Who will manage outbreaks? A crisis looms for infectious disease specialists
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Infectious diseases medicine is crucially important to the future of worldwide health, but there are growing indications that the field has reason to worry about its own future.

Would-be medical specialists across the United States were matched with specialty training programs earlier this month as part of an annual ritual known as fellowship “match” day. Of 335 infectious diseases fellowships up for grabs, 117 were not filled, according to the National Resident Matching Program. A number of the unclaimed placements were at some of the country’s most prestigious medical schools.

By way of comparison, all 374 clinical gastroenterology fellowships were filled.

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“It was an historic bad,” Dr. Wendy Armstrong, a spokeswoman for the Infectious Diseases Society of America, said of this year’s match, which comes on the heels of several years of bad matches.

“We are all concerned,” said Armstrong, who teaches infectious diseases at Emory University School of Medicine in Atlanta. “In the specialty, this is a significant topic of conversation. We are concerned that this could become a crisis.”

The match, as it is known, is a process that helps medical schools fill more than 8,500 fellowships in 50 specialties ranging from pediatric surgery to geriatrics, from cardiology to oncology. There is another match, the results of which are announced every March, that places graduating doctors into residency positions in hospitals — the last part of their general medical training. Both are run by the nonprofit National Resident Matching Program.

In some specialty areas, every available fellowship position is typically spoken for — as was the case this year for fields including oncology and hematology. For other fields, the percentage of filled positions reaches near 100 percent.

For infectious diseases programs, however, the results are much less auspicious. Only 65 percent of the available fellowships were allocated during the 2016 match, Mona Signer, president and CEO of the National Resident Matching Program, said in an email.

Dr. Dan Diekema, director of the division of infectious diseases at the University of Iowa Medical College, has likened what’s happening to his specialty to “a dumpster fire” — a complete disaster no one wants to address.

“The number of [infectious diseases] programs that did not fill on Match Day is really steadily rising in a pretty rapid way,” Diekema told STAT. “The trend that’s undeniable is that fewer and fewer people are interested in going into infectious diseases.”

Interest may be waning, but the need for these specialists may actually be on the rise. This, after all, is the field that trains doctors to deal with problems like antibiotic resistance, a looming global crisis. This is the specialty that manages disease outbreaks; its practitioners help hospitals prepare to safely treat Ebola patients and manage that care if such patients arrive. These are the programs that train the future staff of public health departments. These fellowships create the future HIV specialists.

The recruitment problem has drawn the attention of the Infectious Diseases Society of America. Armstrong, who chairs the society’s training program directors committee and recruitment task force, said the group is exploring ways to attract more fellows. But it is also trying to determine whether there are simply more fellowship positions than the specialty can support, she said.

She and others say a number of factors are contributing to the problem. In the end, much of it appears to come down to money.

Infectious diseases is sometimes called one of medicine’s “thinking” specialties. Its practitioners often spend hours trying to optimize prudent in-hospital use of antibiotics as part of antibiotic stewardship programs. Or they may, like TV’s Dr. House, puzzle out the source of infections plaguing patients in an intensive care unit.

Other specialities devote more time to conducting procedures or performing surgeries. In a system that typically compensates for tasks completed, doing is a more lucrative endeavor than thinking.

Diekema pointed to a related issue: the rise of hospitalists.

Hospitalists are doctors who do not split their time between private practice and hospital care; they work exclusively in a hospital. Doctors can take a job as a hospitalist after completing their general residency, skipping the extra two or three years of study needed to specialize. “When you have a student debt weighing on you, that suddenly makes that career path much more attractive than continuing to make $50,000 a year as a fellow. You can make $250,000 as a hospitalist,” Diekema said.

If that weren’t attractive enough, there’s this: Infectious diseases specialists earn less than hospitalists, even though they have the extra years of training. Diekema said hospitalists have persuaded hospital management teams that they save institutions money by reducing the amount of time patients spend in hospitals and lowering readmission rates. The same claim could be made about the work of infectious disease doctors but “infectious diseases as a specialty has not made that argument strongly enough,” Diekema said.

This matters because infectious diseases programs are often competing for recruits with hospitalist programs, Diekema suggested. In other words, the people who are attracted to infectious diseases — physicians who like complex cases — are also the people who make good hospitalists.

Some of the infectious diseases fellowships that weren’t filled on match day will eventually be claimed. Some would-be infectious diseases fellows now sit out the match, knowing good programs will be scrambling to fill spots after the match.

Although he understands the compensation problems, Diekema is puzzled more new doctors don’t want to go into his field. “It’s a fascinating and rewarding career. I would choose it again in a second.”

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