By Thomas File, Jr., MD, FIDSA
Over recent weeks, United States Department of Health and Services officials have emphasized two points that should guide public health responses, as numbers of patients and countries affected by the novel coronavirus – 2019-nCoV – continues to climb: That the risk posed by the outbreak to the American public remains low, but also that we still have much to learn about this virus and its spread.
One fact, gained from outbreaks across the last century and into this one, that we have already learned is that the need for ready and trained infectious diseases health care professionals will be great.
In fact, with 26 states monitoring persons under investigation for the new coronavirus, and five state health departments monitoring contacts of people already confirmed to be infected, the need for readily available expertise in infectious diseases already has never been more critical.
As we learn more, the novel coronavirus outbreak will continue to underscore needs for a physician workforce trained in infectious diseases, ready to rapidly respond to emerging and evolving public health and patient safety threats. For that reason, policymakers should act to ensure the availability of infectious diseases physicians and other healthcare providers, scientists and public health practitioners, to prepare for and respond to this, and future, outbreaks.
Infectious diseases physicians play central roles in preparing for possible outbreaks as well as identification and response when outbreaks occur, caring for patients, informing the public, and conducting research and leading public health interventions. The high numbers of symptomatic and infected patients who need evaluation and care can overwhelm epicenters of outbreaks, as we are seeing in the Chinese city of Wuhan and have previously seen in the sites of outbreaks including Ebola, H1N1 influenza, measles and other infectious diseases.
In the U.S., where we have not seen large numbers of cases of the novel coronavirus to date, hospitals are relying on infectious diseases physicians to screen, diagnose and care for patients should the need arise. Even now, however, cities and towns serving people who may be exposed to this – or the next outbreak – lack ready access to an infectious disease specialist.
All public health infrastructures rely on infectious diseases expertise — including from physicians who work for the CDC or state, local or global public health agencies, as well as clinicians who are treating patients and partnering with public health in an outbreak response. These specialists are critical to identifying outbreaks and to tracking and containing their spread. In the increasingly interconnected society that enables pathogens to travel swiftly and with devastating results, outbreaks cannot effectively be contained without an expert workforce across the country and globe working together.
As novel pathogens emerge, more research is needed to better understand how to best prevent, diagnose and treat them. Infectious diseases physicians lead innovative research toward the development of new vaccines, diagnostics and therapeutics that revolutionize our response to outbreaks. Experts have noted that the existence of an Ebola vaccine has significantly increased the effectiveness of our response to the current Ebola outbreak in DRC.
The infectious diseases physician workforce that we have come to rely on, that helped bring about eradication of smallpox worldwide and helped this country to eliminate measles, however, may not be there the next time we need it. From 2011 to 2016, the U.S. experienced more than a 20% decline in the number of new physicians applying for infectious diseases fellowship training. Recent years have seen modest gains, but significant numbers of infectious diseases fellowship training programs still fail to fill their slots. With staggering medical school debt of about $200,000 per new physician, relatively low compensation for infectious diseases specialists is a significant factor that has driven more new physicians to specialties with higher compensation for time invested in training. The average salary of an infectious diseases physician, in fact, is $100,000 less than the median salary of a specialty physician. The chief driver of this compensation gap is evaluation and management billing codes, which cover more than 90% of ID physician services and are severely undervalued by insurers, compared to codes for health care procedures.
The U.S. Centers for Medicare and Medicaid Services has begun to recognize the salary disparity facing infectious diseases specialists and other physicians who primarily provide non-procedural care—that means they evaluate and manage complex patients rather than perform procedures. The 2020 Medicare Physician Fee Schedule rule will make modest improvements to reimbursements for evaluation and management codes in outpatient settings. It will be essential for the federal government to build on this first step to ensure that infectious physician services in both inpatient and outpatient settings are valued at their worth, to help make this specialty a financially feasible path for new physicians.
To fully secure the future infectious diseases physician workforce that meets future patient, public health and research needs demanded by outbreaks and routine threats, additional strategies will be needed to reduce medical student loan burdens, fund physician-scientist training and appropriately resource the public health workforce domestically and globally.
Experience tells us that pathogens don’t observe national borders, and that the most pressing question surrounding pandemics that can cause devastating impacts to individuals, families, communities, nations, and economies, is not if, but when, we will be forced to confront their impacts. We must prepare now – and that includes ensuring the workforce that will be needed whenever that may be is on hand — if we hope to respond effectively.
Thomas File, Jr., MD, FIDSA, is president of the Infectious Diseases Society of America (which produces this blog), chair of the Infectious Disease Division and co-director of the Antimicrobial Stewardship Program at Summa Health, Akron, Ohio and is professor of medicine, master teacher and chair of the Infectious Disease Section of the Northeast Ohio Medical University.