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Published On May 21, 2020

CLINICAL RESEARCH

Heroes for a Day

Infectious disease doctors are the linchpin of the pandemic response. But once the crisis passes, will we be wise enough to train more?

On TV nowadays, most of the calm voices explaining the science of the pandemic are specialists in infectious disease. Yet despite their prime-time fame, these physicians typically play far less glamorous roles. They take up largely hidden roles in patient care and health policy, fighting skin infections, sexually transmitted diseases and hospital-acquired infections.

The ranks of this specialty, however, face a shocking decline. It’s a problem that troubles Wendy Armstrong, a professor of infectious disease at Emory University School of Medicine and the medical director of Atlanta’s Ponce De Leon Center, one of the largest HIV clinics in the country. Armstrong has also served as the chair of the Infectious Diseases Society of America’s task force for recruitment.

Q: How would you rate public awareness of your specialty?

A: It’s ironic, because you see our field in the news all the time. When the big medical stories break, they’re so often about some new infection—Ebola, SARS, the newest superbug. And now, of course, COVID-19. But I don’t think many people have a sense of infectious disease doctors as people who work in their hospitals and communities.

I’m embarrassed to say that’s even true of my own friends and family. I tell them I’m an infectious disease doctor, and usually the next question is, “Oh, so do you work at the CDC?”

Q: What role do infectious disease specialists play, especially in the COVID-19 response?

A: At the moment, we wear a lot of hats. There is a place for us in direct patient care. In most hospitals we also take the lead on personal protective equipment. How do you use it properly? How do we apportion PPE at times of shortage to keep people maximally safe? We’re the go-to resource for testing, too. What are the proper diagnostic tests? Are they accurate? In many cases we take part in developing those tests. We also sort through the data on treatments. What works? If we have a shortage of medications, as we do for remdesivir, who are the patients most likely to benefit? And so on.

Q: And outside the hospital?

A: Governors, mayors and anyone responsible for the community’s health will come to us for advice. What do we understand about transmission of COVID-19, and how does that affect the rules around basic services? How do we set up our clinics? What about schools? It’s up to us to synthesize and share the available information.

Q: The number of medical students training for those jobs has been declining for a decade or more. According to the IDSA, 30 infectious disease programs in 2019 failed to fill any of their spots. What's behind that decline?

A: The elephant in the room is compensation. Infectious disease training takes two to three years after completing an internal medicine residency. But general medicine doctors, who don’t do that extra training, are paid more than infectious disease doctors.

At a time when people are coming out of med school with hundreds of thousands of dollars in debt, that is a strong disincentive. People may feel passionately about the field, but it's very hard to make a commitment to train for years longer only to get a pay cut.

Q: There have been pleas to Congress to change medical billing codes. Why is that important?

A: Insurers will pay for a tangible action—a surgery, say—but not for specialists whose main intervention is thinking. We infection disease doctors are not alone in that boat. Primary care, general medicine, some nephrologists and endocrinologists—these are what we call cognitive specialties. The research and thinking they require is simply not compensated on the same order as proceduralists, even though multiple studies show that input from cognitive specialists saves money and lives in the long run. If we can fix perceptions of the value of what we do, compensation will follow and so, I hope, will more recruitment.

Q: Any other reasons enrollment is down?

A: Medical students’ overall exposure to the field is lower. A few decades back there was more of a focus on sit-down lectures with months devoted to microbiology and infectious disease. Now there are much shorter units on microbiology, with students moving more quickly into patient care scenarios. And medical students are now much less likely to be embedded with an infectious disease doctor for a period of time.

Q: What about the personal risks of working in infectious disease? Does that keep prospective doctors away?

A: I don’t think personal danger plays into it at all. There isn’t significantly more danger in infectious disease than in many other specialties. We also have cardiologists at the bedside of COVID-19 patients, for example, and frankly ER doctors and anesthesiologists are at higher risk than anybody else in this pandemic.

Here’s the curious thing. Epidemics like HIV and Ebola can actually fuel interest. We often see increased enrollment after these events because it becomes very clear what role our specialty can play.

I was part of a surge of people who became interested in the field as the HIV epidemic exploded. Many of my classmates and colleagues were anxious to help a patient population that needed advocates and skilled physicians.

Q: How do you begin to recruit these physicians today?

A: One way is to continue to advocate for improved compensation. But at the heart of it is increasing the exposure of medical students and residents to infectious disease work. We learned during one study that three-quarters of my colleagues had an interest in infectious disease before they entered internal medicine residency training. And of those, many told us that they learned about Ebola in high school, watching it on the news or watching the movies Contagion or Outbreak, or reading the book The Hot Zone.

Q: Do we have enough infectious disease doctors? Has the COVID-19 response taught us anything about that?

A: Researchers are crunching those numbers, and it’s safe to say that we currently need every infectious disease specialist we can get. But even if COVID-19 had never happened, the question stands.

We also need these doctors for antimicrobial stewardship: ensuring our precious resource of antibiotics is used appropriately, to defend against drug resistance. The Centers for Medicare & Medicaid Services have said every hospital should have such a program, and that it should ideally be run by an infectious disease doctor.

But if you look across the country, many areas don’t have a single ID doctor. The hotspots for HIV are in the southern states, and even though the most common people to treat HIV are infectious disease doctors, the majority of counties in the south have zero HIV-experienced physicians. And in the opioid epidemic, infectious disease, especially hepatitis C, is rampant. We are trained to be part of those solutions.

Q: What does a future with a shortfall of infectious disease doctors look like?

A: We are looking at tremendous risk. We will feel it most quickly in the fight against drug-resistant organisms—that’s a sword of Damocles hanging over us. And we know the next pandemic will happen, we just don’t know when.

But beyond that, these doctors are needed for everyday care. For pneumonia, or a skin infection, or a tick bite, this is who you consult. I honestly don't want to think about a future without our expertise.