Why No one Wants to Match into Infectious Diseases

An East Coast Academic Infectious Disease doctor & Professor tells the truth no one will say

Today’s stack is long, but WORTH YOUR TIME. An expert ID doc on the east coast, a professor, diagnoses why no one wants to go into ID. Sure, money is a factor, but so is a whole lot more. This article is 100% accurate and biting. Pls read it to the end.

TL:DR

ID docs are poorly paid - more training for less pay is illogical

ID docs pushed pointless, unproven restrictions and refused to return to normal, they tied themselves to public health zealots and average Americans disagree

ID docs love Fauci, but fail to provide an accurate and balanced view of him. He did lie. He made many errors, and kept schools closed. Treating him like a saint is wrong.

Antibiotic stewardship is a buzzkill and hard to know if it helps reduce multidrug resistant bacteria.

ID docs are too woke, and that turns people off

ID docs can’t tolerate people who disagree

ID docs set conference policy that was illogical, contradictory and anti-science.

Vinay Prasad, MD MPH

Why No one Wants to Match into Infectious Diseases

—anonymous ID professor

The 2023 Match concluded in late November 2022. Infectious Diseases as a field rarely has a strong showing in the Match, but given everything that has been happened, the results were particularly disappointing. Let's explore potential reasons for poor Match results and lack of interest in infectious diseases. I focus on reasons which have not yet entered the debate.

No one wants to go into ID

Let me summarize the ID Match results, detailed here in this STAT article. A total of 330 physicians applied for the 2023 ID Match, down from 387 the year before and 404 the year before that. In the 2023 Match, among all fellowship programs, 44% were unfilled. Even programs with a strong track record of ID success, such as the University of Washington and Emory University, did not fully match. Overall, 25% of all fellowship positions were unfilled nationally. The STAT piece contains interviews with several leaders in ID education across the country. However, the analysis, in my view, is incomplete and lacking.

ID docs are poorly paid

We should begin by stating the obvious: If ID practitioners earned $400,000 per year, we would not be having any problems recruiting to our field or engaging in any of this discussion about lack of interest in ID. The first and foremost problem, before any other hand wringing or overanalysis occurs, is too much work for comparatively less pay. Of course physicians are overall making a great salary and are in the upper echelon of wage earners in America. But relative to other physicians who have had the same education and time investment in their training, ID physicians are earning less.

Who in their right mind wants to go into a field where you do additional years of fellowship training only to earn as much as or less than someone doing Hospital Medicine? It literally defies basic logic and basic economics. When I tell my non-medical friends about ID as a field, they are astonished we even have as many people as we do. Let's not pretend for even one minute that gastroenterology as a field is more intellectually engaging than ID. I am stating the obvious, but to say it as explicitly as possible, if gastroenterologists were not making the salary they make, their field would not be nearly as competitive as it is now.

And as an aside for my ID colleagues who say physicians should do ID "because they love it, and not for the money," I suspect these are the same people who grew up in an era where college didn't cost up to $70,000/year at some institutions and people did not routinely leave medical school with up to $400,000 in debt. So if anyone sincerely believes that ID will attract more applicants by showing people more about how "cool" it is as a field, I fear they will be sorely disappointed.

So, with that clearly stated, although compensation and lifestyle are the primary drivers of specialty choice for trainees, let's now turn to explore other potential reasons why young physicians might not choose ID as a future career. I present 6 possible contributing reasons below. Many of them might be uncomfortable for my ID colleagues, but this discomfort should not be a reason not to talk about or consider them as possibilities (which itself is one of the points).

1. Infectious Diseases is inextricably linked to public health. This might not be a net benefit. There has always existed a close relationship between the field of ID and public health. It has never been brought into sharper focus in recent memory than during the COVID-19 pandemic. If ID leaders believe that tightly associating ourselves with public health and governmental research agencies without appropriate and reasonable criticism of their failings and shortcomings is a path to success, they have no clue how that might be perceived by others not in our field, let alone outside of the medical world.

Much of the criticism the CDC received in 2021 and 2022 from the ID world was that they were not doing enough to stop the pandemic -- that there should have been more restrictions in place. This is totally at odds with the broader public, which moved on from the pandemic long before the ID establishment did. If you believe this just shows that we are smarter than everyone else, you are welcome to hold that view. If your goal is to attract people to our field, a different analysis might be required. In addition, the ID community's lack of strong criticism of the closing of public schools for as long as they were in the United States is a sad and pathetic failure. ID practitioners pride ourselves in fighting for the little guy, the underdog, the downtrodden, and the forgotten.

Did we do that for kids during the pandemic, or did we simply oppose Trump because he was on the other team? ID docs are usually big fans of European countries on most social issues -- why not on how they handled schools? (And before anyone claims, "Well, my kids seemed fine even with the closures" or "I don't know anyone's kids who were affected", please know that you are not routinely in contact with kids in situations who likely suffered significantly because their public school was closed, so you have a huge confirmation bias in terms of your personal interactions.)

A strong piece of evidence of the absolute lack of trust in public health at the moment is uptake of the COVID-19 vaccine among kids. As of November 30, 2022, only 10% of children under the age of 5 have received even a single dose of the COVID-19 vaccine. What that means is that 90% of parents are not following the CDC's recommendations on this topic. This 90% includes a huge number of Democrats and independents (if one's argument was going to be that these parents are all right-wing conspiracy theorists). The vast majority of criticism of the CDC's COVID-19 vaccine and booster recommendations is coming from outside the ID community. Is it really the case that all of America is crazy and only infectious disease practitioners know what is correct?

Another piece of evidence that linking ourselves to public health probably doesn't matter is that some ID fellowship programs which were recently chosen to have combination ID fellowship and CDC Epidemic Intelligence Service training did not fully match. So the potential "carrot" of having a guaranteed spot at the CDC after ID fellowship training was not enough to entice more people to apply to ID.

The final example is an anecdote (and not data), but it is instructive. I recently attended a holiday party hosted by my spouse's employer (my spouse is not in medicine). Within 10 minutes of having walked in, someone asked me, "So, as an infectious disease doctor, is it just making you crazy to see so many people packed into this room without masks?" I was not offended by the question; I found it amusing. I simply responded, "Well, like most of America over the last 12 months or more, my family has decided to just get back to normal life. Everyone has more or less come to that conclusion at some point, including almost everyone in medicine." But what the exchange showed me is that the reputation of ID for many in the general public might be one of excessive restrictions and not necessarily one of compassionate and selfless care, which is the mental model we have for ourselves.

The point of all this is that by inextricably linking ourselves to public health, we may be harming our reputation, not helping it.

2. The Infectious Diseases world has decided to embrace and venerate Dr. Fauci rather than provide a balanced critique of his performance during the pandemic. At the recent 2022 Infectious Diseases Society of America (IDSA) conference in October, it was announced that a new award would be created starting in 2023 to honor Dr. Fauci. The purpose of the Anthony Fauci Award is in part to honor an IDSA member who has shown "courage in leadership in speaking scientific truth".

As has been detailed by Dr. Vinay Prasad and many others, Dr. Fauci changed his guidance on universal masking in public within a matter of 6 weeks at the beginning of the pandemic when not a single shred of new scientific evidence on this topic had been published in the interim. He either lied the first time or the second time. My own view of the matter is that he said then, and continues to say now, that which he believes is the politically expedient, somewhat left of center position, which he will change in subtle ways based on his reading of the public's mood.

The best example of this is schools. School closures, which disproportionately harmed minority and underprivileged children, was a terrible policy decision, and one that was advocated for by Dr. Fauci. Now he is slowly trying to back away from it and not claim responsibility for his advocacy of certain policies. He certainly has a right to say whatever he wants, but let us not for an instant believe that he has always been speaking scientific truth at every instance. That is simply a farce. Yes, Dr. Fauci did a lot to help combat the HIV/AIDS epidemic, and I support those efforts. But that history of good work does not absolve some serious errors in judgment and communication that occurred during the COVID pandemic.

The other fairly obvious conflict of interest is that as the head of the National Institute for Allergy and Infectious Disease, Dr. Fauci controlled the funding stream of academic ID physicians across the country. It is in the self-interest of all ID academicians to cozy up to him and not provide fair criticism of his policy proposals. It is not hard for medical students, residents, ID fellows, and the general public to see this obviously ludicrous conflict of interest.

3. Antimicrobial stewardship and infection control are not the educational winners ID practitioners believe they are. Many ID educators are in the antimicrobial stewardship and infection control spaces. These topics naturally lend themselves to education since they involve a lot of practical knowledge which trainees, faculty, nursing staff, and others need on a daily basis. For this reason, after the Match results were announced, many ID physicians bemoaned the fact that "everyone needs ID" but "no one wants to be us". That is true, but perhaps not for the reasons they might think.

ID perceives itself as helping the hospital, teaching practitioners, and saving lives through antimicrobial stewardship and infection control. However, have we ever surveyed trainees and other faculty about their actual perception of ID in these spaces? I hear all the time through indirect means that antibiotic pagers are mostly a pain for busy residents and faculty. When they do call, the person they get on the other line might often make them feel like an idiot. ID practitioners love joking about how silly it is to add on Flagyl to cover anaerobes when someone is on meropenem, but they have not for a second considered that many people might politely smile, nod their head, and move on from what they perceive as a mere nuisance when informed of this antibiotic coverage point. ID needs to shed the reputation of being the scolding schoolteacher of the hospital.

Let us also not forget that it was many infection control programs at hospitals that instituted draconian visitation policies during the pandemic. At the very beginning of the pandemic, perhaps this was understandable, but certainly by 2021, these policies were largely not needed. And even if they were needed to decrease nosocomial transmission of COVID-19 (a dubious proposition), shouldn't this concern have been balanced against the need for patients to see their loved ones in the hospital? Many trainees have not forgotten this experience in the pandemic, which created substantial moral injury for some, and the responsibility for which is, correctly or incorrectly, is attributed to infection control programs in hospitals.

Sure, trainees usually think ID physicians are smart. But the relevant question, which we haven't asked, is whether they want to be like us. And if the answer to that question is no, the next important question is, Why not?

4. ID physicians' embrace of a far-left political identity is not necessarily helpful for recruiting people to our field. An article published in The New York Times in 2016 showed that infectious disease doctors as a group are more aligned with the Democratic Party than any other type of physician. Although the article is several years old now, I suspect the results of the survey are probably still accurate for the most part. ID physicians often wear this identity as a badge of honor. Obviously, we must be smarter and more informed than everyone else. But have we considered for a moment that being so openly left-wing and partisan might not attract a broad range of trainees to our field? Would a somewhat right-of-center internal medicine resident from Tennessee feel welcome in our specialty? The answer to that question is a resounding no. If your response to this is, "Well, we don't want Republicans as ID physicians anyway," then you are doing nothing to promote widespread interest in ID as a field. Don't forget that ~75,000,000 people voted for Donald Trump. Some of them might have even been in medicine! The point is that, although you are welcome to have whatever views you have, wearing your political leanings on your sleeve so openly might not attract as many people to our field as you think it does. You simply don't know if it's a net benefit or a net harm to our specialty's reputation.

(By the way, in case you're wondering, I voted for Bernie Sanders in the Democratic Party primary in 2016 and for Joe Biden in the 2020 election. I endorse the following policy proposals: universal basic income, universally funded pre-K for all kids, universally funded community college or trade school, a marginal tax rate of 50% for the highest-income earners, strict regulation of investment banking and trading, protection of same-sex marriage, Roe v. Wade standards for abortion care, expansive maternal and paternal paid leave policies, and student loan debt forgiveness.)

But I have enough self-awareness to know that not everyone agrees with me, and if my goal is to attract people to my field, perhaps my approach shouldn't be to shove my views in everyone else's face all the time.

This article about faculty gender disparities was recently published in Open Forum Infectious Diseases, an IDSA journal. ID is already known to be the most left-leaning specialty in medicine, as described above. Is ID the field that really needs a publication about this topic now in 2022? If we are really interested in moving the field forward, a broad survey of all ID practitioners, including men and women, and dialogue among parties with differing viewpoints about the right way forward would be more useful. Otherwise, all this article achieves is a feel-good moment for everyone who already agrees that people should be treated equitably and fairly. I know of exactly 0 ID Division Directors around the country who are not trying to recruit and promote women faculty as quickly as possible. (And for all those who say that this is an anecdotal claim not backed by data, the same could be said for a study of 3 focus groups in a field of thousands of people.)

Perhaps the article might have the opposite effect of discouraging men from applying to ID. If the rebuttal to that is, "Well, Cardiology is doing the same thing" or "Who needs men anyway?", I guess that is okay (and one is not prevented from holding that viewpoint), but it's not a useful solution for a field where we can't even fill all the open positions. We are not in a situation where people are desperately trying to enter our field as the starting point, as with Cardiology.

5. For all of its reputation as one of the most deliberative specialties, the field of ID does not tolerate viewpoint diversity well. At the recent IDSA conference in October 2022, the opening plenary session involved a conversation between many people, including Professor Emily Oster of Brown University and David Leonhart, a New York Times journalist. I was in the audience. The conversation was polite and respectful. There was an exchange of ideas. Yet, before the opening plenary, many people I know told me that they would be missing the opening plenary session because the choice of speakers was "too controversial" and there were "COVID minimizers" who were being platformed. One prominent ID Twitter activist posted this. Of course people are welcome to skip any session they don't wish to attend, but what kind of message does it send to trainees that we are unable to tolerate the opinions of those who might slightly disagree with us on life-changing policies?

Another example of this is the open letter submitted to the American Public Health Association protesting the invitation of Dr. Leana Wen to speak at their conference. I don't necessarily agree 100% with everything Dr. Wen says or does, but I would not sign a letter prohibiting her from speaking at a conference. This is a sad reflection of public health, and because of the ID community's links to public health, it ends up being a sad reflection on us. The details of this story can be found here.

The current director of the CDC, Dr. Rochelle Walensky, was a signatory of the John Snow Memorandum. Many of the authors and signatories of this document were not in favor of robust debate regarding how to handle the pandemic. I did not explicitly support either the Great Barrington Declaration or the John Snow Memo. But shouldn't the most deliberative specialty in medicine be interested in debate and deliberation?

All of this does not go unnoticed by medical students and residents. They understand how COVID policies impacted their lives, their families' lives, and their patients' lives. We should not assume they supported us all along simply because they didn't speak out against it. Trainees are in a vulnerable position, and we should not assume their silence corresponds to agreement.

6. The recent IDSA conference was a demonstration in anti-scientific thought and practice by the leading national infectious disease organization. First, attending the meeting required proof of vaccination. Does anybody really believe that in October of 2022, vaccination status has anything to do with the ability to contract and/or spread SARS-CoV-2? Certainly infectious disease physicians should be among the leading people who understand this. Given this reality, what exactly was the purpose of the vaccine mandate at the recent conference? Was it to virtue signal that we are on the "right side"? Was it to increase vaccine uptake rates, which are already likely to be very high among ID practitioners? Was the IDSA "following the science" on this topic?

The conference also had a masking requirement. However, masks could be removed during any of the following activities: eating, drinking coffee at any time, meeting up at the bar in the evenings, and basically any other time you wanted. So what exactly was the purpose of this requirement? My best guess, not being on the inside of the planning, is virtue signalling. I very much like and respect Dr. Paul Sax. He is a great ID clinician and a brilliant writer. Yet this piece was a tortured attempt at reconciling the utter lack of utility of the mask policy. I highly doubt ID physicians are confused and nervous. At the bars in the evenings gleefully drinking and spending time together, not many appeared to be showing any signs of PTSD about being together without masks.

For the record, I fully support ID docs being able to get together and spend time with one another to bond when we haven't been able to in the last few years. But let's not pretend that this is at all intellectually or cognitively consistent with a daytime, inconsistently enforced mask policy. And let's also not pretend the reason for it is collective PTSD. The more likely reason is virtue signalling.

Does this recent conference have anything directly to do with the Match results? No, it of course didn't directly impact how the Match played out. But trainees are not stupid. Even a rationally thinking second-year medical student can figure out these policies don't make any sense. How can the specialty which prides itself on being intellectually rational attract people to our field if we are making such basic irrational choices with the claim that they represent "science"?

In summary, the recent Match results were disappointing for the field of infectious diseases. I am saddened by that. The most obvious reason is imbalance between salary compensation and the amount of work being done and training required. If this fundamental problem were fixed, ID would not be struggling regardless of other factors -- plain and simple.

But since such a change is unlikely to occur in the near term, we would do well to pause and engage in some more self-reflection about ways in which we could be doing better to attract a wide array of bright, dedicated, and engaged people into our field. That starts with a return to the bedrock principles of infectious diseases which we have always proudly espoused: data-driven, rational thinking; encouragement of vigorous and thoughtful scientific debate; inclusion of different types of people and different viewpoints; and promotion of public health through harm reduction, compassion, and love rather than unnecessary rules, mandates, and proclamations.

Why Anonymous?

Let me address the obvious question as to why I am writing this piece anonymously. I am an ID faculty member at an academic center on the East coast but am somewhat early career and cannot risk the personal and professional backlash that might ensue if people knew I harbor these views. That itself is an indictment of the current state of affairs with regard to open and honest debate and lack of viewpoint diversity in academic medicine generally and ID specifically. If one wishes to criticize me for lacking courage, I accept that criticism. But it is more important to me to have a job in order to help take care of my family than it is to have these views specifically attributed to me.