Increasing Subspecialization in the Field of Infectious Diseases: Evaluating Challenges and Strategies to Move Forward

This is the authors' abstract. We don't add key points for this paper.

In the preceding article, Moore et al detailed the internal medicine National Residency Matching Program match trends and workforce challenges. The declining interest in infectious diseases (ID) subspecialization has left many in the field concerned for the sustainability of the discipline and its ability to meet the service needs of the public. Despite these trends, the opportunities in ID are broader than they have ever been. New epidemics continue to occur, placing ID issues on the world stage. The United Nations recently held a high-level meeting to address the crisis of antimicrobial resistance. Human immunodeficiency (HIV) infection, tuberculosis, and hepatitis C continue to affect millions of people around the globe. It is important that we as ID subspecialists learn how best to share the many exciting aspects of our field with trainees to foster the next generation of ID physicians. In this article, we will explore the challenges to and potential strategies for increasing interest in ID careers. Prior to developing strategies to increase interest in ID, we felt it essential to first understand the factors that influence subspecialty choice and, specifically, interest in ID. To do this, we conducted a national mixed-methods cross-sectional study of graduating internal medicine residents [1]. Of the 590 participants, 42 (7%) applied or intended to apply to an ID fellowship program, 188 (32%) self-identified as having interest in ID but ultimately chose another career field, and 360 (61%) were never interested in ID. The top career field chosen among residents who were interested but chose another field, interestingly, was not a high-remuneration field but rather general internal medicine (26%), followed by hospital medicine (16%), suggesting that multiple factors aside from salary influence career-related decisions. We also noted that 65% of all participants and 72% of those who selected ID as a career became interested in their chosen field before or during medical school, which expands our intervention points beyond residency, where most of the focus had previously been directed. Specifically looking at the undergraduate medical education (UME) experience, we found that only 14% of residents experienced case-based pedagogy and that 70% of learners relied on memorization, rather than more-effective techniques, when learning ID and microbiology. Interestingly, those who experienced nonmemorization and case-based learning had an increased likelihood of selecting a career in ID (relative risk ratio, 3.7–3.89) [1], suggesting that pedagogy may influence interest in the field. In addition, residents who chose ID as a career were more likely to rate their ID knowledge at the end of medical school as good or very good, compared with only 45% of those who never considered a career in ID. By examining these 2 findings, one could theorize that using more-effective pedagogy leads to improved learning outcomes and thus increased self-efficacy in the field [2]. The theory of self-efficacy posits that learners who, on the basis of objective measures, believe they are capable are more likely to consider further engagement in that career field. Self-efficacy not only arises through objective measures such as performance, but also through acquiring information from other sources, such as observation of others and forms of persuasion (verbal or other) [2], which include mentor relationships and exposure to the broad field of ID. In fact, we found that residents overwhelmingly noted that mentorship positively influenced their career choice and that <25% of those who were interested in ID but chose another field had identified an ID mentor, which could represent a missed opportunity. When asked to identify the most important intervention for increasing interest in ID, participants most commonly selected improved ID salary. However, only 45% of those who were interested in ID but chose another field would have selected ID if the salaries were equal. Further, when asked how likely an increased salary would increase residents’ interest in ID, 97% chose “neutral to unlikely,” suggesting that the decision about whether to pursue a career in ID involves a multifactorial process [3]. In our study, we identified a number of factors that contribute to career decisions among internal medicine residents, which we can break down into the following themes: effective pedagogy, exposure, mentorship and role-modeling, and financial support. Learners weigh information pertaining to these themes, gleaned from experiences, through an iterative process between the unconscious and conscious. With this information, learners develop a sense of self and understanding of the field, which together then enable the learner to ultimately commit to a specific career [1, 4]. Experiences in premedical studies, UME, and graduate medical education (GME) all contribute to this final decision. Because the strategic focus has broadened, given our understanding of when learners become interested in their ultimate career choice, we must entertain strategies that target not only internal medicine residents, but also medical students and premedical learners. Thus, we will present strategies broken down by the themes identified in our previous study [1], which can be applied to each stage of learner. Effective pedagogy leads to improved knowledge retention and assessment outcomes, which signal positive feedback to the learner, thereby increasing their self-efficacy or belief they can succeed in the field [2]. This self-efficacy drives further motivation and advancement in the field [5]. Unfortunately, most of the microbiology teaching experienced by medical students is delivered passively, such as in lecture format, which we know to be much less effective than active-learning pedagogical methods, such as case-based discussion or flipped classrooms [6–10]. Although many educators are moving toward these active-learning methods, it may not be possible to transform all educational sessions into case-based or flipped sessions. Still, instructors can make simple changes to the organization and presentation of their didactics to improve learner outcomes (Table 1) [6, 11, 12]. However, a number of barriers exist that prevent microbiology course directors and faculty from transforming their curricula and pedagogy, including those involving learner buy-in, technology resources, time availability, and faculty development. To address these challenges, Dr Brian Schwartz created a medical education working group within the Infectious Diseases Society of America (IDSA), which is tasked with providing faculty guidance and support to advance education in microbiology and ID curricula in UME and GME programs; the working group’s efforts are described further elsewhere in this supplement. Strategies to Increase Interest in and Reduce Barriers to a Career in Infectious Diseases (ID) Abbreviations: HIVMA, HIV Medicine Association; IDSA, Infectious Diseases Society of America. Strategies to Increase Interest in and Reduce Barriers to a Career in Infectious Diseases (ID) Abbreviations: HIVMA, HIV Medicine Association; IDSA, Infectious Diseases Society of America. For UME learners in the clinical period of their education and for those in GME programs, the opportunities for formal teaching are more limited. Nevertheless, the same principles apply. Teaching activities while rounding on the ID consultation services can include active-teaching methods, as well as short formal didactics. In these settings, there are often learners at several different levels that make effective teaching more challenging. Preparing teaching points for common diagnoses can be helpful, with clinical pearls of increasing sophistication included for learners at different levels. Some physicians have preloaded images from radiology or pathology services on ever-present smartphones or tablets that can be used for quizzes or discussions to help illustrate points. Bedside teaching provides an opportunity to reinforce details of the ID history and physical examination and to allow direct observation. House staff morning report and noon conferences also provide additional venues for interactive teaching with medical students and residents. As we address below, these formats also offer critical opportunities to expose learners to the breadth of ID and serve as role-modeling experiences. Although various opportunities exist to influence learners, many ID physicians feel that there are increasing barriers to teaching within academic medical centers. These include limited protected time for faculty to develop their knowledge of newer teaching methods and for attendance at conferences, such as morning reports. Increasing ward team and consult volume has led to rounds that proportionately focus more on throughput than teaching, and teams are more often fragmented, altering the teaching environment. Recognizing these challenges, many training programs are working to restructure the clinical experiences to further emphasize educational goals. Nevertheless, changes in the structure of the teaching programs also lead to less exposure to the ID subspecialty. Only a minority of programs require that residents complete an ID consultation rotation. In addition, with the growth of hospital medicine, subspecialty attending physicians, including ID physicians, less frequently attend on the inpatient general internal medicine service, leading to fewer opportunities for interaction with residents. In this environment, ID physicians must be proactive about securing teaching opportunities and maximize the impact of those experiences. With planning and training, effective ID teaching can readily occur despite these barriers. When residents were asked to specify the areas of ID that appealed to them, the responses were broad, although HIV medicine, global health, and general ID were mentioned most frequently [1]. Anecdotally, however, trainees often are surprised at the vast array of career options within the field of ID. One might argue that this is predictable because the majority of exposure to ID occurs in the inpatient setting, which provides the learner with first-hand experience of only a subset of potential career pathways. Considering that the top career choice for residents who were interested in but did not choose ID was primary care, this could be a missed opportunity. Studies of decision making indicate that experience and information are critical factors that contribute to the final outcome [4]. Applied to subspecialty choice, actual exposure to a career or information from reliable sources is needed. In the case of ID, it is challenging to expose trainees to the opportunities in public health, advocacy, the pharmaceutical industry, antibiotic stewardship beyond the lens of the “antibiotic police,” outpatient HIV care, and other areas aspects of the subspecialty. Many opportunities exist to increase medical student and resident exposure to the subspecialty of ID (Table 1). In formal settings like those described in the preceding section, the roles played by ID physicians in the clinical environment are numerous. For example, case discussions about patients infected with HIV can include mention of public health roles at the Centers for Disease Control and Prevention, in state or county health departments, or in global health; discussions about patients infected with resistant organisms should include conversations about stewardship and strategies to control antibiotic use or the spread of resistant pathogens; and discussions about diagnostic tests and interpretation their results can highlight the roles for ID physicians in the microbiology laboratory and options for combined training in ID/medical microbiology. Participation in teaching in the UME curriculum provides an opportunity to discuss the opportunities for the ID physician and can lay the foundation for long-term relationships and mentoring as students move into the clinical years. To increase exposure outside the classroom or workplace, many institutions have developed ID interest groups for medical students (IDIGs), which can serve as a mechanism to expand the learners’ understanding of the field, build mentoring relationships, and create a community of practice among learners. Recognizing the potential power of these groups, the IDSA offers a stipend to support new or existing IDIG events that can be expanded to include residents. To date, 55 IDIGs have been supported. A variety of formats that will enhance exposure to an array of ID physicians in different roles and thus exposure to different career options can be used in the IDIGs, including panel discussions, ID jeopardy, case presentations, movie screenings, book clubs, “speed dating” sessions, and workshops. IDIGs also provide an ideal forum to discuss current outbreaks, advocacy opportunities, and other topical efforts (such as those drawn from media headlines) that demonstrate the critical role that ID physicians can play in patient care, public health, policy, and discovery. National meetings offer some of the best opportunities to expose trainees to the breadth and depth of the field. Meeting organizers should be aware of this role and tailor meetings to be trainee friendly. This may include offering substantially reduced or free trainee registration, expanding trainee travel scholarships (even for those not presenting abstracts), developing trainee educational tracks, and organizing opportunities for trainees to interact with one another and meet good ambassadors for the field (fellows, luminaries, and individuals from different career pathways, as well as those of different sexes and racial, ethnic, and other backgrounds). These options should be widely advertised to residency program directors and medical schools. As a result of these efforts, the number of trainee attendees reached a record high in 2017, with >1300 such individuals, composing nearly 20% of the total meeting attendance. Although these initiatives have been adopted by the organizers of IDWeek, they should apply to other ID-focused meetings, annual meetings of the Society for Healthcare Epidemiology of America and the American Society of Tropical Medicine and Hygiene, and the Conference on Retroviruses and Opportunistic Infections, to broadly capture trainee interest. Mentorship serves 2 main functions—it increases the likelihood of career success, and it provides psychosocial support—both of which lead to improved learner outcomes, compared with outcomes for those who are not mentored [13]. As is clear in this definition, mentorship not only applies to the oversight of scholarly projects, but also includes the critical role mentors can play in enhancing clinical skills and providing career advice to trainees. Influential mentorship has been repeatedly identified as important in choosing a subspecialty. For example, in one study of surgical residency graduates, 75% of respondents indicated that an mentor was important or very important in career choice, and 72% the same field of subspecialization as their mentor were found among where their training as the of were very to their most have been noted among medical To foster mentorship and increase learner engagement in the IDSA formal the IDSA the HIV Medicine and the Mentorship Program (Table 1). 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The majority of mentorship relationships are not developed through formal programs but rather from We ID faculty to identify as potential mentors to their UME and GME in career and attend resident and other information should be included in formal and students should be to with potential mentors if they are interested in learning more about the field. 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