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.