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Does anyone want my job? An ID fellow’s perspective

Eli Wilber, MD
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The 2022 ID Match was disappointing with 44% of programs and 26% of positions going unfilled compared to other internal medicine subspecialties such as cardiology and hematology/oncology, which routinely fill nearly all of their programs. The discourse as to why there is a shortage of applicants has focused on lower compensation for ID physicians relative to other internal medicine subspecialities, including hospital medicine.

This is an important issue, and it is certainly true that the average ID physician’s compensation does not represent our value to our patients and to the health care system more broadly. High medical student debt coupled with inadequate compensation likely makes ID an infeasible choice for some, so addressing these should be one key component of a broader strategy to build our workforce. However, there is more to this story, and I worry that focusing solely on efforts to boost ID compensation will compromise our ability to respond to this recruitment crisis.

Feedback from residents

My perspective is that of a second-year ID fellow and former chief resident at a large academic internal medicine residency. The PGY-3 residents who just completed the fellowship match were my interns as a chief resident, and I have mentored, formally and informally, multiple “ID-curious” residents over the last few years. Several have chosen to pursue ID fellowships, and others have opted to take other paths, usually starting careers in hospital medicine.

Talking with those current and soon-to-be hospitalists, the theme that emerges time and time again is the tension between being a generalist versus a specialist. They offer some version of “I realized I could be happy as just a hospitalist … I did not need to do a fellowship.” Relative long-term compensation is not their primary motivator, although they are motivated by getting an attending salary now to finance major life events and release the pressure of delayed gratification built up by more than a decade of post-secondary education.

Put more bluntly, they do not see in an ID career a trade-off worth the opportunity cost of “keeping their life on hold” another two to three years. Taken a step further, the current generation of residents who have trained wholly during the COVID-19 pandemic, with varying levels of support from their parent institutions, are especially wary of making additional sacrifices for a health care system that they do not perceive as consistently valuing them.

To be clear, these observations are anecdotal; however, there are data to support the broader claim that improved compensation is not a panacea for ID’s woes. A 2016 analysis examined reasons for not pursuing a career in ID by IM residents both with and without an initial interest in the field. Compensation was the most common response for those initially interested in ID but choosing another career, but this only represented ~20% of respondents; a desire to be a generalist (~18%) and perceived limited job availability (~13%) were roughly equivalently popular choices. When asked what intervention they thought most likely to increase interest in ID, a plurality (32%) of residents chose improved salary. Furthermore, if ID salaries were equal to those of their chosen career, 45% of respondents who considered ID but ultimately did not apply for ID fellowship reported that they would have chosen ID instead. Thus, while salary is clearly meaningful, several other factors are also key in shaping career decisions.

A more contemporary (but still pre-COVID-19) analysis of IM residents’ career choices and attitudes found that IM residents could be divided into four profiles: the fellowship-bound-academic, the altruistic-longitudinal-generalist, the inpatient-burnout-aware and the lifestyle-focused-consultant. Only ~2% of those in this study chose ID as a career, but all who did met the profile of the fellowship-bound-academic, which maps to the archetypal ID physician — interested in research/education, had a key role model who influenced their training and were willing to sacrifice personal comforts for their career.

In contrast, the inpatient-burnout-aware group (more than half of whom became hospitalists) prioritized ending training as quickly as possible and were willing to make career sacrifices to improve their lifestyle. It is easy to envision how the COVID-19 pandemic would cultivate the inpatient-burnout-aware mindset, and indeed the residents I speak to identify their own or peers’ experiences with burnout as motivation for ending training.

Wide-ranging efforts needed  

What then is the solution? Efforts to improve ID physician compensation (such as the recent successful push to develop a targeted loan repayment program and IDSA’s Physician Compensation Initiative) should continue as they can make a meaningful difference for those residents for whom student debt burden and salary are key factors in their career decisions. However, these efforts, on their own, will not be sufficient. Simultaneously, we should redouble efforts to demonstrate to medical students and interns the wide variety of career paths available in ID and how impactful those careers can be.

While it is true that ID fellowship does not unlock a procedure like cardiac catheterization or the ability to prescribe chemotherapy, there are things that we do better than everyone else. The expertise gained in ID training makes it possible to adapt rapidly to novel pathogens, diagnostics and therapeutics and balance stewardship priorities with individual patient care trade-offs. This expertise is what makes the ID physician the optimal public health officer, hospital epidemiologist or antimicrobial stewardship director, each a role where your work can touch hundreds or thousands of patients a day. This far-reaching impact is largely invisible to medical students and junior trainees; however, it is precisely by involving them in this work that we can give them a sense of ownership and accomplishment that inspires the passion that counterbalances the opportunity cost of extending training.

More radical solutions should be considered as well in the context of an expected continued generational trend towards prioritizing lifestyle over traditional career achievement. Increasing direct compensation for fellows could lessen the near-term opportunity cost of extending training and make major life milestones such as becoming a parent or buying a house more attainable.

There is also a role for expanding targeted one-year programs, such as the HIV Clinical Fellowship Program offered by the HIVMA and the IDSA Foundation. This approach directly confronts the opportunity cost problem of extended training while still addressing a deficit in the workforce and respecting the broader expertise that comes with formal ID training. We should consider if there are additional sub-fields of ID where concentrated training could allow sufficient proficiency that could help alleviate the skewed national distribution of ID physicians.

I came to ID fellowship seeking rigorous clinical problems, an opportunity to marry interests in diagnostic reasoning and clinical microbiology, and a community of like-minded individuals who DO care deeply about our patients, their lives and even what pets they have. I am happy to say I have “found my people,” and I feel prepared and excited to begin a career serving patients and learners alike. My hope is that we rise to this challenge so that more trainees get to experience the same.


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