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Future infectious disease workforce in jeopardy, despite rising need

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Holly Korschun
Rochelle Walensky, Wendy Armstrong and Carlos del Rio propose solutions to increase physician workforce.

The number of newly trained infectious disease physicians will not match future needs posed by challenging and emerging diseases or an expected increase in resistant microbes unless new solutions are quickly developed, warn infectious diseases experts in an invited commentary in the journal Clinical Infectious Diseases.

"Headlines reporting new infectious disease (ID) outbreaks instill public panic and fear," note the authors. "Those of us in ID have led the response to these and many other threats that never reach the media. We are the physicians trained to treat patients, guard the health of the public, and contain cost. Yet, the future of our essential specialty may be in danger."

First author of the commentary is Rochelle P. Walensky, MD, of Harvard Medical School, and co-authors are Wendy S. Armstrong, MD, and Carlos del Rio, MD, of Emory University. They are also members of the HIVMA Board of Directors.

Despite a decrease in mortality rates from infectious diseases in the first half of the twentieth century, rates of disease have been stable over the last 35 years with spikes in deaths due to influenza, pneumonia, and HIV. And deaths due to drug-resistant pathogens are predicted to rise substantially over the next several decades, with a dwindling pipeline of new antibiotics.

At the same time, the number of new physician trainees entering the infectious disease (ID) field has steeply declined since 2011. Between the 2009-10 and 2016-17 fellowship matches, the number of adult ID programs filling all their positions dropped by 41 percent and the number of applicants declined by 31 percent. In 2015 fewer than half of U.S. infectious disease fellowships filled their incoming classes.

By the 1970s, advances in medicine led to a perception that ID would no longer be needed as a medical specialty, but that was quickly followed by a rise in tuberculosis rates, the beginning of HIV as a global pandemic, the appearance of Ebola in humans, and hepatitis C as a cause of post-transfusion hepatitis. And over the decades those diseases have been seen more often in settings of poverty, mental illness, addiction, discrimination and incarceration, which requires complex care coordination. And new therapies for cancer and transplant have resulted in more immunocompromised patients with susceptibility to infectious diseases. Infectious disease physicians are also more important than ever in addressing problems of hospital-acquired infections and antibiotic stewardship.

"In a recent study I conducted with my colleague Erin Bonura, we explored the reasons for the mismatch between supply and demand in infectious diseases," says Armstrong. "Primarily, the value of ID as a specialty has been under-recognized and under-compensated. Yet despite this, ID specialists often rank among the most fulfilled physicians."

Because of concerns about ensuring a stable ID workforce, the Infectious Disease Society of America and HIV Medicine Association held a Town Hall meeting at ID Week 2016 to address the topic. That meeting resulted in several initiatives to expand medical trainee interest in ID, including efforts to foster mentor relationships, enhance trainee conference attendance, and advertise the many career alternatives offered by the field.

The Commentary authors themselves offer several suggestions:

  • support innovative teaching methods and enhanced exposure to ID during undergraduate and medical education;
  • combine board certification pathways such as ID/clinical microbiology and ID/critical care, and offer training for senior fellows in pharma;
  • add ID as a qualifying specialty for the National Health Service Corps;
  • encourage the National Institute of Allergy and Infectious Disease to develop programs that enhance early exposure to ID;
  • and stabilize the public health infrastructure to support the response to emerging, often unexpected epidemics with money earmarked for workforce salaries.

The authors conclude:

"Detecting, preventing, treating, and communicating the threat of infectious diseases before their impact spills across health systems depends first on a prepared and vibrant workforce. Investments and political will toward reform in the financing of training, research, reimbursement, and stewardship are critical to ensure a robust workforce of ID physicians dedicated to fighting the unrelenting infectious threats to individual and public health."

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