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To prepare for the next outbreak or pandemic, we must strengthen tomorrow’s ID workforce today

Carlos del Rio, MD, FIDSA
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To help drive investment in the field of ID and ensure a strong voice for ID experts in decision-making for pandemic preparedness, IDSA partnered with the Johns Hopkins Center for Health Security to draft “Infectious Diseases Experts: America’s Link Back to Everyday Life,” a report that documents the complex, varied and extensive contributions of ID experts in the COVID-19 response and makes policy recommendations critical for strengthening the ID workforce. We surveyed adult and pediatric ID division chiefs and hospital epidemiologists and interviewed diverse experts across the country.

On Sept. 29, I presented the report’s findings at a congressional briefing hosted by the Capitol Hill Steering Committee on Pandemic Preparedness & Health Security. As the report describes, in addition to directly caring for high numbers of patients with COVID-19, most ID experts took on a significant number of new or expanded roles in their hospitals and clinics, including leading clinical trials, managing and prioritizing complex administration of COVID-19 therapeutics that were often in limited supply, scaling up testing and vaccination, and developing and updating guidance to keep pace with emerging science and to allow elective health procedures to resume safely. Hospitals in rural communities often lack on-site ID expertise and relied heavily on ID experts using telehealth to support their general internists.

For the most part, the significant extra work our field undertook in response to COVID-19 was done without any additional compensation. Relying on health care professionals to step up and volunteer, rather than adequately staffing and resourcing our health care system, is not sustainable. It is contributing to considerable burnout among health care workers and creating barriers to patients seeking care.

Major impacts in all communities, urban and rural

While initial waves of COVID-19 were in more urban areas, the pandemic quickly swept into our rural communities who suffered high rates of serious illness and death. Rural hospitals struggled with high patient volumes and the need for extremely complex care. For example, when the pandemic first hit my state of Georgia, it did so not in Atlanta but in Albany. No one would have predicted that southwest Georgia would be hit so early and so hard by the pandemic. With a population of 90,000, Dougherty County has registered 23,000 cases and more than 500 deaths from COVID. After the first case was diagnosed there in March of 2020, approximately 50 people died in the next month from COVID. Phoebe Putney Memorial Hospital, a 600-bed local hospital, was quickly overwhelmed. This major referral hospital that provides care for most of southwest Georgia has no ID physicians on staff. We must grow the ID workforce to expand access to ID care.

As our report discusses, ID experts also played critical roles in our communities, advising schools, sports teams, businesses, farms, meatpacking plants, travel authorities, event planners and others how to reopen safely — facilitating safe in-person learning and economic recovery.

We helped augment public health, frequently serving as trusted, objective messengers in our communities. When the public struggled with mistrust of government officials, they were able to turn to local ID experts for information on how to navigate often confusing recommendations and how to balance efforts to prevent infection with the need to resume daily activities. Partnerships between public health and ID clinicians enabled the creation of COVID-19 testing sites and vaccination clinics. In short, public health officials told us that communities with ID physicians were more resilient than communities without.

But nearly 80% of counties do not have a single ID physician. The needs are not limited to physicians. One quarter of health care facilities report a vacant infection preventionist position. Before the pandemic, more than 10% of clinical microbiology positions were vacant, and we know this shortage worsened significantly over the course of the pandemic, as significant demands for testing led to burnout among the workforce. Shortages are typically worst in rural communities, and they have a significant impact on patient outcomes, both during pandemics and in so-called “peace time.”

Lack of a sufficient workforce contributed to increases in HAIs, including drug-resistant infections, during the pandemic. CDC estimates that hospitals experienced a 15% increase in antibiotic-resistant infections and related deaths during the pandemic. A study of 53 hospitals in the southeast documented a 24% increase in central line-associated bloodstream infections. Interestingly, there was a 48% increase in community hospitals as compared to academic medical centers. As the authors explained, “… community hospitals struggled to manage complex COVID-19 patients, to advocate for resources, staff, and infrastructure, and retain focus on patient safety in the absence of an onsite ID physician champion.”

How to strengthen the ID workforce

So why are 80% of counties still lacking an ID physician? Despite ID being an intellectually stimulating and rewarding field, we struggle to recruit. Last year, only 70% of ID physician training programs filled their slots, while most other specialties filled all, or nearly all, of their programs. ID is the fifth lowest compensated medical specialty, even below general internal medicine, despite extra years of training. High medical student debt is driving more physicians to the more lucrative specialties and contributing to the dearth of ID physicians. The ID workforce also needs to become more diverse. According to 2020 data from AAMC, only 5% of ID physicians identify as Black and only 8% as Hispanic or Latinx. Physicians from underserved communities may be more likely to have medical school debt and higher amounts of debt, making it even more difficult to recruit these physicians into ID.

IDSA is championing federal policy proposals that would make a significant impact on the ID workforce:

  • The BIO-Preparedness Workforce Pilot Program, as included in the PREVENT Pandemics Act, would provide loan repayment to health care professionals with ID expertise who work in underserved areas or certain federal facilities, such as Ryan White Clinics;
  • The Public Health Emergency Outbreak Activation Act would provide increased reimbursement during an ID-related public health emergency to cover the increased work associated with the prevention, diagnosis and treatment of the infectious disease. This will help ensure that clinicians have the resources necessary to mount outbreak responses and help prevent gaps in care;
  • Improving the valuation of inpatient evaluation and management codes would help ensure ID clinicians are more fairly compensated for complex care and would help close payment disparities across medical specialties.

The next outbreak or pandemic is a matter of when, not if. We need to train tomorrow’s workforce today to ensure all of our communities can be better prepared for the next pandemic.


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