Sunday, December 21, 2014

The dumpster fire (part 2)

Earlier this week Dr. Stephen Calderwood, President of the Infectious Diseases Society of America, posted on our blog a response to several posts that we have written to shed light on the problems plaguing the specialty of Infectious Diseases, which are primarily the interlocking issues of low pay relative to other subspecialties of Internal Medicine as well as hospitalists, and the dwindling number of young physicians pursuing training in our field. While we thank Dr. Calderwood and IDSA for his post, we remain unconvinced that the leadership of IDSA appreciates the gravity of the situation at least as gauged by their response.

I spent some time this morning reviewing IDSA’s website with regard to the issues of low reimbursement/salaries and the inability to recruit new trainees. I couldn’t find much. In a recent newsletter to the membership, Dr. Calderwood mentions “the decline in match results” in one sentence that contains a link to his post on our blog. That’s as much as I could find about this year’s dumpster fire. There are also a few letters to CMS urging some reforms in payment.

Dr. Calderwood rightfully points out the importance of mentoring our trainees to foster more interest in ID. But ethical mentoring now requires that we have frank discussions about the relatively low pay of ID physicians with young doctors who are in the process of career discernment. I tell would-be ID physicians that they need to come to terms with the fact that they will work harder and make less money than their peers who are hospitalists. And the issue isn’t just about money, it’s about how valued you feel. Several months ago in the midst of such a discussion with an internal medicine resident, the response of the idealistic young doctor was jarring. “I know all about the salary problems in ID,” he said. “My dad is an ID doc who had to close his practice because he couldn’t generate his salary.”

The situation for ID is likely to worsen. There is now a CMS demonstration project on eConsults. In this model, primary care doctors ask specialists for consults that are electronic only (chart review without seeing the patient) with expectations for a response within 72 hours. Sort of like a curbside on steroids. Here’s the really crazy part of the concept: for this service the requesting physician is paid the same as the specialist who provides the consult (i.e., each receive 1 RVU). Who’s the loser here?

As I see it (and as many others do from my discussions with colleagues across the country), ID is in free fall, yet we have a la-belle-indifference response. To give benefit of the doubt, I guess another explanation could be that IDSA is actively engaged but too shy to let its members know. As I think through all these issues, for the first time I’m asking myself: why am I a member of IDSA?

There are many questions that should be addressed. Here are some:
  • How do we truly demonstrate the value we add? The few papers that address this question don’t provide convincing results (i.e., they seem to underestimate our value and provide fodder for maintaining the status quo).
  • How can compensation models be changed to fairly reward the work we do and acknowledge the additional training and skills we possess? More directly, why is the pay of the ID subspecialist less than the pay of the hospitalist?
  • Should the ID fellowship be shortened to positively affect the cost-benefit calculus of additional training? Do trainees who plan to enter private practice really need hands-on training in research or scholarly activities? Would it be more fruitful and time conserving for these trainees if research projects were substituted with more training to better interpret evidence? 
  • Should hybrid models of training be developed to lessen the economic impact on trainees (for example, could training be integrated with hospitalist practice? Various models could be envisioned—such as one month hospitalist attending, alternating with one month ID fellowship)? This would increase the fellow’s salary, and even if the total duration of training were extended, may entice more residents to consider ID training). Some would probably continue this model beyond training into employment.
The reality is that few people are pursuing ID training, and even among those who do, very few want to pursue an academic career. Despite all the voting that residents have done with their feet, we continue to mostly offer a one-size-fits-all training model with financial punishment when training is over. It's time to put out the dumpster fire and thoughtfully begin to rebuild our specialty. But first we should spend some time contemplating the words of Albert Einstein: “Insanity is doing the same thing over and over again and expecting different results.”

Tuesday, December 16, 2014

GBV-C Co-Infection Associated with Improved Ebola Survival

GB virus C (GBV-C or Human Pegivirus - or even Hepatitis G) is associated with high viremia but there is little evidence that it causes disease in humans. Back in 2001, Jack Stapleton and colleagues (including Dan) showed that GBV-C co-infection significantly improved survival in HIV+ patients. The thought behind this association is that GBV-C attenuates aberrant immune activation.

Given that GBV-C infects between 10-28% of individuals in the three countries that have experienced the highest level of Ebola infections in the recent outbreak, Michael Lauck and colleagues in Madison wanted to examine the influence of GBV-C co-infection on Ebola outcomes. Using a cohort of 49 Ebola infected patients with outcome, age and gender data available they assessed the association of GBV-C co-infection on mortality.

Overall, mortality in the cohort was 69%. However, while mortality was 78% (28/36) in GBV-C negative patients, it was "only" 46% (6/13) in GBV-C co-infected patients. The unadjusted and adjusted analyses are in the Table below. The higher p-value with unchanged OR in the multivariable model likely represents a loss in power and not age-related confounding as the authors claim. Minor quibble - they presented a case-control (OR) analysis for this cohort of patients with a significant p-value. Analyzed as a cohort study, the RR=0.59 (0.32-1.09), p=0.0950. Either way, if I had Ebola, I'd also want GBV-C.

Monday, December 15, 2014

Guest Post: IDSA’s Take on the Match Results

This is a special guest post by Dr. Stephen B. Calderwood, MD, FIDSA, President, Infectious Diseases Society of America (IDSA)

The first annual IDWeek Mentorship Lunch, IDWeek 2014    

The IDSA community is over 10,000 doctors strong, and we’re all concerned with the match results for this year. But the dumpster fire metaphor is only half right: Yes, it’s a crisis, but we aren’t shrinking from it. Everyone at IDSA is fighting for our specialty, and we need our whole community to join in. 


HAI Controversies has talked before about this, and Mike Edmond put the blame squarely on the economics of being an ID doctor. The Society continually advocates for better compensation for ID services and how to value their input differently under health care reform. This past year, IDSA has pushed hard for ID specialists to be required for hospital stewardship programs. To help individual doctors with compensation, several IDSA veterans compiled The Value of the ID Specialist, a comprehensive study that documents how ID consultations result in better outcomes and lower costs.  And for IDSA members, we offer a Value Toolkit (login required), which collects presentations, videos, and documentation to help ID doctors make the case to their own employers, hospital administrators and health plan executives.

Funding for Research and Public Health

Funding cuts in research and public health affect all of us, not just ID specialists, and IDSA joined hundreds of other professional societies to Rally for Medical Research. In addition, our policy and government affairs team works tirelessly, advocating for more research funds for HHS agencies and encouraging the White House and Congress to commit more of the federal budget to infectious disease research and public health.

We actively encourage our members and the public to join these efforts. In three minutes, you can let your congressional representatives know that budget cuts hurt the infectious disease community, and ultimately the patients we serve. Of course, you can also contribute more directly: the IDSA Education and Research Foundation supports medical students and young investigators with fellowships, travel grants, and research funding to help recruit more people to our specialty and to help with their early career development.


Mike Edmond’s post led with a moving tribute to the mentor who inspired him to choose ID. IDSA is dedicated to expanding our mentorship efforts. In addition to our two Fellows’ meetings every year and our scholarships for medical students, we launched a new Mentorship Program at IDWeek 2014. Students, residents, and fellows were teamed up with seasoned ID professionals and explored the meeting together. We’re actively trying to expand our mentorship programs, and encourage our members to volunteer for these efforts.

Responding to the match is a community effort that will require a multi-pronged approach. We at IDSA are all thankful to have an active, involved, and passionate community of ID doctors in our Society who want to see the specialty thrive and expand; we welcome all thoughts individuals may have in better addressing this issue. We certainly want to ensure that we continue to attract the very brightest and committed individuals to our specialty. We’re committed to ensuring that the future workforce brings the clinical expertise and new knowledge needed to address the many problems we face, including the enormously important areas of antimicrobial resistance and stewardship, HIV, TB, emerging infectious diseases (such as Ebola!), and all the other key areas our specialty contributes to so uniquely on a daily basis.  

Friday, December 12, 2014

What is Healthcare Quality Improvement?

Dr. Mike Evans, a staff physician at St. Michael's Hospital in Toronto, and his team at the Evans Health Lab have released another excellent whiteboard video. This time they cover QI in healthcare.  Brilliant and clear as always.

Thursday, December 11, 2014

The world will end in 2050 because...resistance

UK Prime Minister David Cameron requested a review of the health and economic burden of antimicrobial resistance in July. Quicker than you can say supercalifragilisticexpialidocious, economist Jim O'Neill has delivered his report and the results are surprising (at least for those who don't follow this blog). Utilizing commissioned studies from KPMG and Rand Europe, the Review estimates that the economic losses attributable to antimicrobial resistance will total $100 trillion and 10 million excess deaths will occur annually by 2050. In fact deaths do to resistance will surpass other major causes of death even the 8.2 million due to cancer. (see figure on right) Of course, cancer deaths might rise due to the fact that we can no longer safely give chemotherapy without effective antibiotics. The report covers these issues in a sobering section titled: "The secondary health effects of AMR: a return to the dark age of medicine?"

Good times.

The independent Review will outline recommendations for an international response by 2016. In the meantime, I leave you with my favorite figure from the report below. Just for reference, $100.2 trillion is 6 times the size of the US GDP (2013). Perhaps this will wake up the world to antimicrobial resistance?

Additional Source: BBC

Sunday, December 7, 2014

Infectious Diseases and the Terrible, Horrible, No Good, Very Bad Match

Here we go again. Another internal medicine subspecialty “match day” and another record (bad) day for ID. How bad? The previous record (set last year) for unfilled ID programs was 54. This year 70 programs went unfilled, meaning that for the first time ever there were more programs that didn’t fill than that did. Almost 100 funded ID training positions unfilled in a single year!

We’ve blogged about this trend before, here and here, and discussed some of the reasons that ID is in decline as a specialty (along with some suggestions for how to turn this around). I don’t have any new insight, except to make the point that this is now beyond a crisis situation for our specialty. It’s a dumpster fire.

Saturday, December 6, 2014

Killed by an Abundance Of Caution?

Back in August, I wrote:
“most patients returning from the outbreak area with febrile illness (those meeting the Person Under Investigation (PUI) definition) will not have Ebola, but they may be very sick. If an overly stringent lab protocol prohibits or delays laboratory testing, substandard medical care may lead to adverse outcomes.”
In September, I wrote:
“the overwhelming majority of those with febrile illness upon return from the outbreak areas will not have Ebola—but they may well have something requiring urgent attention and appropriate therapy (malaria, typhoid, meningococcemia). Prompt laboratory testing will be essential, and potentially life-saving…..However, many hospitals plan not to let any samples from suspected Ebola patients cross the threshold of their laboratories. [This] could be dangerous for patients presenting with “severe non-Ebola infection” who happen to have been in an outbreak area in the prior 21 days.”
Well, the CDC has just released a report on their initial experience with “PUIs” in US hospitals, and there’s this disturbing little nugget buried within:
“At least two persons who tested negative for Ebola died from other causes. Based on reports from health departments and health care providers, in several instances efforts to establish alternative diagnoses were reported to have been hampered or delayed because of infection control concerns. For example, laboratory tests to guide diagnosis or management (e.g., complete blood counts, liver function tests, serum chemistries, and malaria tests) were reportedly deferred in some cases until there were assurances of a negative Ebola virus test result. In other instances, radiologic studies, such as computed tomography and ultrasound scans, or evaluation for noninfectious conditions, such as severe hypertension and tachycardia, were reportedly delayed while a diagnosis of Ebola was under consideration.”
Given the ratio of PUIs to actual Ebola patients presenting to US hospitals, it is quite likely that more patients will die in the US from AOC (“Abundance of Caution”) than die from Ebola. Back to CDC now:
“…it is important to recognize that the likelihood of Ebola even among symptomatic travelers returning from these countries is very low. In the hospital setting, where policies and procedures should be in place to safeguard health care workers, consideration of Ebola should not delay diagnostic assessments, laboratory testing, and institution of appropriate care for other, more likely medical conditions.”
In other words: diagnose and treat the patient, not your Fear of Ebola.

Image from The Keep Calm-O-Matic