Pay Is a Key Driver
Many experts think the main reason for low interest in the ID specialty is fairly simple: pay. The specialty is among the 20 lowest paid specialties in all of medicine, according to Doximity's 2020 report on physician compensation.
Last year, the average salary for an infectious disease physician was $277,881, compared with $527,231 and $485,817, respectively, for cardiology and gastroenterology.
"I think that's definitely the primary driver of the lack of interest in infectious diseases," said Timothy Sullivan, MD, an infectious disease physician at Mount Sinai School of Medicine in New York.
Medical students graduate with hundreds of thousands of dollars of school loans, Sullivan noted. "And so when it comes time for trainees to choose a specialty, I think they're understandably drawn towards more lucrative fields because they're burdened with these massive loans."
Unlike procedure-based disciplines such as cardiology or radiology, infectious disease is referred to as a "cognitive" field. Providers make patient diagnoses, coordinate care, develop hospital infection control and prevention protocols, and communicate public health messages – tasks that don't typically result in large reimbursements.
Gastroenterologists are reimbursed for each colonoscopy, and oncologists earn money for prescribing chemotherapy. But an infectious disease clinician might spend an hour and a half with a patient reviewing records, looking at films, and piecing together what's causing their illness with little pay.
"The reimbursement for that is extremely low," Armstrong said. "Because thinking is not reimbursed."
Attracting Trainees
Many experts have pointed to a mismatch in how infectious disease care is reimbursed, calling for an overhaul in the way the specialty is valued.
Armstrong said restructuring payment models to value cognitive work not only in infectious disease, but in others such as rheumatology or primary care, is needed. However, in the absence of a total overhaul, starting with a better understanding at the hospital level of how to compensate the work that does not occur in the room with the patient is a step in the right direction.
Additionally, there has been a push to lift financial burdens on medical trainees, with IDSA and other medical organizations supporting new legislation that aims to reduce the stressors of medical school loans.
The Bolstering Infectious Outbreaks (BIO) Preparedness Workforce Act, introduced in the House of Representatives in October, would create a loan repayment program for health professionals and clinicians who conduct bio-preparedness activities or provide infectious disease care, either in underserved communities or federally funded healthcare facilities.
Compensation is certainly not the only factor driving lower fill rates in infectious diseases. The methods of teaching microbiology in medical school (which are often based on memorization and recitation) may not foster interest early on, or some trainees may just want to do more procedures. But experts still believe that restructuring payment models is critical to sustaining a supply of infectious disease professionals.
Sullivan said the future of infectious disease physicians, as well as other cognitive specialties, will eventually come down to how the healthcare system values this work. "I think that focusing on the issue of compensation is going to be really important," he said.