SYMPOSIUM


The infectious disease manpower crisis: finding the cure


BY STEVEN L. BERK, MD


The challenges of infectious diseases, including new pathogens, dangerous outbreaks, antibiotic-resistant bacteria, and the perils of international travel have never been more publically appreciated. These challenges require a well-trained workforce of infectious disease specialists. Just when the need appears to be greatest, however, the interest in infectious diseases among today’s young physicians is at its lowest point.


INTRODUCTION


The satirical Gomerblog from July 2016 written by Dr. 991 the


focuses on


infectious disease consultant. The title of the blog is “Epic consult note starts with ‘Once Upon a time,’” and the blog goes on to describe an excessively long note written by an infectious disease (ID) consultant. It quotes a make-believe orthopedic resident saying the note was as long as War and Peace but with better character development. “Sources close to Gomerblog state the plot is full of twists and turns, memorable characters, and the most complete documentation of antibiotics ever given. … The description of the rash is so vivid you feel like you were there at the bedside.” The article says the ID physician was not available for comment, as he was still making rounds until after midnight. This is funny material aimed at the


well-known meticulous nature of the ID physician in attaining a history and performing a physical examination. Any ID physician will have some real-time funny material, as well. For example, I recall the young woman I


60 TEXAS MEDICINE February 2017


saw on an excessively busy Boston City Hospital obstetrics service. She had a high fever and shaking chills but with a normal abdominal exam and clean episiotomy incision. Shortly after introducing myself


to her as the ID consultant, she explained that she had been to Africa weeks before and wondered if she might have malaria as she had seen malaria patients with similar symptoms. Within minutes, a thick smear proved her to be right. It is nice to have time to take a history. Then there was the patient who not


was responding to treatment


despite being on the recommended antibiotic for community-acquired pneumonia. The history obtained included some interesting characters — six or seven pet parrots, all of whom had died in the same cage, one after another. Treatment for psittacosis saved the patient. As for vivid rashes, every ID physician will remember the telltale petechiae, Osler’s node, or Janeway lesion missed by all until the ID consultant emerged to diagnosis and treat endocarditis.


BEDSIDE SUPERHERO?


Has the infectious disease consultant become the irrelevant, epic note writer now replaced by hospitalists who try to keep notes brief and consultations as few as possible? Has the antibiotic guru become unimportant because of readily available antibiotic guidelines or by the pharmacists who are the new antibiotic gatekeepers? Or is the ID physician still a bedside superhero who reminds our fellow physicians that the key to diagnosis and treatment


is often locked into the individual patient evaluation, especially history and physical examination? Clearly, all is not well in the field of infectious disease. First of all, if the best and brightest are not attracted to the field, if they are not the most respected bedside clinicians, then what will they have to offer? While there is certainly a pool of outstanding students who choose internal medicine and then ID as a subspecialty, the embarrassing fact is, the most knowledgeable students, at least based on U.S. Medical Licensing Examination (USMLE) 1 scores, are choosing surgical


specialties over


internal medicine. The average student going into internal medicine has a USMLE score 15 points below the student who has matched in orthopedic surgery. If there is a certain irony here, that is left best unsaid. Internal medicine continues to be a relatively noncompetitive field for U.S. graduates. At the level of fellowship, the news also is not good. Recent match results from the National Resident Matching Program show there is a decline in the number of ID fellowship positions filled, a decline in the total number of applicants, and a decline in U.S. and international medical graduates. Only 49 percent of ID fellowship programs were filled in 2015.2


Elite academic programs sometimes went unfilled.


SUBSPECIALTY SELECTION FACTORS Bonura et al3


surveyed graduating


internal medicine residents to de- termine the factors that went into choosing a subspecialty. Learning experiences in medical school were important. Mentorship and scholar- ship during residency training often influenced the resident who chose ID as a specialty. Salary and preference to be a generalist were dissuading fac- tors for those considering infectious diseases. If the choice of an ID subspecialty


is linked to medical school experienc- es, then how we teach microbiology,


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