I'm an ID doc since 1972 still active in vaccine research.
ID docs have a process, not an anatomical home such as cardiology, GI, etc. All organs get infected and systemic spread can be a catastrophe. The process we have is antimicrobials, optimizing normal physiology, augmenting immune strength, reducing an innoculum, preventing overwhelming inflammation (cytokine storm). There is a continuum from minor to major and strategies change depending when the intervention starts.
Being immersed in the this world for 45 years has been an intellectual adventure of the first order. It also has given me tools that have enriched an emotional satisfaction. I lost count on how often I made the difference in peoples lives.
Did I get paid? - you bet I did.
5
Please remember that along with infectious disease practitioners ( doctors) the people doing laboratory testing that support your diagnoses are also in short supply. People entering the field of Medical Technology over the past 25 years has dwindled. We too are facing a crisis to aid in microbioloical testing as well as in other areas of the laboratory. For those unfamiliar with my occupation, we are the ones doing the lab testing that you doctors use to form a diagnosis for you. We do the Maldi/ mass spectrophtomer testing, the molecular PCR testing, the Gram stains, cultures, viral work, bacterial, fungal and AFB(TB) testing. We are the ones who test those "specimens" you collect for the lab.We are the ones who challenge microbes against various antibiotics to see if correct selections have been made, or appropriate therapy can be initiated. We are college educated members of the "team" in any clinical setting runninglab testing 24 hours a day 7 days a week in your hospital, clinic, reference lab, so that the ID doc can help your physician get you better, whatever the disease( or in my case infection) may be. In my near 40 years of laboratory work and dedication there has never been this kind of critical shortage in both infectious disease and laboratory staff. We need to work togetherto make the public aware of this crisis, because no matter how we try, those bacteria and viruses will continue to outwit us ( gain more resistance) in the future.
6
I am a Medical Laboratory Scientist, another field facing shortages. Specifically, I work in microbiology, and therefore work closely with (and for) Infectious Disease doctors. Med Lab Scientists are the ones working behind the scenes, performing much of the testing that Infectious Disease doctors rely on to treat patients. We use "matrix-assisted laser desorption ionization time-of-flight mass spectrometry" (known as MALDI-TOF) to identify bacteria and yeast that may be causing infections. We perform antimicrobial testing, providing doctors with the information they need to know what antibiotics will treat an infection. In other words, we perform the testing and provide results, results that are often critical for an Infectious Disease doctor to treat the patient. The Infectious Disease doctor interprets those results to treat each patient in the best possible manner, considering the patient's full clinical history including a multitude of results from other areas such as pathology.
I'm lucky enough to also work with a pharmacist that specializes in infectious diseases, forming a team that works together to treat the patient.
Medical Laboratory Science is a field that does not have much name recognition. People look at me blankly when I tell them what I do. So I'm hoping by responding to this article to bring a little more recognition to an area in the medical field that is also essential, and struggling. Thankfully, it's also rewarding
3
The author is a doctor at Cornell, where I received my first degree. I took classes with medical students, an environment that was more cutthroat than nurturing and I turned to physics instead and have had a successful (and lucrative) career in industry. Infectious diseases have always interested me, how things might be different if top tier universities approached learning differently.
1
Show me the money.A dedicated,very busy,infectious disease specialist was going to quit his job at my hospital.The insurance reimbursement was so low that residents were making more money than him.I am for single payer system but looking what Medicare does to some doctors makes me nervous.
22
More importantly, we need scientists (chemists, physicists, biologists, pharmacologists) to develop the antibiotics needed for the treatment. For that, federal funding rates need to increase. Big pharma has a limited interest in developing antibiotics since a cure is less financially rewarding than treatments for chronic illnesses. Moreover, developing novel antibiotics will need an extensive understanding of pathogenic microbes at the fundamental science level. But at this time scientists, unlike physicians, are paid poorly so we don't attract people to the profession. Those in the profession are stretched thin and can barely make ends meet at most research universities. Once proper antibiotics are developed, we won't necessarily need MD level physicians to diagnose and medicate.
15
@Cynical : we are still using the same antibiotics discovered 70 years ago. Modern second-line drugs are not efficient anymore and we have no better alternatives in the pipelines. Pharma firms dont make enough money with antibiotics compared to eg cancer drugs. Its not the scientists or MD. Its the food industry.
3
@Marc Yes we do. My husband’s drug Omadacycline was approved this year.
3
@Cynical Bacteria will then become resistant to THOSE antibiotics, so we will continue to need doctors to diagnose and scientists to develop the next line of antibiotics.
10
We need to recognize that healthcare is a national security issue and develop a comprehensive, publicly-funded defense strategy.
If Russians were poised to cross the Bering Strait and invade Alaska, we wouldn’t be searching for “free market” solutions or extolling the virtues of Adam Smith’s invisible hand. And yet on an annual basis, Superbugs are claiming American lives in numbers nearly equal to the population of Juneau or Fairbanks.
37
Thank you for bringing this to the attention of NYT readers. I had no idea that these physicians were not paid adequately. After a terrible accident and subsequent hospital-acquired infection I was under the care of an infectious disease specialist for two years. I truly believe he saved my life. All the other surgeons and specialists got in line and did exactly as he said.
3
After 40 years of Army active duty and government civil service that sent me into some of the wildest parts of the planet, I owe my good health, if not my life, to ID physicians. The good news always was that I'd come back with a "known" that was treatable, or at least survivable. My fear is the emergence of something that will require the investigative and diagnostic talents of more ID physicians than currently exist.
3
In case you missed it, the OP-ED said this problem results from government Medicare policy that directly impacts pay for doctors with different specialties.
Why has government been so unresponsive to so compelling a need, that results in the deaths of thousands?
If the Federal government takes even greater control over healthcare, why would anyone think this type of problem would not become more widespread throughout healthcare in the US?
From the OP-ED
"The problem is that infectious-disease specialists care for some of the most complicated patients in the health care system, yet they are among the lowest paid. It is one of the only specialties in medicine that sometimes pays worse than being a general practitioner. At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist.
This has to do with the way our insurance system reimburses doctors. Medicare assigns relative value units to the thousands of services that doctors provide, and these units largely determine how much physicians are paid. "
1
I have known Dr. Brian Scully at NY-Presbyterian since 2001, when he quite literally saved my life by finding the correct anti-biotic to fight the infection that was killing me. Over the past twenty years, he has repeatedly saved my neck from infection and infection. (I'm a transplant patient, and thus immunosuppressed.) His unparalleled medical knowledge has undoubted saved hundreds of lives, if not thousands. I'm wholly indebted to him and his team of ID MDs.
6
Sobering thought: Average age of American virologists is 55. Not enough of them in the pipeline. Who will discover the next virus like HIV or Zika?
1
It's the fault of the AMA and the surgical/procedure-driven specialties.
"Fundamentally, the entire payment model of American health care drives medical centers, doctors, and hospital managers to push for more fancy procedures at the expense of primary care doctors. How’d we get here? Since 1992, Medicare has depended almost entirely on the American Medical Association for guidance on how relative values should be set. In a devastating critique published in the Annals of Internal Medicine, scholars from the Urban Institute and the University of California-San Francisco explained that Medicare uncritically accepted 95 percent of the AMA’s recommendations, which are formulated by the group’s Relative Value Scale Update Committee, or RUC.
Of the committee’s 29 members, 23 are appointed from subspecialties like cardiology and dermatology. Just three represent primary care, even though half of all Medicare dollars are spent on face-to-face encounters. Their meetings are closed to uninvited observers. Unsurprisingly, over time, the relative values of various procedures far outpaced face-to-face “evaluation and management.”
https://slate.com/news-and-politics/2009/09/the-hidden-public-private-cartel-that-sets-health-care-prices.html
Sheila Leavitt
4
An eye-opening write-up, and I thank the author for it. But in a culture awash in the sentiment that "just take this pill and you're fixed" is the curative delusion shared/desired by all is it really so surprising that the role of the ID is so underpaid; especially in relation to the peer-group? You want to change this situation? Fix the delusion.
John~
American Net'Zen
4
Americans have not yet realized that health is a global problem .
6
Foolish humans, the problem for the earth is not new types of bacteria or fungi, the problem is you. Superbugs are coming for you because of your over-reliance on antibiotics, but also because your numbers need to be decreased.
Nobody likes to hear this kind of thing, but I'm sorry, it's true. Since humans will not reduce their birth rate enough, the death rate must increase, or the entire ecosystem will be ravaged. Higher rates of lethal infection are a possible savior of our species and the planet as a whole.
I got sick with a rare tropical infection and the ID doctors I saw were the cruelest, most dismissive, and dishonest professionals I ever encountered. They flat out told me we don’t treat those ailments and said if I was Ill it was mental. This article seems to explain why. The other issue I never hear anyone talking about is the overprescribing of immune suppressing drugs for vague meaningless diagnosis. Antibiotics loose money. Immunosuppressive drugs make money because they are taken indefinitely. This is good for business and terrible for patients and the world. As long as healthcare is about money as opposed to results it’s only gonna get worse.
Maybe there is a shortage of infectious disease doctors because they don’t want to get infected?
Substitute Infectious Disease specialist with any Physician or even Surgeon who deals with Children and it’s the same. The salaries are very low compared to what their adult counterparts get paid to do the same thing. With children the stakes are even higher as decisions made my pediatric practitioners has lifelong ramifications. But who cares? Children cannot vote or drive policy. When I listen to politicians and policy makers talk about how children are our everything it wants to make me gag. Put our money (not yours) where your mouth is and then let’s talk...
1
Give my kid a few years--he's happily pursuing his 8th grade science research paper assignment on the "pathogen of his choice" at the moment.
When I expressed interested in going into ID I was discouraged by my attendings. “It’s a one disease speciality” they told me. “So monotonous”
Always can drop Infectious Disease and become a plumber. Pays more if you're in it for the money.
Otherwise stick to what you're passionate about.
2
I look forward to seeing infectious disease doctors stand with other doctors to fight for universal health care.
1
We need to do what we can to preserve these amazing physicians who enter the field of medicine, and infectious diseases, for all the right reasons. Infectious diseases specialists are some of the most special in the hospital. They are known for the large amount of time spent on each patient, with careful thought and attention to ALL aspects of the patient, including personally reviewing radiology, microbiology, pathology in addition to careful discussion with patient and hours spent understanding the patient's medical history. They take the time that it needs in order to appropriately treat the most complicated patients in the hospital.
Infectious disease doctors go into their specialty despite the knowledge of lower compensation because they are generally the students who want to save the world. They are also among the most altruistic, and dedicate their lives to treating vulnerable and underserved populations, in the US and across the world. The system has taken advantage of these doctors and we should fix it because in the 20 years that I have been in practice, as the workload and complexity of patients increases with new pathogen threats and multi-drug resistance, there is clear burnout in trainees and faculty due to lack of personnel and increased work hours. We should not be punishing this group of dedicated physicians because of some arcane pay structure that values procedures and equipment over thought.
8
Americans - unlike people in any other developed world country - are billed for their healthcare per procedure, per consult, per scan. This skews profits away from general medicine, away from long term care, away from diagnosticians and towards procedure heavy fields that can bill more line items - it’s obvious that a dermatologist can see X number of patients and bill for Y number of procedures that an ID doctor cannot.
Combined with the quarter of a million dollars it costs to train (again, unlike any other developed world country) and you naturally create these dramatic imbalances in the system.
This isn’t an error or a deviation — it’s the American corporatist system of education and healthcare producing exactly its intended effect. The system itself is failing and without dramatic restructuring it will continue to do so until it is too late.
64
Nearing retirement after > 33 years in clinical practice, I fell in love with ID pre-AIDS ,enjoyed the intellectual challenges and the ability to help patents recover BUT to make a living I practiced critical care medicine full-time and ID part-time. In my career I have seen the gross perversion of compensation directed away from cognitive specialities towards surgical, procedural specialities. Only a major revamp in compensation ie less payment for procedures, more for primary care and cognition will stem the tide. I see little evidence that this will happen in my lifetime, too many entrenched groups will fight it.
66
As a society we don't value treatment of infectious disease because we take for granted that it is easy. It is not. The golden age of anti-infectives that started with drugs like penicillin and terramycin lulled us into believing that the cure for any infection was just a pill away. The world could pay dearly for that complacency. Doctors and people in the pharmaceutical industry have know for well over a decade that the age of the super bug was coming. For drug companies, like doctors the incentives for doing anti-infective research have evaporated. And the clock is ticking.
I have been a scuba diver for 30 years. I witnessed my first coral bleaching in 1993. Even now 16 years later people still debate the existence of climate change. Mankind has its head buried in the sand about too many issues and our willful ignorance may presage our ultimate decline.
57
Family doctor here, retiring soon, thank God.
I like ID docs-they're helpful. One in Spokane just helped me with a malaria case. But Dr. McCarthy isn't the Lone Ranger out riding all by himself. There's a big shortage of us as well. Why? Not enough money for the work, or, if you like, too much work for the money. Same with general internal medicine, which has to be one of the most agonizing jobs in the country. Geriatrics? Fuhgedaboutit. It's worse than internal medicine.
Med students know about the ROAD to happiness: Radiology, ophthalmology, anesthesiology, and dermatology. More money for the work, or, if you like, less work for the money. Sweet, sweet procedures.
Want more ID docs, family docs, internists, geriatricians, nephrologists, neurologists? Medical students respond to financial incentives, their above-average altruism notwithstanding. Without a raise of 100K or more, when it comes to going into these specialties med students and America got nothin' to talk about.
89
@vbering. Agree wholeheartedly. Thanks. Like you, i think the author holds himself in a bit higher regard than is appropriate or any of us. Sadly, I see the loss of the ability for all of us to be a bit of a generalist instead of being so focused on being a “specialist” as a major issue as well. Most doctors focus on their specialty with no regard for treating a whole patient. I have enjoyed being a primary care doctor but am saddened by where medicine is going.
5
My wife is an infectious disease physician, and I'm a nephrologist (see paragraph 1). We both work in teaching hospitals so we know something about the trends in new physicians joining our specialties.
I am very proud of my job (and love it) and my wife is as well. But currently in internal medicine, cardiology and GI (the "procedural" subspecialites) are ascendant. The author is completely right: it is because reimbursement for procedures from insurers is high, while the reimbursement for thinking and talking is low. I am not asking for more money: I actually think I make plenty (though it's a lot less than you think). But because of procedural reimbursement, cardiology has an abundance of resources and there is an arms race to keep cardiologists.
I just retired my 14 year old Accord. The interventional cardiologist who parked in the garage where I was a resident drives a Porsche with the license plate "I CATH U" (I am not kidding). For new physicians, even if it's not a matter of *personal* reimbursement, why not go to a specialty with high prestige and high resources? Expecting lots of people to move away from these is like expecting water to flow uphill. At one of the hospitals where I work, two years ago, twice as many residents went into cardiology as all the other subspecialties. Combined.
We (still) wouldn't trade our specialties for any other. But as a country we are reaping the effect of our choices of what's important to pay for.
110
I owe my life to the intervention of an infectious disease specialist. I was being treated by a rheumatologist for an apparent auto-immune disease that I in fact did not have. As my condition dramatically worsened I was directed to the Mayo Clinic where a team of physicians of various specialties correctly diagnosed my problem--a quite rare fungal infection that had spread throughout my body (disseminated sporotrichosis)--and constructed an effective treatment program. It took three years of IV and oral anti-fungal medication and dozens of debridement surgeries to fix me, but here I am today to advocate for infectious disease specialists everywhere. I also heartily endorse the Mayo Clinic strategy of pulling together a team representing all relevant disciplines to best ensure a path to recovery.
108
This is what happens with a capitalist-driven model for healthcare. Too many cosmetic dermatologists and not enougj infectious disease specialists.
86
@NR
No it is not the capitalist system.It is the government control that sets the fees for Medicare reimbursement.Medicare then followed by private insurance that have a monopoly.In Massachusetts a doctor is compelled by the state to accept Blue Shield rates.Maybe we need a doctors union.
6
Great article. Is there any chance that the infectious - disease specialist getting infected by the patient concerned ? Or is it that he or she only studies pathological reports and cells to arrive at the conclusion in consultation with the physician and radiologist as mentioned by the writer without having physically examined the patient ?
"The problem is that infectious-disease specialists . . . are among the lowest paid."
Unfortunately, in our late capitalist society, the people we need the most are too often poorly paid: infectious disease specialists, general practitioners and family medicine doctors, gerontologists (for our aging population), and so on. But also teachers, police and fire fighters, social workers, home health care workers, climate scientists, and on and on.
When people like Donald Trump can make billions from shady real estate deals, and doctors who specialize in infectious diseases may not be able to repay their massive student loans from medical school, you know there's a problem with the system.
If we do not overhaul our healthcare system and rethink the rapacity of our increasingly unregulated markets, the status quo could, quite literally, kill us.
127
@jrinsc
Police, go, and teachers have unparalleled pensions —some will get over 1.5 million dollars or more in retirement. When you get rid of their pensions and healthcare then I would entertain a small pay raise.
2
@Driven
As a teacher myself, I can tell you from personal experience that your comment is nonsensical. Yes, I know the story you refer to where some public teachers in NYC gamed the system for large pension payouts. But public teachers also went on strike in Kentucky, Oklahoma, Los Angeles, and elsewhere because they're still make $35,000 a year after years of work (with at least that much in student debt, after additional years of graduate training). Teaching often requires 60 hour weeks, yet some teachers need to drive Uber just to make ends meet. The idea that I or ANY teachers I know can look forward to a $1.5 million pension is preposterous. The average yearly pension for teachers in my state is roughly $26,000 per year. That you would want me to give that up as well as my healthcare for a "small pay raise" is heartbreaking, and proves my point about how devalued such professions are.
48
@Driven
Yes, there are as many of these as Reagan's Welfare Queens. But Conservative count, there are billions and billions of these people in California alone.
9
I'm an ID physician-scientist. I love everything about what I get to do every day. My fellow ID docs are an amazing bunch of people - smart and dedicated and absolutely essential when dealing with resistant bugs and so many other things in the broad field of ID. There is also a growing shortage of primary care docs especially in rural and remote areas - again a career less chosen because of relatively less pay. The cost of education in the US is an important factor with specialty choice. If you have 300K (on average) debt after med school some choices of specialty are not an option. I'm fortunate to have trained in the UK, I finished med school with no debts. Let me say that again - no debts. It was far easier for financial pressure not to feature in my specialty choice. Regardless of specialty choice there are easier, quicker ways to financial security, to use your intelligence and to a stable career than medicine - I would not do it for any of those reasons. If you want to give far more than you get & make a difference every day, do it.
2
My PCP is an ID specialist. She is great. Two thoughts: 1) IDSA doesn’t do itself any favors with its outdated guidelines on Lyme disease, and should focus more on diagnosing and treating coinfections and complicating factors, including tick-borne coinfections, biofilms, fungi, and heavy metals.
2) ID specialists could generate great value and healthcare cost savings if they focused more attention on assessing jawbone health, detecting low-grade jawbone infections, and referred to oral surgeons for treatment. The tall border wall between medicine and dentistry, lack of EMR and EDR sharing, jurisdictional issues, and lack of health insurance coverage for dental perpetuates the oral cavity as one of the greatest overlooked sources of disease, and essential for restoring health.
3
@Laura Henze Russell
The IDSA was sued almost to the point of bankruptcy by the State of Connecticut for its Lyme Disease guidelines, even though the scientific evidence for those recommendations was quite strong and every single one of its recommendations was upheld by an independent panel in 2010. Lyme disease, like so much else in the scientific world, has become politicized such that organizations like IDSA are fearful of legal retaliation for issuing guidelines that are deemed "controversial" by nonspecialists but are not, in fact, controversial in the slightest.
There is a significant amount of legitimate ID research in both the clinical and basic scientific realms on various tick-borne illnesses. However, that has not stopped a slew of quacks who spread misinformation about these infections, and state medical boards are loathe to sanction professionals since these charlatans have found political protection from gullible politicians.
6
Maybe we should let PhDs with expertise in microbiology and immunology help treat/diagnose. They are certainly as qualified, if not more so, to understand the complexity of these cases. While all individuals want to be compensated for their skills, the compensation for an infectious disease doctor is likely higher than for most PhD immunologists/microbiologists.
2
The big money is in cosmetic surgery. Until the states pay the tuition of infectious-disease doctors (with an agreement to practice within said state for a defined number of years) the "shortage" will continue.
4
Do hospital administrators really want to invest in prevention of infection? Gee, that might reveal just how dangerous it is to be a hospital patient. It wasn’t that many years ago that hospital doctors were less than conscientious about routinely washing their hands. Bathroom facilities in medical providers continue to be designed without due attention to contagion. Just this year my surgeon denied my request to to test prostate material to identify bacterial infection. It seemed senseless to keep taking the same antibiotic that was no longer a good match for the underlying cause. Prevention takes time, patience, curiosity, and less concern with monetary gain. These are not the current attributes that reign in our medical system.
2
As a physician, I found this article overly simplistic and fraught with inferences that are questionable at best. It is unclear that the health care system will need more Infectious Disease doctors if the superbug issue becomes more pervasive. As has been demonstrated on numerous occasions in medicine, when a new health problem arises, programs are quickly developed to make it relatively easy for non- specialists to handle these issues. This is almost always true of cognitive issues which is the domain of Infectious Disease doctors. Specialists are in much greater demand when a skill, rather than cognitive input is needed, such as the ability to perform surgery or a cardiac catheterization. As artificial intelligece is rapidly penetrating the medical field, the reliance on physician cognition is likely to be less impactful, not more.
Second, despite the archaic nature and surgical focus of the RVU system, it does not directly affect physician income - demand does. If the superbug issue truly becomes impactful and it truly requires more Infectious Disease doctor manpower, their salaries will rise.
1
@FIFA does not have the high ground
"programs are quickly developed to make it relatively easy for non- specialists to handle these issues"
maybe. quickly developed programs may have unintended consequences which create things like overuse of antibiotics, opiates, etc.
A good deal of the first-line doctors get paid by the number of patients that they see so they need tools to quickly diagnose and treat patients. We then put faith in the consistency of individual doctors capabilities.
I would love to see a more system approach to medicine than exists today - that probably means changing the business model. If every industry forces specialization to a narrow field of study and value, then we will continue to see more of what Dr. McCarthy is pointing out not only in medicine but also in other professions and important expertise will be lost.
Wonderful article! It certainly outlines the financial pressures and overwork that discourage fine internists from taking on a career in ID. Ultimately, policy is the expression of our values. And the policy to massively over-remunerate procedures over thought that has been adopted AMA/Specialty Society Relative Value Scale Update Committee has wreaked this stark income disparity.
Make cognitive medical work great again wouldn’t fit well on a hat— but that’s what we need to do.
And lastly, as an ID fellow at a busy medical center— I can tell you that the work is busy and deeply frustrating at times, but also just so enriching when we make those difficult diagnoses or help patients turn the corner from a truly horrific infection. Joy abounds even if money does not. :-)
13
A local friend who worked at one of the largest hospitals in Taipei told me that infectious disease doctors were much lower on the totem pole than those specializing in oncology or chronic diseases. But then came the 2003 SARS epidemic, and the infectious disease specialists became rock stars as they deployed their training to bring the epidemic under control, showing true heroism in treating the patients affected. Also as a result, Taiwan developed new protocols that would enable the healthcare system to shut down transmission of dangerous pathogens as quickly as possible, such as caring for outpatients with fevers separately from the ER, and issuing insurance cards with IC chips that hold a record of every medical facility where a patient has previously sought care. I hope the US will wake up to the need for advance planning and not wait for an epidemic to take hold.
7
I can't imagine studying medicine in an era when most doctors will inevitably be second-guessed by $15-an-hour pink-collar insurance company "case managers" following algorithms. Until we have a national system of medicine in this country, doctors are just as much at the mercy of insurance companies as their patients.
13
I was all set to do an ID fellowship, and then my wife informed me we couldn't afford it. Moving to another state, another three years of resident level salary, two kids to feed, and then a significant drop in salary from what I make as an acute care physician (hospitalist), more accumulated interest on med school debt. As a second career physician I just couldn't justify it to my family. Which was a real pity because I love ID and because of the low fill rates you can get into really exceptional programs pretty easily. Hopefully compensation will turn around soon or we will be in trouble.
19
My takeaway from this piece is that we should be saying thank you for your service not only to people in fatigues but also to people in scrubs. Thanks Doc.
16
When your car breaks down and you take it to the mechanic , they have standard charges for Diagnostics before they give you the bad news about the repair cost.
The Infectious Disease medical associations should devise a standard set of diagnostic procedures that they typically conduct to diagnose what is really wrong when a patient has a fever, lung issues, or whatever.
These diagnostic actions, whether a lab test or a consult, can be given a price range based on geographic location and can be compensated by insurance. Further compensation can be due when the medicine selection results in a cure.
4
Drug resistant microbes, like anti-vaxxers, are more a political and public health issue than a medical problem. The real shortage, exemplified by the Albuquerque Journal [Feb.16]: "As of last week, not a single primary care physician in one of the state’s largest group of medical providers was accepting new patients...." Lest you think this is just an issue in poor states, consider this follow-up: "The highest average new patient wait times of any city surveyed was 52.4 days in Boston...yet Massachusetts has more physicians per patient...than any state...."
Almost all the discussion about "Medicare For All" or any similar system misses the most salient issue regarding health care: what good is insurance, if there is no functional access to health care?
Neither Republicans nor Democrats have plans to deal with this fundamental problem. They merely argue over terms of "paper rights", entirely ignoring the real world of real peoples' experiences. In a sense it boils down to a simple case of supply and demand: more patients requiring (and/or expecting) services than there are available physicians.
Unless we address ways to create more supply, increasied demand merely serves to exacerbate the problem. Incentives for people to choose medical careers as primary care doctors over specialists, to work in under-served areas, to see patients rather than just research, and other ideas need to be considered as much as the issue of the breath and source of medical insurance.
6
@Steve Fankuchen. Brilliant! Thanks. As an aside, we need to make similar considerations when we discuss privatization of the VA. Much of America doesn’t have the civilian PCP’s to absorb the VA patients.
1
If the US Congress tries to change the Medicare physician reimbursement every member of Congress will have a face-to-face meeting in their home district with an average of 42 surgeons. They will demand that Medicare does not change the current system.
For those of you whom have never interacted with a surgeon who fears a loss of income from a change in reimbursement, be thankful.
Not as bad as facing Viserion or an M1A1 Abrams tank, but overall an unpleasant experience.
6
In our culture, it seems that no one wants to pay anyone, regardless of the years of education and training and developed skill, for essential and necessary thought work while too many current elected officials and administrators falsely assume that intelligent databases and algorithms will make up the difference.
If we want to value the work of trained professionals and "build in" higher level cognitive skills of physician and other key specialists and sub-specialists, including ID docs and public health practitioners, we will have to reformulate the entire payment structure from the ground up and reinvest in and reinvigorate our training and development programs including our teaching hospitals.
Sadly, at a time that more resistant strains are emerging, our public health infrastructure and it's staffing -- that used to often include more ID docs, and far more highly trained post grad specialists, has been left to deteriorate through underfunding and unwise and deadly tax cuts at all levels.
Our systems for planning and anticipating health care staffing and for funding education, training and placement have not only failed to keep up with population growth and demographic changes, they've deteriorated while new health threats have, as we knew they would, have begun to emerge.
6
It's funny how a few suspenseful articles in a major publication like the New York Times has finally brought to light what many of us in medicine already know!
My "doctoring" teacher in medical school was an old gastroenterologist who said that there were three tenets of good patient care: 1) Always listen to your patient without interrupting. 2) Always lay hands on your patient. 3) The Infectious Disease doctor is always the smartest guy in the room.
This shortage isn't limited to infectious disease doctors, though. The least competitive specialties, which often have shortages of specialists, are often the ones that have the lowest pay: infectious disease, rheumatology, primary care (family and internal medicine, pediatrics), geriatrics...
Insurance companies reimburse to do, not think. And medical student, who graduate with >$200,000 in debt after 8 grueling years of post-secondary education, no doubt consider this.
13
This article hits the mark. There is little to attract new physicians to the field of ID. As a practitioner with 30 years in the field I can tell you that our role is essential for complex hospital patients with surgical infections, pneumonia, preventing hospital acquired infections and speeding their recovery. Many of us serve or chair committees that again improve the quality of care but bring no monetary rewards. I at one point was a member of 5 different hospital communities being the chair of 2 major communities. Needless to say this doesn’t lead to a good work-life balance. Then throw the low pay scale into the mix and your unlikely to be seeing a bunch of new recruits to the field of infectious diseases.
You may ask yourself how does the field have anyone involved tobegin with considering the discription. It sparks a passion that brings you to the bedside, the lab, and all the other places you need to go to uncover the answer to the patient’s illness no matter how long the hours.
17
I am am ID doc, graduated med school in the 80's. It is depressing to read this article because back then there was talk of doc's doing procedures getting paid more and the primary doc's and cognitive specialties being under-compensated. Nothing has changed! Part of the problem is the medical profession itself. The medical industrial complex chugs alone uncaring about the real interest of patients. The warped reward system is self-perpetuating with complicity of AMA and the physician profession. I am always reminded of which organization killed Medicare for All proposed in the 1950's - the AMA.
30
Underpaid- oh dear. I am a PA working at a community free clinic I do the work of a physician for less that 80 K annually. Oh wait, I get a week of paid vacation.......
5
@WIndhill Your comment is unempathic, even cruel, and totally misses the point, which is: there will be no one to save us, because we as a society are mistreating those who have the skill, knowledge, perseverance and dedication to save us. We, all of us, are [not nice word]. I hope that clarifies things.
18
@WIndhill
Look up opportunity costs. Docs come from a different cognitive class than PAs and nurses, smarter and with more options in life. You have to pay these kinds of folks more or they'll go into science or tech or finance. Then PAs wouldn't have people to bail them out when they get into trouble.
21
@WIndhill
Sorry you have this resentment. As an ID physician I get calls from various PAs and NPs (and other physicians) who require my assistance in managing ID-related clinical issues on a regular basis. This is a service that is provided free by my hospital to community providers in my state. We receive the highest number of calls among the various sub specialty services at our hospital. My colleagues and I receive no compensation for these calls and we consider this a community service. Speaking from experience you are way off base if you are somehow equating your training and expertise with that of ID physicians.
54
This is simple... pay them more!
Increase the value of an infectious disease consult by 100%, and increase the value of follow up care!
It’s not rocket science, just basic business principles!
9
@Shp. And who, exactly, will be doing the paying part?
3
The multi-drug resistant crisis will certainly in no way be cured with more ID docs unless those ID docs are in some way able to guide policy and practices that address the root causes of the epidemic: antibiotics in industrial farming, overuse of antibiotics for any fever at any urgent care, end of life care that minimizes futile months-long antibiotic-ridden ICU stays.
11
Medicare paying premium fees for invasive procedures, while miserably underpaying cognitive specialties and primary care, has led to the epidemic of unnecessary dangerous procedures, and the shortage of access to primary care -
- plus the lack of subspecialist access in moments where e.g. an Infectious Disease specialist could have saved a life.
7
This article spoke all truth. I commend my little sister, an ID physician at an urban hospital, and all ID specialists who take on this extremely necessary work. The copious, detailed note-taking after hours upon hours of consulting with other practitioners and examining patients yields extraordinary medical contributions that often go unnoticed. We need these cerebral clinicians and they deserve appropriate compensation. The medical establishment will have you believe there’s a shortage of doctors but it’s really all spin- the nursing and physician assistant lobbyists have such a grip on the medical community that somehow they’ve been framed as your primary medical providers with years less of experience and training. Somehow a masters in nursing diploma from an online university evolved as the equivalent of completing a MD residency fellowship. Ridiculous! We need properly trained NPs and PAs to serve the roles they are meant to serve, not replacing physicians who’ve spent their entire lives devoted to the study and PRACTICE of medicine. Unfortunately, so long as the powers that be that control the business side of medicine keep pushing them as your primary care providers, we’ll continue to see a “shortage” of these specialists.
23
Drug resistant microbes, like anti-vaxxers, is more a political than a medical problem.
The real shortage, exemplified by the Albuquerque Journal [Feb.16]: "As of last week, not a single primary care physician in one of the state’s largest group of medical providers was accepting new patients...." Lest you think this is just an issue in poor states, consider this follow-up: "The highest average new patient wait times of any city surveyed was 52.4 days in Boston...yet Massachusetts has more physicians per patient...than any state...."
Almost all the discussion about "Medicare For All" or any similar system misses the most salient issue regarding health care: what good is insurance, if there is no functional access to health care?
Neither Republicans nor Democrats have plans to deal with this fundamental problem. They merely argue over terms of "paper rights", entirely ignoring the real world of real peoples' experiences. In a sense it boils down to a simple case of supply and demand: more patients requiring (and/or expecting) services than there are available physicians.
Unless we address ways to create more supply, increasing demand merely serves to exacerbate the problem. Incentives for people to choose medical careers, to become primary care doctors over specialists, to work in under-served areas, to see patients rather than just do research, and other ideas need to be considered and debated as much as the issue of the breath and source of medical insurance.
5
@Steve Fankuchen
No incentives are needed for people to choose medical careers. We have an abundance of interested, qualified young people in this country. What we lack are sufficient training slots.
5
@MF
MF, thanks for engaging. I agree that there is an abundance of interested, qualified people for medical careers, but I do believe incentives are needed to facilitate, if not encourage, their working in areas, geographic, communal, and medical, where they are most needed.
If you come out of med school with huge student debt and the desire to start a family in a locale with good schools, where are you likely to begin your career, a San Francisco suburb or Pine Ridge, South Dakota?
3
Did you not read the article?
ID fellowship positions are going unfilled.
Most graduating MDs start professional life with a large amount of student debt. By the time they finish their internal medicine (or pediatrics, or other) residency, they are getting to an age where many want to start a family. A three to four year ID fellowship is underpaid to begin with. Years later, as a board certified infectious disease physician, these young (now older) docs are still making a relatively paltry income. Peering down this path, many (most, apparently) consider the alternatives, and choose an easier way.
After a three year dermatology residency (for example) a new diplomate can be making much more than can an infectious disease diplomate after 6 to 7 (or more) years of post-MD training.
4
I’m an ID doctor who works in the Midwest. We have been using telemedicine extensively and that solved the problem of the lack of ID physicians in many small towns in the Midwest (Iowa, the Dakotas, western Minnesota). It’s a win-win situation for patients and doctors at the same time. In many specialities that don’t require procedures, I see that as one of the possible solution to the problem.
20
An insightful article, that highlights, yet, another reason for why financial incentives in medicine need to change, a successful Infectious Disease specialist prescribes as little as possible of the product (e.g., antibiotics) that he is selling, but at the same time, market forces that govern medicine are based on quantity not quality... also, what (for profit) business, e.g., drug company, wants to spend billions, developing drugs, for which the whole idea is to use as little as possible... in short, to set the ship straight, financial incentives in medicine, need to change...
8
As we think about socializing medicine, considering that economic incentives actually do matter for our best and brightest, do we think that lowering income of MDs will actually improve access to health care?
5
@LTJ Lowering barriers to entry and helping young doctors and nurses to get started will help with access over time. Changing the American state by state board licensing will also help. The AMA operates as a cartel, which like all cartels, stamps out competition.
5
As a physician, I am grateful for and respect the opinions of my colleagues in ID. It's invaluable.
However, from the perspective of a career choice in medicine, if I were advising a young physician on which specialty to choose, I would not recommend ID. When you look at where things are going in medicine, I think it's fairly certain that AI will play a greater role in clinical decision support. Most of the data that the ID doctor has to review is already digitized (labwork, cultures, radiographs, current antibiotics) and it is only a matter of time before the EMR system that the hospital is utilizing will be able to provide a recommendation on treatment that will achieve an acceptable level of accuracy - at least acceptable enough to the many hospitals in the country that don't have access to an ID specialist. It may still take some time, but it's not as far off as most doctors probably imagine.
This is a concern for many of the cognitive based specialties.
1
Rick, I’m an ID physician but you’re not describing how a typical ID physician works. ID doctors don’t just prescribe antibiotics. They correlate everything they read in the data and interpret it differently. Many of the “pneumonias and osteomyelitis and possible TB/fungal infections” on imaging reports that AI may interpret as infections aren’t actually infections.
Half of my decisions are made by re-taking a good history and physical exam. The bug-antibiotic match is just a small part of the job. That’s what some doctors (and pharmacists) don’t seem to understand.
58
@Rick As an ID physician for over 20 years, I am sadly chuckling (followed by a tired facepalm) at the assumption that AI can click its way to accurate treatment by using algorithms. Can the radiologist can make a definitive diagnosis and treatment plan for your patient without your involvement? All that data requires clinical correlation, history and physical (sometimes repeated and often more nuanced than the EMR can reflect), and interpretation, based on recent literature more than society guidelines (10-year old literature). Will the AI be conferring with the Micro supervisor on what the colonies look like on a culture to better predict antibiotics for the septic father of four? . Or go to the lab & look at slides itself because the evening shift’s Gram stain report doesn’t make sense?
15
@Rick
As a physician I decided to learn about AI by entering a team into the AI XPrize. My project aimed to integrate the medical literature, static data, to identify systematic flaws in statistical methodologies and better understand medical reversal and the reproducibility crisis. The judges who reviewed my year two report explained that AI wouldn't meet the expectations of such a project -- and the "corpus" was static published medical literature. AI will likely serve us with localized "islands" of capability, where the clinician will continue to synthesize what the AI provides, stitching these capabilities together. Infectious disease is one of the most interesting fields of medicine: there is a "bad guy" and it is up to the detective, the ID specialist, to solve the mystery. So many contextual clues and problems arise. I chose a different "cognitive" specialty, but ID would be my next choice. If we made DeKruiff's (updated) book Microbe Hunters part of the high school biology and health curriculum, and a few other classics, I'm sure it would inspire more interest. If it were taught differently, I think more medical students would be inspired to pursue a career. AI is not likely to threaten the specialty, but is only likely to enhance it.
9
I am a nephrologist and my practice includes 6 nephrologist and 2 infectious disease specialists. These are the specialties that the article notes can't fill specialty training slots, but for different reasons.
For Infectious Disease specialists the pay is generally low and income is generated by seeing lots and lots of complicated patients. For Nephrologists the work involves many sleepless nights caring for the sickest, most complicated patients in the hospital. The pay is about half of what a Cardiologist or GI doc makes. Why? They do procedures that are highly compensated.
If I had to do it over again I would not be a nephrologist. It's simply not worth it. The idea of training to become an ID specialist is laughable. Totally not worth it.
How much nicer to work daytime hours as a Dermatologist and make a fortune.
31
@Jon Tolins I sympathize greatly. I don't think dermatology is that great. Imagine having to stare at moles with a magnifying glass all day. But no doubt what you do is mostly thankless, and hard, and wears you down, and thus kind of awful. Sorry...
1
As opposed to surgeons, most cognitive doctors are overworked and underpaid.
18
@turbot Surgeons have some of the hardest lives out there. Remember that it's the admins and the lords of the healthcare industrial complex who have pitted doctors against each other as they toil in the darkness of the mines. Divide and conquer. Pity we can't be colleagues any more.
6
@turbot
It is not only surgeons but procedures.
4
Surgeons actually have the most arduous training of any physicians. They continue to have demanding work hours throughout their careers. I am an internal medicine physician with nothing but respect and gratitude for my surgical colleagues and the care they render to our patients. Yes, they are well-paid, and they earn every dollar with hard work.
6
A most important article. We are running out of effective antibiotics for a myriad of infections, but Candida (a fungus) is particularly treacherous. We may have brought this catastrophy upon us, given that the abuse of antibiotics is rampant. Government, via the INH for instance, may need to prioritize the study and discovery of new methods and drugs to ameliorate this crisis; also, and urgently, the need to educate the public, and physicians, and agricultural and poultry businesses, to name a few, to change for the better. Just don't count on any miracles or rational thought and action in these Trumpian times so filled with ignorant prejudice, lack of long-term planning and proper allocation of resources to end our self-made epidemia.
3
I am an ex-hospitalist turned PCP, a person who may have considered ID at another time, but as a breadwinner, I can’t take the pay cut of fellowship and ID faculty pay. It will be interesting to see how the pediatric venture into making hospital medicine a sub specialty works for recruiting ID docs. Maybe an answer?
2
I’m an ID doctor. If you do academia or work in a big city, your salary will be low (often 100k or less). But in many other areas especially the Midwest, an ID doctor can make 300plus and get 6 weeks of vacation.
5
There's a shortage of physicians in this country. Period. This come mainly from accepting too few students to Med Schools. The US graduated 19,553 students in 2018 with a population of 327.2 million. 1 graduate per 17,000 people. The numbers in other countries:
Germany: 1:13,000
Israel 1:9000
UK 1:9000
I bet other European countries have even better ratios.
We graduate too few doctors, which keeps physician in short supply and increase their costs...
14
@TLM actually it is the lack of graduate medical education funding (residency positions depend on federal funds) that determines the number of new physicians generated each year. Many medical students are left without a residency position in order to complete their training. Congress has seen this come across their desks several times since 2000 and has passed on expanding this funding.
6
I have zero expertise in infectious diseases.
That is why I want to express my thanks to Dr. McCarthy and his colleagues for all of their hard work and sacrifice.
The only useful action I can take is to write to my representatives in support of increased science funding. I just finished sending messages to President Trump, my two senators and my representative, requesting that they continue to make science funding a priority, with special emphasis on CDC and NIH.
I have no idea if anyone if their offices will actually read my messages, but I certainly feel just a little bit better making my voice heard.
24
I am an ID physician in private practice. I see more and more ID physicians stop practicing ID and work as internal medicine hospitalists or primary care physicians. Sadly, not using ID skills pays better and allows better work-life balance. We receive office referrals from cities 2 hours away just because ID specialists are absent in their towns. These are not necessarily medically underserved areas, they have most other sub-specialists. Due to lack of manpower, we have no options but to triage those outpatient referrals and accept only a fraction of them. I am rather pessimistic about future of ID practice in the communities. With less young physicians choosing to go into ID, ID private practice groups are obviously ageing. We are not able to attract younger generation.
15
The US system is doomed because of certain inherent weaknesses. As long as it is held hostage by the rapacious hospital ("nonprofit") systems,the capitalistic insurance cos. and big pharmas there will never be any money left for the somewhat simplistic patients and also simplistic doctors and nurses.The reason I called the patients simplistic is that I do not think they understand the system and will not vote for something that benefits them. The same applies to the doctors - they are happy with a system which does not value the thinking process any more .
10
As an internist I know first hand how real and frightening this trend is. All the cognitive specialties are in decline. Patients should be terrified.
79
It’s not even as bad as it’s gonna get. Between electronic medical records, pushed through by Obama, and other perks of modern practice, doctoring just isn’t what it used to be. Attorneys saw that a half century ago, in the advent of “the billable hour.”
10
Feeding antibiotics to healthy animals is stupid, and needs to be outlawed. Over the counter sale of antibiotics in 3rd world countries (viz. India, Africa) is stupid, and needs to be outlawed.
32
I'm boarded in both Pediatrics and Pediatric Infectious diseases. When I was in practice, I loved ID, but I had to do General Pediatrics so I could make ends meet. Well said Dr. McCarthy.
48
We need a plan to deal with a possible infectious disease pandemic. New drugs, more specialists, protocols for managing an outbreak.
The United States should be leading a global effort, as it is a global problem.
Yet we are governed by an anti-tax, anti-science party which can't even accept that climate change is real.
These problems will not be solved by business, which won't invest their money for the good of humankind. That's what governments are for.
Stupid, stupid Republicans.
27
@Eric
Eric Trump is a narcist,a crude person not a role model for little kids.Please lets not overdo the Trump hadret.
This was a problem under Clinton,Bush and Obama. I am for a single payer system but I pray that I won't regret it.
The problems we have can be laid at the front of our government past and present.
1
My husband, Dr. Mark Nelson, invented Omadacycline. He won the Heroes of Chemistry award (From the American Chemical Society) along with all the chemists that worked with him. (To be presented in August) He doesn’t make a fortune either, but he is helping society. He is an expert in Doxycyclines. And understands all about drug resistance.
I am an RN who works for Homecare and I set up a lot of patients for home IV antibiotics. Infectious Disease is consulted, but it is all telehealth. They never see the patient in person or examine them. I get that they review everything. I admire them. But I miss the hands on care. Maybe I am old fashioned (I graduated from Nursing school in 1980)
23
@Janice Badger Nelson
I am an ID physician in private practice. We are so short-staffed and overworked that we are unable to see all referred patients in our office face-to-face. In fact, we triage all referrals and accept only the ones we feel benefit most. This is the very sad reality. I don't do telemedicine but it at least allows patients to receive recommendations from ID without an office visit.
15
"A generation ago, most well-rounded doctors knew what to do when a patient developed a fever. Not anymore." The author lost me here. I agree with many of the other points the author made, but this unsupported overstatement makes me not trust anything the author said that I didn't already know. I hope the author demonstrates better reasoning in clinical consults.
4
@Carrie I believe she means that medical knowledge has exponentially expanded since then. I’ve observed this just in the 20 years I’ve practiced internal medicine and ID. Ours is specialty not limited to an organ system. We have to keep up with more than infectious diseases. Having practiced internal medicine in the past, I know it’s impossible for one doctor to be well-rounded enough to do everything we used to. It’s hard enough to keep up with all the developments in ID alone anymore, even with daily emails from the journals! I also teach, which forces me to keep up, and I still don’t feel that’s enough. Best regards!
2
It's deeply disappointing to read the comments critical of this article and its author Matt McCarthy. This is not a political issue or an opportunity to criticize a political group, but a serious health problem and soon to be a crisis. Simply put, we need more ID docs with better pay to diagnose/treat an increasing number of patients. Since we're fast losing the battle against Superbugs, we don't have time to let the market forces establish the salaries and availability of ID docs. Unfortunately politicians are too busy quibbling each other over stuff versus developing effective health care policy to save lives. So, what's more important - saving 25,000 lives per year or seeing Trump's tax returns?
12
@Indy970
Sorry—use the PA
@Indy970
Maybe both?
7
@Thomas Zaslavsky
If Trump committed a Tax crime the IRS will get him.The reason to get his tax returns to weaponized it by the Democrats.Look "how much money he made ,how little charity he gave ,who he gave the charity for etc.What is the matter if qll that was legal.The Democrats should with the president get together and work for the good of the country instead launching stupid investigations that lead to a dead end.
1
Everyday there seems to be a new report about drug resistant super bugs. Most experts agree we've brought this on ourselves through our use and mostly abuse of antibiotics and anti-fungicides.
However, we seem to collectively dragging our feet on doing anything about this. The World Health Organizations predicts that by 2050, just about 30 years from now, more people will die from infectious diseases than cancer. Let that sink in.
Unfortunately the U.S. currently has leadership, if you can call it that, far more concerned with short term election optics and making sure the economy stays overheated enough come 2020 than existential threats to humanity.
Superbugs aside, throw into the mix super storms and the like triggered by climate change, and I suspect we're not going to be happy campers in the coming decades.
12
@JHM
Literally, in the past few days I believe the Times has had a new article about a different drug-resistant infection every day. (You meant "Every day"; "everyday" means "ordinary".) Need I say "horrifying"?
3
Pharmacists trained in infectious disease can help support some some of this shortage in providers, as they are trained in how to assess which agents will provide correct coverage for the infection, to assess for response and efficacy, and when an agent should be discontinued (background: community pharmacists, like those in CVS and Kroger do go over this during their 4-year PharmD education. The pharmacists I'm speaking of above work in the hospital and are increasingly likely to have completed a year or two of residency after achieving their PharmD). While it sounds like there are changes that could address the need for more appropriately trained MDs, the burden doesn't need to entirely fall on one healthcare profession.
7
@Ailish
The problem with using PharnDs is their expertise is limited to pharmacology of antibiotics- IDs have the understanding of how an organism may move between anatomical sites, the difference in culture/ genetic/ molecular diagnostics, and weight the risk/ benefit ratio of the whole clinical scenario. I love my PharmDs (critical care) but their input (while highly valued) isn't sufficient to treat these patients.
15
@Cydney
Best reply of all others. Lay folks need to know the complexity of ID. Medical practice always is a bit more complicated when another living entity such as a parasite, bacterium, virus, fungi, etc might be responsible for a disease process. They do not always follow set rules.
7
@Ailish Most pharmacists I've dealt with recently on behalf of family members and friends with complex health issues were mostly focused on following the procedures and guidelines of the pharmacy benefit entity the patient's health insurance plan used with the formulary parameters of the patient's health insurance. At best, the pharmacists had a secondary focus, and, sometimes, even less than that, on the most appropriate and likely effective drug regimen and schedule for the patient. If pharmacists are ever going to be helpful to the patient and the patient's care provider doing the prescribing, then the structures for actual employed practice of pharmacists have to change radically. This argument for higher level training/PharmD degrees for all pharmacists has been used over and over again for over a decade while, at the same time, the number of prospective employment venues have dwindled due to the aggregation of pharmacy retail outlets into just handful of chain options through either unquestioned or mostly unregulated mergers and acquisitions, all made worse by the shady secretive pricing and distribution practices by the pharmacy benefit entities who work directly with the pharmaceutical manufacturers, the pharmacy distribution houses and, at times, directly with the health insurers in order to maximize each other's profits and maintain and grow ever larger market share, profits and overall market position power.
1
Great work, Matt! And timely. We need more researchers and clinicians like you taking care of us.
15
Do we really expect better from a nation that still has Americans walking around with no insurance or insurance they wont use because of cost?
The inequities in our society run from schooling, housing, jobs and pay, tax rates. not in my backyard issues, race, age, policing, and on and on. No surprise a medical group with little clout finds itself behind the cut and slash guys, far behind.
On a more positive note, my internist. He's worth 3 surgeons.
17
As was said before: Indiscriminate use of antibiotics in agriculture is they key contributor to the problem.
- About 80% of total antibiotics use is in agriculture, not in human medicine.
- Perfectly healthy animals are treated contiously because antiobtics allow dense animal husbandry without rampant infections, and because antibiotics enhance yield of meat (for reasons not well understood).
- Occurence of antiobtic resistance in many large farms is known, and from the animal dung the resistant bacteria gets onto fields and into drinking water.
- From their superbugs get into human - who can spread the rsistant bugs without knowing because carriers often don’t show symptoms.
- Bacteria can spread resistance between different strains.
Yes, human use should be limited to cases where this is needed, but people familiar with medical practice will know that e.g. after surgeries there is no other way than use of antiobtics to prevent deadly infections. There are also viral infections - e.g. flu in the elderly or in immune compromised patients - where antibiotics use to prevent severe complications such as pneumonia is justified (of course antibiotics don’t work against the viral infections themselves, but against bacterial super infections which are quite common).
The use of antibiotics in human is by far the lesser problem for the rise of antiobtics resistance compared with the systematic and widespread use in agriculture.
2
@LL
I think you're partially mistaken. Antibiotics used in animals for routine purposes like speeding growth or maintaining health (substituting for cleanliness) are a big problem. That is not the only major problem. Widespread misuse of antibiotics in humans is another. A third, which we can't do anything about, is that the germs will naturally evolve resistance.
4
@LL One step all of us can take is to buy meat specifically labeled as produced without antibiotics. If consumers do this overtime, the meat producers may find reduce or hopefully eliminated market for meat produced with antibiotics.
2
Sorry doc, but the pathologist at the hospital was responsible for, and reported on the pulmonary
cytology and/or biopsy. You don’t get to bill for that too. Just like with the radiologist, they get paid to sign out the imaging studies.
3
@michael sherman md Come on, man. The radiologist and pathologist provide interpretation of the limited (literal) slice that they see. They never examine the patient or review all the data. They can’t put it all together into a final diagnosis, nor do they prescribe the plan of treatment. I don’t always agree with their interpretation, either. Other clinicians and surgeons review films and path, too. Being smart, pathologist and radiologists sign off reports with “clinical correlation required”. :}
6
Homeopathy has a proven success rate in epidemics, a higher success rate than conventional medicine. If you read actual statistics, not just opinions, you will see that this is the case.
1
Antibiotics are used indiscrimitaley in mass animal husbandry, they are everywhere in the environment and are the engine that creates superbugs. We destroy well-balanced ecosystems that can contain such diseases (HIV). Then we wonder why nature threatens us with untreatable fungal, viral and bacterial diseases. Pharma research cannot identify effective mechanisms for new drugs fast enough to keep up with this exponential evolution. Nature is the real lab and we are it's guinea pigs.
5
Whereby it isn't lucrative enough for drug companies to develop new antibiotics, the governments of the west should anti-up and start the research. They should have seen this coming 20 years ago.
2
They did. Researchers were aware of bacteria mutations and potential antibiotic resistance decades ago. It’s a growing problem but not a new one.
12
@Once From Rome I understand that AMR alarms have been sounded, but I wasn't aware any governments have developed new drugs.
The doctor here seems to be complaining about the low pay and extreme difficulty of this job.
Conservatives would have this man become a hedge fund manager. Easier and pays way better. And according to Conservatives, people are paid by how society values them. These kinds of doctors, school teachers, really are not worth much today in any part of American society, based on their pay. Those jobs are not useful at all in Modern America.
10
@gratis
It is the government that sets the low pay not the conservatives.
1
@gratis Right, not at all useful unless huge amounts of people are dying from superbug infections and then ID docs will be paid like hedge fund managers.
Wait until we have Medicare for all. We’ll have a shortage of all kinds of doctors.
8
@Once From Rome
We already have a shortage. The WHO reports that the U.S. has an average of 2.2 physicians per 1,000 people. Most European countries have significantly better ratios:
Austria 5.2
Switzerland 4.2
Italy 4.0
France 3.2
Ireland 3.0
UK 2.8
Since we are the only first world country without universal healthcare, I don't see how you can draw that conclusion. The anecdotal evidence certainly suggests otherwise.
12
@Once From Rome
You got that right
2
@Once From Rome
Yes, the Conservative trope where people become doctors only for the money. Conservatives do not believe there is even one doctor in the world today who became a doctor to help people. The very idea is way beyond Conservative thought. Money over everything.
13
When enough people die, private corporations will find the solution, provided that the taxpayers fund 80% of the basic research. Of course, thousands will have to die before research is deemed profitable enough to look for a treatment. Or the cure will cost $thousands and thousands per treatment.
That is the way capitalism works. It works that way now, especially for medicine.
That is why America is great.
7
Americans are unaware that health is a global issue.
Like ecology.
They are uneducated about both questions that are now and will be even more in the future the most important problems.
10
If our society really cared about the coming infectious disease catastrophe, the practice of routinely feeding antibiotics to healthy farm animals would be stopped.
About 80% of all antibiotics used in the US is fed to healthy animals on farms. Because it makes the farmers lives easier and more profitable. This has to stop or we'll be paying an enormous price in human illness and death.
If we want more infectious disease (ID) subspecialists, then salaries for ID doctors must be raised. ID docs are not compensated as well as many other doctors and this discourages interest in that specialty.
Compensation for doctors has a lot to do with procedures. Procedures pay well. Thinking and analysis is relatively low paid work. ID docs do very few procedures; they spend more time thinking about treatment. Hence a shortage in numbers and talent. HIV/AIDS doctors are among the lowest paid specialist physicians in America!
The fact that cosmetic surgeons are so very well compensated for their work shows you that America's values are. (Not that all cosmetic surgery is unnecessary, but much of it is. Face lifts and tummy tucks, etc.)
37
@NY Times Fan
ID docs do think about treatment also, but more often about diagnosis. A lot of consultations come after the primary physician or surgeon has looked for the most likely infections, and found nothing.
1
@NY Times Fan
Who sets the doctors pay?It is the insurance companies and Medicare not the free market.
1
If measles mutates because of stupid humans pushing anti vaccination theories it is completely possible to put our entire species at risk.
1
It doesn’t pay to be an ID doc—-you will have to see the PA
Sorry
5
Why would this writer be surprised that the NYTs laments the shortage of doctors. TheNYTs has been leading the charge against doctors for decades. Anti AMA, malpractice reform, over regulation, single payer. I would go so far as to say the NYTs has singularly caused physicians to retire early and to discourage our young best and brightest from going into medicine in the first place.
3
It’s all about the money and life style.
No surprise plastic surgery is the toughest to match.
4
Well, considering that the American infectious disease doctors who went to try to contain Ebola before it killed us all were fiercely criticized when they returned to the USA, and considering that your current president was a ringleader in that criticism, one can see why you've got a shortage.
31
@Everyman
If my memory is correct he wanted these doctors to be isolated until we know that they are not infected.Makes sense?
@GDK no, it does not make sense. First, you make it sound like a carefully thought out suggestion rather than the catcalls of rabid nativists, and a quick review of his tweets and other quotes from the time make abundantly clear he had no idea what he was talking about. And pretending like his pronouncements about Ebola was part of some well-reasoned approach reveals a profound denial of the state of the President's analytical abilities.
Second, only some states isolated workers, while others observed and monitored returning volunteers--I know because I was an ID physician monitored in such a manner. The number of cases of Ebola that resulted from this lack of isolation was zero.
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@GDK just like he wants all Muslims to be banned from travel to the USA until you can "figure out what's going on". So, no, it doesn't make sense. Here's some background from this newspaper a few years ago: https://www.nytimes.com/2015/12/06/opinion/the-unfair-treatment-of-ebola-workers.html
We need to revise the way we reimburse doctors. We incentivize doctors to do more procedures. And as a result, we pay procedural-based specialties (cardiology, gastroenterology) much more than non-procedural-based specialties (ID, internal medicine).
If we re align the incentive structure and pay doctors to THINK rather than DO, then I bet a lot more people would choose infectious disease as a speciality.
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@J D
And then you won’t get your scope for GI bleeds nor stents for your coronary disease. Choose your poison.
@Driven
Drastic idea,how about paying both groups well.Tell Nancy Pelosi that the house should improve payments for non procedural specialties in Medicare.The plastic surgeons are self paid let them bargain with their patients.
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perhaps we should welcome specific skill sets as immigrants. instead, we welcome whoever randomly comes over our border.
our current policy favors those to the south, and discriminates against engineers and doctors (among others) in India, Philippines, Korea, Taiwan, and the rest of the world.
rando's rolling over, is not a policy. Its a lack of a policy.
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@Joe Yoh Have you looked around lately? While I lack statistics, I dare say there are very large numbers of engineers and doctors who immigrated here from the very countries you have cited. Secondly, in what way are immigrants from the south favored?
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@Joe Yoh
We have plenty of qualified people in the US who want to be doctors, all we lack is a sufficient number of medical school slots. Only about 40% of applicants are accepted to even one medical school each year. Given the vast wealth in this country, there is absolutely no reason we cannot provide more training slots for our interested young people.
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I share the concern. Pharmaceutic firms are reducing their research in this field. Global mobility aggravates the problem. But doctors and patients cannot solve it. A radical departure from prevalent animal husbandry and pesticide intoxicated agriculture is needed. The biomass and the number of microorganisms is staggering, their generations succeed in minutes, their evolution and transfer of resistence traits are fast and planetary. Resistant bugs are found in the remotest areas. We humans are no more part of evolution thanks to civilisation and technology. Bacterial / fungal evolution has taken the fast lane and meets our defense system at the microscopic level. There is no escape, we are part of the global ecosystem. We produce the diseases that may eventually wipe us out. We all know what to do . . .
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Quite a detailed, and heart rendering story from the Doctor! Some Doctor's today, can spin a tale, even better than many of our great novelists!!!
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@Counter Measures
"Tale"? "novelists"?
Translation: The article is fiction.
Subtle way to question the premise.
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Added to all the problems inherent with this specialty is that many physicians don't know they need a ID consult, or feel that they can manage without one. When they concede that they could use an opinion, often they just want a free "curbside consult" over the phone; which also pays zero. You see hardly any ID specialists in private practice anymore for this, and all the other reasons you mention. Most ID docs are now employed by hospitals and where they have become semi-administrative in practice, dealing with hospital infection control.
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