I may just be biased but the coolest medical specialty out there by far is infectious disease (ID). It has been a while since I sung its praises on my path to being an infectious disease specialist here, here and here so this is a very overdue blog post.
Everybody in medicine knows that the infectious disease doctor is the smartest cat around. Everybody acknowledges that the field is indeed très cool. But the two prominent “buts”are (1) …but there are no procedures to do, and (2) …but it doesn’t pay well. What can I say? If we did procedures or interventions we would essentially be Dr. Gregory House, that is without the attitude or substance abuse hopefully. If the specialty “paid well” who would want to be a gastroenterologist to do all those recommended colonoscopies? But more on that later.
How cool is it to be an infectious disease (ID) specialist?
Very cool! In short, we are the experts in the diagnosis and treatment of all kinds of infectious diseases. We understand and respect the remarkable inventiveness of the microbes we share our world with. We are experts of when and how to use antimicrobial agents. We are experts in the interpretation of a myriad of blood tests other physicians order but don’t know what to do with the results. We understand best how the human body naturally tries to fight infection and how infections spread. Thus we are one of the go-to people to stop the spread of an infection in a community.
We are medical detectives who work meticulously hard though usually behind the scenes. Don’t expect any hospital to proudly display their infectious disease doctors on large banners along highways like they do their orthopaedic surgeons or neurosurgeons. Don’t expect either to see a full-page advertisement of us in your airline magazine the next time you fly.
We are detail oriented people, master diagnosticians in other words, for whom every case is a puzzle to be solved. The patient is not just the person lying in the bed in front of us at the current moment but also that person projected into the future, their hospital room-mate, their family at home, their colleagues at work, and their community at large. As such, ID specialists are probably more in tune with what’s going on in the world and have a good grasp of history, current events, and politics as compared to other physicians. At least, they would have to be to be very good ID specialists.
ID specialists are consulted (invited to take part in the care of a patient) by other physicians for three main reasons
- to figure out what ails a patient
- to recommend an antimicrobial choice and duration for an infection already diagnosed
- to interpret the result of an unusual laboratory test
Sometimes, physicians just want to curbside us. That means they just want to give us a phone call or stop us in the hallway to ask a quick question. They think their question is so straightforward that they don’t want to give us the courtesy of us seeing their patient so that we too can attempt to make a living. Sometimes, they are embarrassed and they don’t want us to think we are being given “a silly consultation”.
Yet, often times these “simple cases” aren’t. Often there is a twist that reveals itself only after we have gone through the data re-evaluating and analysing it. This is why some physicians, surgeons in particular, hesitate to call us to help them out with their patients. They feel that they know their antibiotics and that we are just going to come by and complicate matters. But I disagree. The patient is often already complicated; it’s just that the seriousness of their condition has not yet been realised.
As is commonly said in medicine diseases and illnesses don’t always read the medical textbooks. That is to say they don’t always present classically. Therefore a piece of history never elicited or elicited but not thought relevant might be the one clue that is missing to figure out what ails a patient. The infectious disease specialist is trained to not just blindly accept the referring physician’s diagnosis as the correct or only diagnosis. We must always question it. If after our own analysis we arrive at the same diagnosis, great. We will move forward from there.
Not everybody needs an ID specialist and not every infection needs our expertise. But in our current capitalist business-like model of healthcare provision and the current state of patient entitlement, our expertise is requested even when not necessary. As one of my colleagues says though, “all these silly consultations pay my child’s college tuition”. I think the worse tragedy though is the presentation of patients who do need our attention but who do not come our way till very late or never at all.
Every week I see cool things. It could be a bacteria I’ve never seen or heard of before, or a bacteria I see all the time doing something brand new. It could be a classic textbook presentation as if in fact the patient is acting out a script. Sometimes, it’s not even an infectious disease diagnosis. It could be a malignancy or an autoimmune process that I diagnose and then set the patient in the direction of the right specialist.
Everyday, I am given the opportunity to reference a medical journal and learn something new. Everyday, I get to interact with other infectious disease specialists and draw upon their experiences because sometimes I don’t know what the patient has. Sometimes, nobody really knows and I am humbled by how little we know despite how far medical advancements have come.
It is frustrating though at times being an infectious disease physician. Many people do not know who we are and what we do. Sometimes, when I approach the bedside of a hospitalised patient introducing myself as the “infectious disease specialist”, I invariably get asked “I have an infection?” while they lie there with pus oozing out their great toe or I’m defensively told “I don’t need the CDC, I’m not contagious”. Sometimes, the patient is irate and doesn’t want to entertain yet another doctor who has a myriad of questions, worse a doctor who “doesn’t even do anything”.
Another frustration is that the healthcare system does not know or does not appreciate what we do. If it did, it wouldn’t pressure us for volume of cases as it does other physicians. Volume not value of care is what physicians are reimbursed for these days. The deep thinking and analytical skills of an infectious disease specialist are worthless to those who control the purse strings! The problem with being an infectious disease physician in the United States now is the expectation for us too to be part of the assembly chain cranking out patients at record speed. What does it say if even the infectious disease physician is forced to be motivated by reimbursement and productivity expectations to meet, interview, examine, and analyse a patient and their studies in fifteen minutes flat or less. When did Sherlock Holmes or Poirot ever rush through a case and successfully solve it?
Right now, the provision of healthcare is moving towards a guideline-based model. But just as textbook patients are rare so are patients who neatly fall into the purview of a checklist or algorithm. Adhering to a guideline in this case, and thus being compliant with regulations, can hamper the care a patient receives especially when you consider the role of an infectious disease physician which often requires thinking outside the box.
A third frustration, especially for me, is not being able to come up with a diagnosis that fits neatly. Society in 2015 has come to believe that everything has an explanation. Worse yet is society’s expectation that everything should be curable and everything should end well. We doctors know that is not true. We know the limits of our current body of knowledge. We understand the limitations of our current laboratory tests and imaging modalities. We believe in the scientific method knowing that what may be true today may be proven false tomorrow. So sometimes a diagnosis is hard to come by. A diagnosis that I can find a code for so I can attempt to be reimbursed for my work.
Personally, I do think we have a vast fund of knowledge especially of the major things that can kill us or cause serious morbidity even if we may not have the cure. But I think we only know the tip of the iceberg. There are many piddling illnesses, chronic illnesses that are not fatal but that make life miserable, that we do not have a diagnosis for let alone a fix. That’s tough for many patients to hear, especially when the words come out of the mouths of doctors who “did nothing but just talk and look at labs”.
Sometimes all that a patient needs is “a tincture of time”. Not another test. Not another pill. Not another scan or MRI. Not an operation. Just time. And maybe some kindness and empathy to boot. We in infectious disease have a lot of that to offer.
That said, no-one should need convincing that infectious disease is in fact the coolest medical specialty. If even the microbes themselves are not fascinating and intellectually stimulating the stories of how they come to make us ill certainly are. Furthermore, my colleagues are among the most humble, caring, and hard-working physicians out there. I consider myself blessed still to be an infectious disease specialist.
Unfortunately, it is increasingly making less sense economically to become an infectious disease specialist. I fear that the consequences of that will not be realised until too late. This past internal medicine sub-specialty match day, more infectious disease programs went unfilled than were actually filled. That’s awful. You would think with all the infections in the news – measles, Ebola, antibiotic resistance – that we in this field would be having a hey-day. Instead our flame is flickering out when it comes to capturing the interest of the younger ones.
I remember when I was an intern, not too long ago, interested in pursuing a career in infectious disease. I kept being asked, “why would you spend more years in training to earn less and work more than you would if you just ended here and become an internist or hospitalist?” For me, I found the field interesting, fascinating even to sacrifice more years of training for less lifetime income. My own debt burden did influence how my career in infectious disease would unfold, seeing how now I’m employed by a private practice, thus I cannot find fault in those behind me with likely more debt at likely higher interest rates who are choosing, wisely from a purely economic standpoint, to avoid what looks like an unsustainable situation. Being a hospitalist these days which requires no additional years of resident training, provides an income solidly many thousands of dollars greater, and a flexible work schedule is very attractive. It is not unusual to find many recently trained infectious disease specialists working as hospitalists.
I wonder how bad it’s going to get before IDSA, the professional organization of infectious disease specialists, speaks out on behalf of our survival. Things need to change.
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