On November 30, 2022, the medicine sub-specialty fellowship match results were released, and Northwestern was fortunate; we filled all 3 of our available positions with some amazing individuals. We look forward to having these individuals join our training program and the ranks of Infectious Disease clinicians. Infectious Disease as a sub-specialty, however, had a less than stellar overall match. Only 56% of programs filled their available positions and 26% of positions went unfilled. Since these match results were released, many have been questioning, why are there so many unfilled positions, why is there a decreased interest in infectious diseases as a career path and why the decrease in the numbers of applicants. Floating out in the inter-webs are reasons such as “The low pay for Infectious disease physicians”, “The lack of respect for Infectious Disease physicians”, “The workload ID physicians have”, and other reasons. I have no idea why the match results are so low. I have no idea what drives people to pick one specialty over another. I have thoughts on the reasons that everyone is bringing up and here are my thoughts (brought to you in my stream of consciousness and rambling manner).
The Compensation. Many will focus on the lower compensation for ID physicians. On multiple surveys of physician’s compensation, Infectious Disease is near the bottom of the median salary. That median salary for ID is between $250,000 and $300,000 per year. For comparison the highest average salary for an IM specialty is cardiology with $490,000/year. ID is not far form IM (the specialty that is oft referred to as taking all the available candidates), which has an average salary of $250,000-$300,000. That is about the same as ID. You can choose IM and start making money right out of residency, instead of “wasting” 2-3 years in fellowship making far less money as a fellow. The average starting salary for IM is 145,000, much less than the average salary, and the average starting salary for infectious disease is 150,000. These salaries are similar, as a specialist you are a few years behind, but does that really matter? It is still quite a lot of money to make, with not much of a difference between those salaries. The average American salary is 50,000, the average lawyer salary is 215,000, starting 100,000. So ID and IM do very well compared to most. And if it were about making money sooner, why not become a PA (average salary $110,000/year) or NP ($120,00/year) and less training and less debt. What about all the debt we have? Yes, we do have debt, I have debt, but the starting salary for ID is high enough for anyone to pay back their debt and still live a comfortable life. So, ID salaries are substantial (well over the American average salary). In my opinion, we like to focus on compensation because it is easy to compare between specialties and complain that one group is getting paid less than another. And we come to point two, the workload.
The Workload. I think this is very difficult to compare the work of on physician to another. Who is to say that one physician works harder than another? Do I really work harder than the transplant surgeon who has been in the OR doing transplant after transplant for 12 hours straight and has not seen her family in 2 days? Have people really compared the amount of work on physician does versus another? My friend, a general internist, has clinic 5 days a week, sees 30 patients per day, she has notes to write on each of these patients, has to follow-up all those labs/radiology/consult notes, has to contact consultants about her patients, has to answer Epic messages from patients and is the practice director for a community based clinic, so has loads of administrative duties to take care of and meetings to attend. My friend, an electrophysiologist, is in the EP lab 12 hours per day, ablating atrial fibrillation or placing a pacemaker, one mistake can be detrimental to patient and my friend, he also has clinic patients to see and inpatient consults to see, and all those notes to write and all those Epic messages to answer and all those PCPs to contact. Am I really working harder than my friend the internist or electrophysiologist? Are they working harder than I am?
Nobody applies for ID. Each year there are about 400 applicants to ID. Each year since 2018, there have been about 350 individuals that match into ID (about 30 per year do not match). There are >400 spots for ID and each year since 2018 there has been 5-20 spots added per year. In this most recent match, there were 441 spots available across the US, an increase of 5. Of the available spots, 328 filled and 113 went unfilled (74% of the spots filled). To put this into context with prior years, 2018 there were 394 positions available (321 filled, 81%) and 350 applicants, in 2020 there were 436 positions (358 filled, 82%) and 387 applicants. This is a fast increase in the number of positions for a constant number of applicants. Some programs have 5 or more fellows in their program. Why? That seems like a lot of fellows at a single program. That is why now we have programs like the University of Washington not filling in the most recent match (they have 8 fellows per year). Is this why 44% of PROGRAMS did not fill. Which is the more important metric, programs not filling, or positions not being filled? Maybe there are too many positions at some programs and in total. Yes, there was a drop in the number of applicants and that is problematic and has me concerned, but why?
Nobody appreciates ID. One major issue with ID is that any physician can do what we do. Any physician can prescribe antibiotics or order blood and urine cultures. Any physician can interpret these tests. ID does not have a procedure that we control. What ID adds is a focus on the antibiotic (is it optimized), the diagnostic tests (are they reliable and appropriate for the clinical situation) and reassurance that a provider is doing the right thing (agreeing with the management plan or diagnosis). As ID physicians we get to interact with every specialty in the hospital and assist with the care of many different types of patients.
So what can be done? I think we must push for fair pay, learn to work smarter and encourage people to pursue a career in ID, but these same principles apply to all sub-specialties in medicine. What we need to do is find out why people choose a career in ID. Why they do not choose a career in ID. We need to find ways to recruit medical students and residents into careers in ID. If a student or resident is interested in ID, they should be encouraged to pursue that path by medical school mentors, residency program directors and practicing ID physicians. We need to mentor and nurture the future of ID (from med student to fellow). There should be programs in place to help encourage mentoring and encourage pursuing a career in research or infection prevention or medical education while a fellow.
We need to accentuate what makes ID such a fantastic specialty. In those compensation surveys, 50% of ID physicians felt fairly compensated (this is a good number compared to most specialties) and 94% of ID physicians said they would choose the same specialty. This is amazing. ID physicians love what they do.
What do ID physicians do:
We get to be part of pandemics, infection prevention, medical education, public health, transplant programs, HIV/AIDS programs and STI clinics. We get to care for people with acute infections. We get to help people through truly terrifying episodes. We get to establish long term relationships with our patients. We get to help a person progress from severe illness (AIDS) to health. We get to speak with the media when there is an outbreak or something going on with a specific infection that shall not be named. We get to educate medical students and teach microbiology and antibiotics. We get to be core faculty members of internal medicine programs. We get to innovate the way medicine is taught and the way we learn medicine. We get to oversee antimicrobial stewardship programs within hospitals and hospital systems. We get to oversee infection prevention and hospital epidemiology. We get to be the CEO or CMO, or whatever group of letters, for a hospital. We get to ask and research amazingly interesting aspects of science. We get to work for the CDC or NIH. We get to work for the pharmaceutical industry to ensure there is always an anti-infective pipeline.
We need to encourage, not blame. We need to find out why people go into ID and why they do not go into ID.
I love this specialty and I truly enjoy the work that I do every day. And I am looking forward to the great things that will be accomplished by the 328 individuals that matched into an ID fellowship position this year.