BOSTON, Ma. — It was Christmas Day. I was on call at the hospital and was waiting for my wife and 6-week-old son to come so we could eat lunch together. She was bringing kimbap, sweet potatoes, and avocados. But then my pager buzzed.
On the phone was a hospitalist physician.
“Is this ID? We have a new consult for you,” she said. “This man has a history of dementia. For some reason he has a urinary catheter to empty his bladder. We gave him an antibiotic, but now his urine is growing a resistant bacteria.”
I sighed. Yet another catheter associated urinary tract infection.
I walked up the stairs to his hospital room. He was bald, thin, and sitting alone in bed. The peas and fish on his tray were untouched. There were no gifts or tree in his room. I washed my hands, put on gloves and a yellow isolation gown, and introduced myself.
“How are you?”
“Ok, I guess,” he replied.
“Do you know where you are?”
“I’m not sure.”
“You are in the hospital. Do you know what day today is?”
“It’s Christmas Day. Do you have any family coming in today to spend the day with you?”
“I don’t know.”
“Ok. What city are we in, sir?”
“Boston,” he said.
“Correct! Do you know who the President of the United States is?”
I examined him. Then I stood back.
“We are going to recommend that your doctors change your antibiotic. But since today is Christmas, maybe you’d like to sing a carol together? Do you know any?”
“Sing?” he asked. “What would we sing?”
“How about Jingle Bells?”
We started slowly. His head bobbed up and down and his voice was soft but his eyes were bright and he knew the words by heart.
“Jingle Bells, Jingle Bells, Jingle all the way
Oh what fun it is to ride in a one horse open sleigh…”
After we finished, he paused.
“I hadn’t sang that in a long time,” he said. “Thank you.”
Before starting my infectious diseases (ID) fellowship, I spent two years at the Centers for Disease Control and Prevention (CDC) as an Epidemic Intelligence Service (EIS) Officer (“disease detective”). I worked on a variety of infectious diseases including HIV, tuberculosis, and MERS-Coronovirus. Working at CDC, I came to realize that America needs many more ID and public health specialists than we currently have.
Besides being the year of Ebola, 2014 was also the year that President Obama put forth a National Strategy to Combat Antibiotic Resistant Bacteria. The strategy was well thought-out. But there aren’t nearly enough ID and public health doctors to carry out its recommendations.
The story you’ve probably never heard is that ID is in a crisis. During the 2014 fellowship “Match,” 99 of 327 ID fellowship positions went unfilled. Meanwhile, the “procedural subspecialties” like cardiology and gastroenterology did fine in the Match.
There are a number of reasons so few young physicians want to go into ID. Infectious diseases is one of the cognitive specialties. ID doctors spend hours interviewing and examining patients and writing long notes. Unlike cardiac catheterizations or colonoscopies, notes are poorly reimbursed and don’t pay back our large medical school loans. (Singing Jingle Bells with patients also doesn’t pay well, despite the benefits of music therapy).
While modern American medicine is in a rush to admit patients, perform procedures, and bill, bill, bill, an ID consultation is an exercise in deliberation. ID doctors must stop and think, “When did this patient start having fevers? What were the initial symptoms? What is the most likely diagnosis?”
The Infectious Diseases Society of America has responded to the poor Match results by creating a task force on ID recruitment. This task force is examining the match results, other data and existing efforts to recruit young physicians to ID. Another prominent ID physician, Dr. Ronald Nahass, has argued that ID should use business models that incorporate return on investment, margin improvement, and other financial metrics to achieve a proper determination of our value as a specialty.
I don’t regret my decision to go into ID. Every day brings challenges and opportunities. But I am worried about the future of ID, and you should be too. Will you or a family member ever need surgery? Have cancer and need chemotherapy? Be admitted to a nursing home? If so, there is a major risk for an infection. It’s unclear that there will be an ID doctor out there to take care of you.
I got back on the phone with the hospitalist.
“I think this was a partially treated urinary tract infection. You can get away with a few days of an oral antibiotic, since he’s looking so much better. But what’s most important is that the nursing home avoid placing another Foley catheter in the future unless it’s absolutely necessary.”
Then I went down to the cafeteria to find my wife and son and have a Christmas lunch.
Philip Lederer is an Infectious Disease fellow at Massachusetts General Hospital and Brigham and Women’s Hospital, and a former Epidemic Intelligence Service Officer at the Centers for Disease Control and Prevention (CDC). His views do not represent any of those organizations. Follow him on Twitter at @philiplederer
Thanks SR. The issue goes well beyond pay for ID and the other “cognitive specialties” — it speaks to the heart of the American health care system, with a focus on procedures and lack of emphasis on prevention. But if the money doesn’t change, nothing else will.
I am a procedural subspecialist but I recall with great affection the mentors I had in Nephrology, ID, and Hematology. They were always the smartest of the bunch. I don’t think we need ROI modelling tools to come up with the obvious. If you pay people for doing x, a lot of people find their way to doing x even if they aren’t in love with it. If you don’t pay people for y, then the ones doing it probably really love it.
So..we probably have a lot of really terrific ID docs around who love and are committed to their field. But I agree completely that if we want to have a broad range of expertise that we can turn to when we are all sick or consumers of the healthcare system, we need to create payment reform that evens the playing field so that people aren’t as likely to use money as an incentive for pursuing a field.