Advocacy, Workforce & the Future of ID: A Conversation With IDSA Leadership

Jeanne Marrazzo: [00:00:14] Welcome to Let's Talk ID. I'm Doctor Jeanne Marrazzo, the chief executive officer of the Infectious Disease Society of America. I want to start by sharing how excited I am to be joining IDSA during such a critical point in history, and honored to be working with a tremendous group of leaders on our Board of Directors who are deeply committed to the field of ID and the future of IDSA. I'm joined today by three of those board members President Dr. Ron Nahass, the President-elect, Dr. Wendy Armstrong and Vice President Dr. Max Brito to talk about some of our top priorities. Welcome, Ron, Wendy and Max.

Wendy Armstrong: [00:00:52] Thanks, Jeanne.

Max Brito: [00:00:53] Thank you.

Ron Nahass: [00:00:54] Thank you. Jeanne.

Jeanne Marrazzo: [00:00:55] Great to have you here today. So, Ron, let me start with you. It's been a wild ride for your first several months as president, and I'd like to start by talking with you about IDSA's response to the dangerous changes being made under the current administration. In particular, what's happening at HHS under Secretary Kennedy. IDSA joined the American Academy of Pediatrics and other health and medical societies in a lawsuit against the secretary last year. Ron, can you talk about what that lawsuit was about and where it currently stands?

Ron Nahass: [00:01:26] Great, Jeanne, thank you. Yes. And, you know, it was really great to see the house of medicine come together with that. IDSA was really leading in that along with the AAP. It's great to have seen the result. Working with our attorneys, we were successful in getting a stay, or a temporary stay, for HHS from implementing its updated schedule for vaccination. I think this was really one of our primary goals. It also stops the HHS from implementing its updated childhood immunization schedule, and it stops most of the new ACIP members from serving and devoting until our full lawsuit is actually decided. We think the judge was actually pretty smart in the way that he approached it, because the stay is harder to appeal. And so we're waiting now for our full trial. It's unclear whether the administration will actually try to appeal that or not. We're optimistic that the stay will hold. Our full case is still to be heard. And in the full case, we're actually looking for permanent removal of the ACIP members. We're also asking that the appointment of the ACIP members with relevant expertise follows the usual process. As many of you are aware, the process has been so disrupted. We end up with folks that really don't have the right expertise. And so that's an important part of our lawsuit. And finally, we're really looking to have the non-evidence based recommendations made by the ACIP and HHS actually overturned, not just state as we currently stand. Right now, we're in the middle of waiting for additional information. The administration has to produce the administrative record and the lawyers that are working on our behalf, and others that are working on this lawsuit are waiting for that complete record before the trial can go forth.

Ron Nahass: [00:03:20] I will point out, many of you have heard we've made a statement in this regard that just this month, ACIP updated its charter, which creates additional challenges for all of us. It over prioritized vaccine safety and vaccine injury, and added liaison members that create greater risk for misinformation, a challenge we're all facing as we try to reach out to our communities and try to advocate for appropriate vaccines. We've put out this media statement about a week ago. I think that described a lot of our efforts in that regard. Lastly, I would say that we're really committed to seeing this through. And as I mentioned, the IDSA board, staff has really been amazing in its leadership, as has been demonstrated by getting lots to join together. I've been fond of using the term the house of medicine. You've probably heard me use that term. It's really important that the house of medicine be aligned, and this lawsuit is really one of those efforts in which IDSA has really led in that effort of trying to get the house of medicine aligned. And so I'm really excited to, one, have been a participant of that and to help support all of our members efforts in achieving that. In fact, actually a couple of our members have agreed to testify, if necessary for this lawsuit. Again, sort of demonstrating the amazing ability of this community to come together. So it's really been a challenging time for all of us, as you alluded to for this first year. But a lot of good stuff is happening in this regard.

Jeanne Marrazzo: [00:04:47] Yeah, thank you so much for that. And on a personal level, I don't think any of us can thank you enough for your courage and you're really embracing this as a leadership challenge. You've been very vocal, not just on behalf of the society but on multiple media platforms. I guess one question I'd just ask you is the response you've gotten because I've gotten nothing but incredibly positive, supportive comments from our membership. People seem to be very proud of our stance and in particular, proud of our, really just standing up for science and for the health of our community.

Ron Nahass: [00:05:20] It has been an interesting experience. As I've said, I'm not a social media maven, but I have been doing a little bit of posting and I will say that the community and I would say the larger community, larger medical community, the larger healthcare provider community has been so grateful for our voice and the way we've been out there in speaking. But I will say it does pose challenges. So we need all of our members to be advocating collectively, as I say, around the house of medicine, because there is this small group of people who you will read the chatter, that continued to try and misinform, which is unfortunate for our community, for our patients. And so it's grateful to get that positive feedback. But we all have a role in that. So I really want to encourage everybody to don't be afraid to step out. We're in the right lane here. In the house of medicines appreciating it, our ancillary staff are appreciating it, and we need to be uniform in our efforts to do that.

Jeanne Marrazzo: [00:06:20] And we at IDSA have your back. I'll just add one thing. And then I think I'm going to turn it over to Wendy to comment. I'm really glad you mentioned the updated ACIP charter because that was really alarming. And that just came out last week, even after the judge had ruled on the lawsuit that we and the AAP had put forward. If anything, that updated charter just normalizes the expectation that vaccines are dangerous. And you've got to heighten your awareness and your scrutiny of some of these quote unquote negative outcomes, like neurodevelopmental toxicity and the sort of stuff. So really strong statement on behalf of IDSA that you put out that I think many people are looking at as a model of responding to this kind of thing. Wendy, please go ahead and comment.

Wendy Armstrong: [00:07:03] Yeah, I want to say again that I think people are incredibly proud that IDSA and HIVMA are leading the way. And just on that note, another area where advocacy has been really successful and where we've been really vocal has been at the state level, where many of you may have heard about Florida restricting available antiretroviral therapy for patients living with HIV. And again, it was our organization that really led the way, convening individuals to create an effective advocacy response with our colleagues in Florida. And money has been passed to rectify that change. And so this reach of the society in many areas of ID to advocate for the health of the nation is wide. And I'm really proud of that.

Jeanne Marrazzo: [00:07:50] As you should be. Max, did you want to comment? You are center of the middle of the country, so we definitely need to hear your perspective.

Max Brito: [00:07:57] Just to emphasize what Ron and Wendy and you said, this is not time for apathy. We need everybody involved at the state level, at the national level with lawmakers, because, you know, we need to get the right message out in terms of vaccine safety because it is impacting public health doctors, infectious disease providers. You know, some of us are more involved than others, and we're very busy in our daily lives, but we really, really need everyone to get involved to help us get the message across and try to promote vaccinations for the health of the public. So we need your help.

Jeanne Marrazzo: [00:08:37] Thank you very much, Max. And I would just pick up again where Ron emphasized in that there is no time to be timid and also can't really rest because every time we think we have a victory, there's something else that comes up. If the people who are trying to do these things that we consider unscientific, unsafe, are persistent, we have to be even more persistent and even more smart. This entails that we have a critical mass of people advocating, right? Which gets us into the question of the ID workforce. And I want to turn to Wendy. You've been a fellowship program director, more recently, you're a new division director at the University of Colorado, and you've always been a critical voice in helping us understand the trends in applications to ID fellowship. And you've also been a big advocate for ways to sustain our workforce. So I wanted to ask if you could update us on where we are with these efforts, both generally and also from IDSA's effort to strengthen the workforce.

Wendy Armstrong: [00:09:40] Let me start with where we are, because I think there's actually some nuance to this that often gets overlooked in the narrative that we hear. And so, you know, first of all, I would say that the narrative is often that infectious disease has terrible match and terrible match rates for the past decade. I will say actually that in the cohort, starting in 2021 and 2022, we matched more individuals than any time in history in infectious disease, with almost 90% of programs filling. After that, the story changes a little bit. There was a decline that I think had a lot to do with post COVID exhaustion for trainees. And we also opened new programs and offered more slots. And so our match looked worse because of the percent of programs and positions that were filled. But in fact, it was that was an overly negative appearance. All that said, the truth is that this year was not a good match for us, as far as numbers. I will say it was a good match as far as people. We saw an incredible quality of residents entering into ID fellowship and are overwhelmed with the passion and the commitment and the talent in the new class, but there were fewer people. This is the year that's been really different, and I think there's a lot of reasons for that. I think obviously, infectious disease has been at the center of the bullseye for commentary from the administration and so on.

Wendy Armstrong: [00:11:02] And I think there is concern among our trainees about declining opportunities within infectious disease. And also for those wanting to pursue physician scientist pathways. What do we do from here and what are we doing? There's a combination of efforts, some of which are IDSA led and some of which are our responsibility. I'll group those into a couple of areas. First off, we know we have data that shows that exposure matters role models, mentors going to meetings, the ability to see yourself in the career and see yourself being able to earn enough money and sustain your life. And so within IDSA, we have started to reach into younger and younger cohorts. The Step program is one example of that reaching to medical students who are thinking about how do we reach into high schools and to younger people to educate them about the opportunities in ID? We've done great work over the past several years in IDWeek programming, the mentorship tracks for trainees, discounted rates for trainees. The BugBowl, which is a real feel good, brings in trainees. And so those are important. We've been advocating for loan repayment, and that's a continued discussion in Congress and one that we are pushing until that's successful. And there's certainly have been gains in compensation with some of the new G codes. I can clearly see the millions of dollars impact on reimbursement within our own division.

Wendy Armstrong: [00:12:26] It's important, though, for us to all be role models, and I want to spend a second on this. Honestly, I believe that we were the original advocates for patients coming from all walks of life and with any nature of stigmatizing disease, really, before social justice and disparities were a thing. And I think now the conversation we just had about IDSA being out front advocating are the kinds of messages that are incredibly welcome to young people today. People want to see physician groups that are taking action. We need to make it clear that we are taking action. We know we are, but sometimes our trainees are less aware of what's going on at the front line. But the trainees want to be part of that. And that's a powerful message that we have. We have a powerful message about our need and the clinical variety of patients that we see. There are more and more immunocompromised patients HIV transplant, biologics, chemotherapy. Ortho ID is a burgeoning area. Of course, we've always valued the diagnostic dilemmas. I think a lot of people see ID as linked to vaccine preventable disease. That's obviously a really important part of what we do, but that's not all that we do. And that's actually an important message. Infectious disease doctors have the opportunity for longitudinal care or for consultative care.

Wendy Armstrong: [00:13:41] But again, one of the things people want to hear about today is that we have the opportunity to get to know our patients and their stories. That's part of our history. It's also part of what we do. And that re-engages with the joy of medicine that sometimes feels lost, as many feel that medicine becomes more corporate. We have a lot of strengths. And so part of our job is to role model and to talk about those things. We also are deeply engaged in advocacy at the NIH and have baked workforce into every portion of that advocacy to include training awards like T32s, as well as mentor K awards and so on for young faculty members so that they can see that they can build a career. There was an article in The New York Times by Frank Bruni, who's a professor at Duke, that really hit me, and I'm going to paraphrase it a little bit, because it hit me for our community, for infectious disease. You know, he talked about the need to communicate to his students. But I think we need to do this too, that for all of our specialties, current trials, it still brims with opportunity, its promise greater than its woes, and a blurry future isn't the same as a bleak one. That's the messaging we need to get out while we, at the same time work on all these fronts that I just mentioned.

Jeanne Marrazzo: [00:14:53] Yeah, thank you for that. Very informed overview. Couldn't have said it better myself. A couple of things I would just pick up on one, you mentioned one of my favorite words, which is nuance. I feel like we're even more than ever living in a world of headline news. And headlines are necessarily not subtle. They're meant to be black and white and grab your attention. And I think interpreting the data as you have, particularly with what's happening with fellowship, is really important because people see failure, people see challenges, and they kind of run the other way because it is tough starting out a career. The one other thing too, the current language being used by the administration in so many ways is insulting and marginalizing to so many people, not just providers we work with, but also to our patients. And I think it's so important for IDSA and all of us in our role modeling to have a refreshed commitment to inclusion, diversity, equity and access. And that's something we'll never back down on. And I personally will never back down. And I know none of you would. So thanks for that. And I do think looking forward, we do have a lot of opportunities.

Ron Nahass: [00:15:57] Absolutely. I mean, I think I'm going back to the issue of role modeling and what I said earlier about all being involved in this endeavor. So we're going to have to be intentional about increasing our pipeline and our workforce. This is a wonderful specialty. It's a very exciting specialty. We just need to expose our trainees earlier and earlier, as Wendy was describing to us. And this is where IDSA plays a role. If you involve your trainees in abstracts in meetings and you bring them to the meetings and you see, you know what we do, we see all the fun and interesting things that happen in ID. I mean, it will be much better for our recruitment efforts. It is something that we have to be intentional about. So go to your program director, your internal medicine program director, your medical school, if you are in a medical school, and if you're not in a medical school, if you're a private practice provider, maybe you can host students in your practice or residents that will rotate with you. Volunteer for that. It's going to take a collective effort to show folks what we already know. If you think about what got you involved in infectious disease, I certainly think about my own path. What got me involved is I enjoyed working with someone who was a stellar clinician and, you know, guided me through it, got me involved in infectious disease, got me involved in organized medicine. The importance of this is key. 80% of the counties in the US do not have an ID practitioner. You're not going to have a problem finding a job. And depending on where you want to go, your salary may be higher. I'm a firm believer that when you're in this stage, you should think more about fashion than salary. But if salary is your concern, you know there are areas of the country that need you. There's not going to be a problem in making a great salary.

Jeanne Marrazzo: [00:17:49] Great segue because I wanted to circle back to Ron. You know, Ron, what we've been hearing a lot in the press have been the devastation at NIH and CDC creating problems with training grants, getting secured, problem with research funding so that you can't, you know, pay your fellows or your teams to keep your research projects going. But as you have championed opportunities in private practice, community-based practice abound. And you've been fantastic at really describing how that's shaped your career. And I wondered if you could just say a few words about that and why it's important to you, and how we might look at that as a role model to.

Ron Nahass: [00:18:27] Max sort of almost teed it up to some degree. I think that, you know, lots of times in training programs, there is this thought process that the academic route or that's the direction for infectious disease physicians. But I'm part of a very large group. We have over 60 physicians. We do private practice. We work very much as a collegial group. There's a lot of academic stuff that happens in the group, but we're a private practice organization that sees patients day in and day out. We make a pretty good living. There's a lot of opportunities with it. There's never enough people. We always want to hire more people than there are available to hire. So to a lot of what Max is sort of addressing, and to your point, there are opportunities all over and the private practice model is very viable in infectious disease. And it's been really exciting to actually see and watch our organization grow from a group of a couple of individuals back in the early 90s to now an organization of over really 110 clinicians, that includes a whole lot of advanced practice individuals. So it's an amazing field with a lot of growth potential. The society is really out in front and so excited to have you on board, Jeanne, and leading us into this new era, as I mentioned, and in one of our emails that just the other day you saw, I tend to get a little wordy in my emails sometimes, but, you know, the innovation that AI brings forward for us, I think is exciting. And I'm thrilled to have you helping us think through how we might innovate with AI. Even more exciting times ahead.

Jeanne Marrazzo: [00:20:00] Absolutely. And that will be the topic of another future podcast soon, I'm sure, because we, like many organizations, are really engaging fully in trying to figure out how to leverage all the incredible intellectual property that the society has been using, and also how to help our members use these tools. I think that's a really big piece of the equation. So a question for Max, and this is a question near and dear to my heart as I know it is to you. So when we were together at the board meeting in March, there was a lot of discussion about growing our membership. For those of you who don't know, IDSA has just shy of 14,000 members. Very nice representation across the country. A little bit over 13% are international, so not an insubstantial chunk of members who are global members. A couple of things. One, we recently updated our bylaws to allow for greater leadership role for advanced practice providers and also pharm IDs, specifically on the board of directors. And you and I have also talked about expanding the global reach of our international efforts. So I wanted to turn to you to ask you about these changes and what the board is discussing about expanding membership even further.

Max Brito: [00:21:15] Ron used the term earlier of the house of medicine, and I think we want IDSA to be the House of ID, so we want everyone practicing ID to be part of our membership. We welcome them. And just keeping with that credo, the board changed the bylaws to allow apps to be voting members of the society, along with the pharmacist and along with the physicians and nurses. And that is very important because advanced practice providers are an essential part of our team. They work with us in infection control, stewardship and the council services and very, very importantly, in the provision of HIV care, especially outpatient care. We value their contribution and their friendship and collegiality. We want them in our midst. Now, going forward, we want to continue to increase membership. I see opportunities in three areas. If you practice ID, you should all be members. We want to either gain them back or recruit them. I'm very interested in private practitioners. I mean, we've talked about that in this podcast. We've talked about in board meetings. They're an essential part of most of our ID providers. As a matter of fact, but people are busy and I understand that, you know, in order to be members and participate and be active, you need time.

Max Brito: [00:22:49] And some folks don't have time. So I want us to continue to show the value of IDSA to the private practitioners, and I'm going to be very involved in that in the next couple of years to try to bring these colleagues to our ranks. I'm also interested in retaining ID fellows. I mean, we know in every society, you know, we lose members, we gain them all as fellow members, but then when they go out and practice, they forget to renew their membership or they're not as involved. We really want to keep them. And third, as Jeanne mentioned, we're interested in international members. We want to be the house of ID, so we want to spread that message around. We want our members from Latin America, they know they're very active in the society to continue to be active, to rise to fellowship, and to continue to be members of the society, not just in Latin America, but South Asia. We have a lot of members from South Asia, Europe. We want to be the house of ID for everybody. And so we're going to be concentrating. I think we should concentrate in these three groups to try to grow our membership into the future.

Jeanne Marrazzo: [00:23:57] Thanks so much, Max, and I really look forward to working with you on this. Wendy, can you comment a little bit on our HIV care situation with regard to membership? I think it's a really important point.

Wendy Armstrong: [00:24:07] Those of you who practice in HIV settings know it takes a village to provide good HIV care, including all the groups that Max just mentioned. But there are many family practitioners and internal medicine trained practitioners who predominantly, or to a significant extent, practice HIV care, often being trained through HIV pathways at their residency programs or elsewhere. These individuals are also incredibly valuable members of IDSA and HIVMA. There are spots on the board of HIVMA that are reserved for non-ID trained MDs. And so that's part of the big tent, is you don't need to be a physician who has completed an ID fellowship. Physicians who practice in the ID HIV space are very, very welcome.

Jeanne Marrazzo: [00:24:53] Fantastic. And a reminder too, that you can join our advocacy program without being an infectious disease physician. Period. So we really do need everybody pulling together here. We're coming up against the end here, but I want to just circle back to Ron really quickly. One of the big challenges we've been having and many people have talked to us about is the challenge with H-1b visas. And Ron, you've been involved in this and working on understanding this. So let me hear your thinking about what's going on with that.

Ron Nahass: [00:25:20] That group of individuals, again, the big tent picture has been important to our society. And we're very aware our members have had some of the sessions that I've done across the country have come up to me and said, what are we doing about this? And I want everybody to be aware. There is a bill, a bipartisan bill that was introduced in Congress, H1B for Physicians and Health Care Workforce Act. That is to be considered. That would exclude the $100,000 payment for those physicians, and IDSA has been very busy in advocating that that bill get passed. You can all support that through the advocacy program. So, Jeanne, that was great to mention that and remind us all, but it's important that we let our congressmen know this is a bipartisan bill. So it was introduced by both a House Republican and a House Democrat. So quite an important bill for all of us as it relates to our workforce. So thanks for that reminder.

Wendy Armstrong: [00:26:16] Yeah. And I will say also incredibly critical for our fellowship match and our fellows who are international medical grads who have the opportunity potentially to be either on an H-1b visa or J-1. But H-1b offer a lot more flexibility for those fellows at the end of the day when they're looking for a job. And so really, really important and so grateful for the advocacy. We have to support our international medical grads who are just a very, very important, critical part of our workforce.

Jeanne Marrazzo: [00:26:43] Thank you for your candor and your commitment. Incredibly thoughtful answers, as always. I couldn't think of a better team, along with our IDSA staff who are experienced, really committed people to tackle the formidable challenges of the future. You know, I like to remind people and remind myself that in crisis we find opportunities. So bring it on. That's the message, I think, for the next coming year. So hopefully with all of you, we'll be able to get through this and come out better on the other side. So thank you very much for joining. Tune in for the next episode and we'll see you all soon at IDWeek, if not before.