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Thursday, June 16, 2016

The delusion continues (part 3)

In response to my last post a reader emailed me the following: Very easy to sit at a keyboard and throw blog bombs … I would be thrilled to hear your constructive suggestions for a solution(s).

Fair enough. I'll address that. But it's important, I think, to first say a few words about this blog, which is now in its eighth year. From the beginning, we wanted to make controversial issues a focal point, and the issue of the infectious disease (ID) workforce (or lack thereof) is controversial and a topic of great interest to readers. In addition, we welcome comments and guest blog posts to offer alternative viewpoints. Eli Perencevich, MD, ACP Member, Dan Diekema, MD, FACP, and I don't always agree with each other (as is evident in our posts). The only comments that are censored are those advertising black market erectile dysfunction drugs and other products. And all requests for guest posts have been honored unless the author has conflicts of interest with industry. So readers, please feel free to respond to our posts.

My comments on the workforce/compensation issue and IDSA's response are made in the context of my experience with these issues. In my former job as an infectious diseases division chief in an academic medical center, I had firsthand experience with the difficulties of recruiting fellows and faculty, the inequities that resulted from a purely relative value unit-based compensation plan, and the toll this took on teaching and morale.

At the same time, I was observing a private health system across town crank through a multitude of infectious diseases doctors, each of whom left practice once their guaranteed salary expired and they one by one came to the realization that they couldn't generate enough RVUs to maintain their salaries. Several of these physicians became hospitalists.

In my current position, I see my division chief struggling with trying to balance his budget, offer salaries that can compete with other hospitals and medical schools, deal with ever increasing consultation volumes and expectations for rapid responses to consult requests, while trying to minimize the stress all of this has on his fellows and faculty members. We now have starting salaries for brand new nurse practitioners that are within a few thousand dollars of junior ID faculty salaries.

I'll be the first to admit that my experience may not be the same as others. In the IDSA compensation survey, 1 respondent reported a salary of $1.45 million, so obviously his situation is quite different than mine and his views on these issues probably are as well.

I did a little more research on salaries by looking at the Association of American Medical Colleges data. The median salary for an infectious disease assistant professor is $152,000, while the median for a hospitalist assistant professor is $207,000. For a third year internal medicine resident, that's a huge difference. At the associate and full professor levels, hospitalists still earn more money than infectious diseases specialists. Moreover, hospitalists salaries are rising yearly at a higher percentage than ID's, so the difference continues to expand.

Another interesting finding is that of salaries for chairs of Departments of Internal Medicine. Unfortunately, if you're an infectious diseases doctor you'll earn significantly less than your chair peer who's an invasive cardiologist, a difference of about $350,000. And what do cardiologists learn in their fellowship about being a department chair that would explain that difference? I hate to sound like Donald Trump, but it's a rigged system. And it follows you throughout your career.

As for constructive suggestions for solutions, I've written about this in older posts, but here are a few:
• Focus on the parity with hospitalists, since that's our biggest threat with regards to recruitment of residents into infectious diseases. Until ID salaries are at least as good as hospitalists', there's little reason to think that we will turn this around.
• Consider shortening the ID fellowship 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?
• Develop hybrid models of training to lessen the economic impact on trainees (for example, integrate ID training 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.
• If IDSA is working hard to address these issues, it's not apparent from their website or communications with its members. Most importantly, in my view, IDSA needs to own the workforce issue and honestly deal with it. And that begins by calling it what it is–a crisis. A crisis, magnified by the many problems that are in the news every day, like Zika virus and antimicrobial resistance. I'm not a communications specialist, but it seems to me that these issues could be highlighted to help our cause.

Unfortunately, the two articles and editorial published this week in IDSA's journals spin an unrealistic view of the problem. I doubt that the your-salary's-not-as-bad-as-you-think-it-is campaign will have much impact. Time will tell. In December, we'll see the results of the next Match.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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