SYMPOSIUM


antibiotic therapy, and the manage- ment of HIV disease could be a factor in the declining interest in the field. Methods of teaching basic science in medical schools are rapidly chang- ing. Problem and team-based learning is being substituted for lectures, and the principle of self-directed learning has never been more at the forefront of medical education. There is prob- ably no specialty more dependent on self-directed learning than ID. ID physicians of my generation were not taught about HIV disease during fel- lowship training. Young infectious disease physicians today are piecing together the complexities of Zika vi- rus on their own. Southwick,4


in a paper titled


“Spare Me the PowerPoint and Bring Back the Medical Textbook” suggests active learning techniques such as es- says and short-answer questions, peer instruction, and using basic medical textbooks enhance student learn- ing. Southwick et al5


also prepared a


commentary titled “Infectious Dis- eases Society of America Guidelines for Improving the Teaching of Pre- clinical Microbiology and Infectious Diseases.” The authors believe a new approach that emphasizes active learning may “rekindle interest in the field of infectious disease.” They also recommend a national consensus on factual content with the goal to re- duce information overload. It makes sense that if we are adding to the list of antiviral drugs every year for HIV treatment, perhaps we can go easy on the clinical manifestations of small- pox or tetanus. I have not quite let go of the importance of lecture as an influence on student specialty choice. Training in Boston, I know that I was influenced to choose ID by the lectures of Louis Weinstein on endocarditis, William McCabe on gram-negative sepsis, and Maxwell Finland on pneumococcal pneumonia. I hope in vain that some of the traditional lectures I still give might influence just a few to pursue ID as a lifetime adventure.


Perhaps the real issue gets back not


to lectures but to mentorship as was noted in the paper by Bonura. With- out enthusiastic mentors, students are unlikely to be attracted to internal medicine or ID. Third-year medical students will find a level of intensity and passion in the delivery room, the emergency room, and the operating room that might be hard to match in the internal medicine or ID clinic. Nevertheless, ID has a special excite- ment of its own. Calderwood,6


as president of


the Infectious Diseases Society of America (IDSA), also emphasizes the value of mentors. IDSA, of course, has a great interest in the issue of declining ID interest and potential remedies, including advocating higher pay, improving mentorship, and representing ID physicians as the true antibiotic stewards. The society has a membership category for students and residents, and its foundation provides scholarships for students. It has also paired mentors and students at the national meeting. Anthony Fauci,7


in a New England


Journal of Medicine article titled “The Perpetual Challenge of Infectious Diseases,” just might capture that ex- citement for this generation of medi- cal students. “Among the many chal- lenges to health, infectious disease stands out for the ability to have a profound impact on the human spe- cies.” In fighting ID, the stakes are high, the challenges are global, the breakthroughs astonishing, and the future is frightening and hopeful. The diseases are preventable with public health education, patient education, and vaccination. The desire to travel and play a part in international coop- eration and health care are easily met. History proves to us that there will constantly be new challenges, new opportunities to be at the front line of protecting the public and new avenues for research. To observe in my career the treatment of AIDS as going from hopeless to an arsenal of at least six different types of drugs, all


based on the intricate understanding of viral replication, is awesome. To those who are torn between specialty training and primary care, there is no more challenging primary care venue than the care of the HIV patient over many years. Bartlett,8 in his essay on “Why Infectious Diseases,” describes the value of the ID practitioner as magnified by the crisis of antibiotic resistance, the expanding consequences of international travel, the introduction of sophisticated new diagnostics, and the emphasis on infection prevention.


DECLINING INTEREST


The decline in ID interest does not match up well with various surveys of physician satisfaction. This is not surprising as competitiveness of resi- dency or fellowship position does not correlate with national surveys of physician satisfaction. According to a recent Medscape survey,9


about 50


percent of orthopedic surgeons were satisfied with their specialty. Fifty- one percent of obstetrician-gynecol- ogists, 50 percent of plastic surgeons, 53 percent of urologists, 49 percent of general surgeons, and 54 percent of ID physicians, including HIV spe- cialists, were satisfied with their jobs. Only dermatology is significantly dif- ferent, with 63 percent of dermatolo- gists happy with their choice. The decline in fellowship interest


cannot be easily tied to dissatisfaction in the field. In this survey, the average ID physician salary was $213,000, but the range of salaries in the field is enormous, depending upon academic or private practice in academic medicine, professional rank, and years in service. The decision to develop an infusion therapy practice and the number of hospitals covered and patient mix are also factors. While improving salary is always a quick solution to attracting residents in any field, it is true that higher-paid hospitalists who have fewer years of training than ID physicians are a source of competition.


February 2017 TEXAS MEDICINE 61


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