Steven Schmitt: [00:00:17] Welcome to Let's Talk where it's all ID, all the time. This is the President's Podcast. I'm Steve Schmitt from Cleveland Clinic and I am president of IDSA. And for my first podcast as president, we will address the critical topic of the workforce in infectious diseases. And I'm delighted today to be joined by IDSA's foremost experts and leaders in this area. First, I have with me today, Dr. Erin Bonura from the Oregon Health and Science University, where she is associate professor of medicine and also has a clinical research master's focused on medical education. And Erin is currently a member of the IDSA board of directors. Welcome, Erin.
Erin Bonura: [00:01:06] Thank you. Good to be here.
Steven Schmitt: [00:01:07] I'm also joined by Dr. Wendy Armstrong from Emory University, where she is a professor of medicine and vice chair of education and integration for the Department of Medicine. She is past chair of HIVMA, and, as an aside, a former Cleveland Clinic colleague of mine. Welcome, Wendy.
Wendy Armstrong: [00:01:30] Thanks so much, Steve.
Steven Schmitt: [00:01:31] Well, thanks to both of you for coming on the podcast. Today. We're focusing on the very important topic of ensuring the workforce for the future of ID and IDSA, which is something that you have both been deeply interested and helping to lead IDSA on. Problems like the Covid pandemic and antimicrobial resistance are highlighting what we think is the obvious need for infectious disease expertise. But despite that, 80% of counties in the United States have no infectious disease physician and certain parts of our workforce are aging, and there's been concern that this has the potential to further exacerbate workforce problems. And as a consequence, there's been a lot of talk over the past few years, especially about ID training program match data, with much attention paid to training program and training slot filling rates. So just to level set, what are those numbers and just what do they mean? Do we have a problem?
Wendy Armstrong: [00:02:43] Yeah, Steve, thanks for asking that because I think it's a really important question to answer correctly. The data about the ID Match has been misinterpreted over the years. If you look at the Match, particularly where we have reliable numbers of trainees, which is when we start after we started the all in Match in 2017, we have had, until last year, continual growth or stability in our total number of residents matched into ID. There's a narrative out there that the numbers are declining and that just frankly hasn't been true. What is declining is the percentage of total programs and positions that have filled, and that's a function of having an ever increasing denominator of positions offered and programs offered. So in short, the programs and positions are growing faster than the total number of residents matched. But we have seen growth and in fact, in the total number of programs and the total number of positions, there's been 40% growth over the last decade. We are until again last year, we are really training more people than we ever have in history. Even last year, which was a down year, a slightly down year, we were still training more people than we matched in 2020. In addition, we almost always fill in about an additional 50 people through the scramble after the Match. And so the numbers are frankly even better than that. So is ID in trouble? We had a downturn last year, which we all think is Covid, and it was slight, but overall this is a specialty where we've been training more people and growing and it's honestly been getting more vibrant. People are focused on the wrong numbers. The percent is not the correct number. It's the absolute numbers.
Erin Bonura: [00:04:36] Yeah. Thanks, Wendy. This is Erin. I would echo that entirely. And looking at the spectrum, we have to look at more than just 1 or 2 years and look at the data going back to 2017 when we made that change to the match. And the numbers have been growing.
Steven Schmitt: [00:04:50] Yeah, I'm really glad you mentioned the vibrancy of infectious disease. Boy, we all just came from IDWeek and the energy and the buzz and the numbers quite frankly, were outstanding. And so we talk about the Match. What are we anticipating for this year?
Erin Bonura: [00:05:08] Looking at this year, I think all the early indications are that it's going to be a tough year. It's going to be a little challenging. And speaking with some of the PDs and looking at the initial numbers, I think we do have to prepare ourselves for a challenging Match this year. Having said that, and speaking with many PDs across the country, the quality of the applicants is very high and so everybody's been very pleased with who we've been interviewing. But I think it's important to consider all those factors.
Wendy Armstrong: [00:05:36] The question is why? Why have we had a slight what we expect to be a downturn this year? And we cannot underestimate the effect of Covid on our trainees. There was so much talk about, you know, the Fauci bump and all, you know, how Covid was going to invigorate people. But that was like early in the pandemic. But the pandemic, as we all know, lasted for years. And frankly, people got really worn out and I think actually negatively impacted our specialty. Instead of helping. As any slope has wiggle in it as it's rising, as any line that's rising will have up years and down years. I think that's what we're looking at. I think we're looking at a result of Covid, and I honestly fully anticipate that this will be short lived. Yeah.
Erin Bonura: [00:06:24] Like that. You mentioned that, Wendy. I do think that this is kind of the wiggle area, right? And it is a result most likely of the Covid pandemic. Despite that short increase, it was hard for a lot of people. And I think they noticed that the ID physicians were working really hard in challenging circumstances. And people are a little worn out for a bit. So we'll have to see over time how that evens out.
Steven Schmitt: [00:06:46] Thanks, Wendy and Erin. The three of us really do agree that we need to continue to expand the workforce to meet threats like future pandemics, antimicrobial resistance, the ongoing HIV epidemic, dramatic increases in immunocompromised patients. I mean, we all see the monoclonal antibody commercials on the television every day. We end up treating these folks infectious complications of medical devices, of substance use disorder, and a host of other things that we probably haven't identified. And that means bringing more people into the field. So, Erin, you've studied this. What do the data say and what have you learned in your experience about the drivers that bring learners into ID careers, and what challenges do we have?
Erin Bonura: [00:07:46] In our work that we publish and also in our conversations with learners, one thing comes back all the time are those mentors that they met that drew them into ID and were so engaging. That's been a huge factor. So mentorship and having that mentorship is really important to not just attracting, but keeping folks in the field and moving forward in that. Another part is exposure. We have so many interesting fields within ID and it's really hard to get to know all of that as a trainee, as a medical student, they need to be exposed to see all the vast areas public health, hepatitis B, you know, there's so many different areas along with HIV, global health and infection prevention. I could go on, of course, but we need to be able to share that with our learners so that they can see there's many different areas to go into and they're all exciting, all have wonderful mentorship. And then the teaching aspect, right. So we learned that if you have really engaging teachers that know how to convey this information, they learn it better, they like it more, and they say, oh, this is a career I can go into. And so it's really important to teach those best practices of teaching to the teachers, right, so that they can be our ambassadors to those students and learners. As far as challenges, of course compensation comes up, but it's not the only one. You know, we've seen other divisions and specialties struggling as well, like nephrology that have higher remuneration. So it's not just compensation. We need to focus on these other things that bring people into ID. Wendy?
Wendy Armstrong: [00:09:12] An area that's of significant interest to trainees right now is clinical reasoning. I mean, look at the popularity of things like the Curbsiders and other sort of diagnostics podcasts. That's something, again, that I'd honestly owns to a significant extent, but it's something, again, that our trainees are seeing less. So you mentioned exposure, Aaron. There's also so much flexibility in ID careers. And I think that's something people are anxious to have in their lives but don't actually appreciate. That's part of ID. Also, there are really interesting combined training opportunities like ID critical care. I think we're moving into an era where addiction medicine and ID is going to be a very, very hot topic. ID cared about vulnerable populations and about social justice before it was like the "in" thing, right? We've always taken care of folks with tuberculosis or HIV in the early days, or hepatitis C or typhus, you know, whatever infectious process was affecting those folks who didn't have privilege, has been a space that we have been in, and we've cared a lot about and we've cared about equity. And that's very meaningful to today's learners. But it's again something that we need to make clear because it isn't always clear, given the very small lens that our learners have when they see hospital-based, consult-based medicine.
Steven Schmitt: [00:10:29] There is an ID phenotype, and we all get joy from taking care of folks who need our help. That's what we do. I would urge us all to kind of bring that joy despite the fatigue of Covid. Bring that joy to our interactions with our learners so that they can sense and they can feel our excitement about the field. Workforce is certainly a huge part of IDSA's strategic plan and a big part of the board of directors agenda that we're all dealing with. And Wendy, members are concerned about the future of ID, and they're asking, what is IDSA doing to help move us forward on this?
Wendy Armstrong: [00:11:17] IDSA is doing a lot. First off, there have been a lot of areas that IDSA has worked on in the past. We've been focused on workforce for a decade now, and that included things like moving to the all in Match to make things fairer for our applicant pool, and to be able to study the problem. Developing ID interest groups. We have done workforce studies. The data that Erin mentioned came from an IDSA sponsored study. We've developed the antibiotic stewardship curricula, have developed compensation tool books. The MedEd community of practice was born. So, so many different things. But now I think we're moving forward. And I'm really actually excited about how vested IDSA is in workforce as a crucial part of the strategic plan. We are beyond, I think, the point of studying things and really moving to a point of even more action. There's going to be tremendous amount of focus on how do we inspire interest in infectious disease as a major goal, looking again at sort of education and so on, there's going to be a really significant focus on developing and sustaining careers in ID for our trainees to want to do what we do, we need to be happy and healthy and have a good work life balance and so on. And that's been hard through Covid, and I think we need to turn back to take care of our own. And then alluding to what I said earlier, there's going to be a major focus on expanding and promoting equitable access to a diverse ID workforce and to caring for a diverse set of patients. Our patients are diverse. I'm very excited, and I think IDSA is in the beginning of this process to really prioritize those goals and to think about the exactly the granular, how are we going to do it so that IDSA can invest in a significant way in areas that are going to give us a lot of bang for our buck? Yeah, IDSA is working on this and has been for years, and it makes me actually very proud to be part of those efforts. Erin, do you have more to add?
Erin Bonura: [00:13:11] You said it so well, Wendy, it's hard to add to that, but I'm new to the board. But joining in on these conversations has been really inspiring. People are deeply invested in this, and it's nice to see the work moving into action. So I'm really excited to see where this goes.
Steven Schmitt: [00:13:25] Yeah, I agree, Erin. It's really an exciting time moving into an era of action on this. You know, as I reflected on this preparing for this podcast, it seems to me that this is not just something that is for the board, but really it's going to require the participation of everyone in ID. I'll ask you, Erin, you know, what can ID docs and divisions and groups do to help us attract people?
Erin Bonura: [00:13:53] Yeah, I mean think everybody can do something. So I remember Dr. Brian Schwartz. He said, just find one person to mentor. So just find one student, one trainee that you can provide a link to, whether it be projects or just conversations. That's huge. Make sure you bring your best self to your teaching, right? If you're asked to give a lecture, you are there, you are engaged, you're 100%. And if you need resources, talk to the medical education community practice and we can reach out and help with those. I think everybody has something they can do in divisions. Like Wendy was saying, we need to start to take more care of our own, right? We're doing the best that we can, but maybe we can do a bit better and making sure that our faculty have that right set work life balance now. So I think everybody can pick up something that they can do, and it doesn't have to be really big stuff. It can be like, I'm available for questions and I want to share how wonderful this field is with you. I want to show you all the different things you can do, and maybe have somebody come and shadow with you. See what it's like in clinic outside of the hospital. Right? So I think there are a lot of different things that people can do that might be a little bit easier.
Wendy Armstrong: [00:14:54] There is, it seems, an ever-present undercurrent of discussion about how ID is dying as a specialty. And I just don't get it because our numbers are fantastic. We're not dying. But the more we talk about the fact that we are, that doesn't encourage a trainee to come into ID. We're training more people than we have in the last decade almost at every point of that time. We had the largest IDWeek in history, by a lot. We have more trainees at that meeting than we ever have. We have more areas where we are asked to contribute with, again, growing pandemics, the silent pandemic of AMR, the growing population of immunocompromised patients, and so on. There are a million places that we can work, which is not only in academic or private practice clinical settings, but in many other settings. This is not a specialty that's dying. It is not going anywhere. And so we need to stop sort of this negative narrative and talk about why we all still think this is the best specialty in medicine, and that's what we can do.
Steven Schmitt: [00:16:06] That serves as really fantastic set of takeaway thoughts, Wendy, as we move outward and I'll give Erin the last word, you have any last thoughts that you want IDSA members to take away, as we're all doing what we can to ensure the future?
Erin Bonura: [00:16:25] The thing that keeps coming back to me is this saying that we have that the future is bright. There was so much engagement at IDWeek. Like Wendy was saying, we had over 2000 trainees. We had like 12,000 people at IDWeek. this dip that we might be seeing, we do not think it's long lasting. And really, the future is there and energized, and we just got to bring them in and sustain it.
Steven Schmitt: [00:16:46] Well, again, I've been talking ID workforce with doctors Erin Bonura and Wendy Armstrong. Thanks so much for your leadership on this, Erin and Wendy. And thanks to our members for tuning in to Let's Talk ID.