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Thursday, June 16, 2016

The delusion continues (part 3)

In response to my last post a reader emailed me the following: Very easy to sit at a keyboard and throw blog bombs … I would be thrilled to hear your constructive suggestions for a solution(s).

Fair enough. I'll address that. But it's important, I think, to first say a few words about this blog, which is now in its eighth year. From the beginning, we wanted to make controversial issues a focal point, and the issue of the infectious disease (ID) workforce (or lack thereof) is controversial and a topic of great interest to readers. In addition, we welcome comments and guest blog posts to offer alternative viewpoints. Eli Perencevich, MD, ACP Member, Dan Diekema, MD, FACP, and I don't always agree with each other (as is evident in our posts). The only comments that are censored are those advertising black market erectile dysfunction drugs and other products. And all requests for guest posts have been honored unless the author has conflicts of interest with industry. So readers, please feel free to respond to our posts.

My comments on the workforce/compensation issue and IDSA's response are made in the context of my experience with these issues. In my former job as an infectious diseases division chief in an academic medical center, I had firsthand experience with the difficulties of recruiting fellows and faculty, the inequities that resulted from a purely relative value unit-based compensation plan, and the toll this took on teaching and morale.

At the same time, I was observing a private health system across town crank through a multitude of infectious diseases doctors, each of whom left practice once their guaranteed salary expired and they one by one came to the realization that they couldn't generate enough RVUs to maintain their salaries. Several of these physicians became hospitalists.

In my current position, I see my division chief struggling with trying to balance his budget, offer salaries that can compete with other hospitals and medical schools, deal with ever increasing consultation volumes and expectations for rapid responses to consult requests, while trying to minimize the stress all of this has on his fellows and faculty members. We now have starting salaries for brand new nurse practitioners that are within a few thousand dollars of junior ID faculty salaries.

I'll be the first to admit that my experience may not be the same as others. In the IDSA compensation survey, 1 respondent reported a salary of $1.45 million, so obviously his situation is quite different than mine and his views on these issues probably are as well.

I did a little more research on salaries by looking at the Association of American Medical Colleges data. The median salary for an infectious disease assistant professor is $152,000, while the median for a hospitalist assistant professor is $207,000. For a third year internal medicine resident, that's a huge difference. At the associate and full professor levels, hospitalists still earn more money than infectious diseases specialists. Moreover, hospitalists salaries are rising yearly at a higher percentage than ID's, so the difference continues to expand.

Another interesting finding is that of salaries for chairs of Departments of Internal Medicine. Unfortunately, if you're an infectious diseases doctor you'll earn significantly less than your chair peer who's an invasive cardiologist, a difference of about $350,000. And what do cardiologists learn in their fellowship about being a department chair that would explain that difference? I hate to sound like Donald Trump, but it's a rigged system. And it follows you throughout your career.

As for constructive suggestions for solutions, I've written about this in older posts, but here are a few:
• Focus on the parity with hospitalists, since that's our biggest threat with regards to recruitment of residents into infectious diseases. Until ID salaries are at least as good as hospitalists', there's little reason to think that we will turn this around.
• Consider shortening the ID fellowship to positively affect the cost-benefit calculus of additional training. Do trainees who plan to enter private practice really need hands-on training in research or scholarly activities?
• Develop hybrid models of training to lessen the economic impact on trainees (for example, integrate ID training with hospitalist practice). Various models could be envisioned—such as one month hospitalist attending, alternating with one month ID fellowship. This would increase the fellow's salary, and even if the total duration of training were extended, may entice more residents to consider ID training. Some would probably continue this model beyond training into employment.
• If IDSA is working hard to address these issues, it's not apparent from their website or communications with its members. Most importantly, in my view, IDSA needs to own the workforce issue and honestly deal with it. And that begins by calling it what it is–a crisis. A crisis, magnified by the many problems that are in the news every day, like Zika virus and antimicrobial resistance. I'm not a communications specialist, but it seems to me that these issues could be highlighted to help our cause.

Unfortunately, the two articles and editorial published this week in IDSA's journals spin an unrealistic view of the problem. I doubt that the your-salary's-not-as-bad-as-you-think-it-is campaign will have much impact. Time will tell. In December, we'll see the results of the next Match.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Friday, June 10, 2016

Tips for clinician-educators--give them their money's worth

Medical students pay exorbitant amounts for their schooling in the U.S. They deserve the highest quality teaching. They deserve well trained clinical teachers.

Many years ago I began asking the students if they received their money's worth on rounds or in conferences. This question does 2 things. First, the students know that I am trying to provide a return on their investment. Perhaps more important, the question reminds me that I owe them my best teaching. They do not owe me anything, they have already paid dearly.

How do we convince medical educators that we owe all learners our best every day? If you believe this, then you then must learn to be a better educator.

Being a good physician does not make one a good educator. We need to cultivate our clinician educators. Given the tuition that schools receive, should they not invest in the medical education process?

If you teach medical students, ask yourself: Are you giving them your money's worth? Ask yourself if you can do a better job. Make this a priority. They deserve our best.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Thursday, June 9, 2016

The delusion continues (part 2)

A few hours after I posted on the survey of Internal Medicine residents on why they won't pursue training in Infectious Diseases, a reader alerted me to another new paper on ID physician salaries in Open Forum Infectious Diseases (free full text here with additional data available on the IDSA website requiring a membership password). This study was also sponsored by IDSA. The title of the paper is ”ID Physician Compensation–An Improved Perspective.”

From this survey of nearly 1,900 ID physicians, we learn that the median salary of a full-time physician that is focused on patient care is $210,000. The data are sliced and diced in many ways, and are interesting to review.

The spin in the discussion (alluded to in the title of the paper) is that things are really not as bad as we thought. The authors point out that the often quoted Medscape survey has a small sample size and underestimates the true salary of ID docs. And while that is true, we still need to maintain perspective.

We know that our biggest competitor is hospital medicine. So let's take a look at hospitalist salaries. In 2013 (2 years before the IDSA survey), the overall median compensation for hospitalists was $254,000. So for an additional 2 years of training, the Infectious Diseases doctor will earn $44,000 less than his/her hospitalist colleague. And don't forget, full time for a hospitalist is, on average, 40 hours per week. How many ID doctors work 40 hours weekly?

Unfortunately, for most internal medicine residents, this decision is a no-brainer and I doubt this new survey will have much impact. Spin on, IDSA, spin on.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Friday, June 3, 2016

Tips for clinician educators--practice your talks

This week I will give a talk on acid base and electrolyte disorders. I teach these subjects regularly, yet designing this talk has challenged my skills. My problem is the curse of knowledge.

The problem is that once we know something—say, the melody of a song—we find it hard to imagine not knowing it. Our knowledge has “cursed” us. We have difficulty sharing it with others, because we can't readily re-create their state of mind.

At the board in morning report I have learned to show my work. I give the learners plenty of opportunities to ask questions if I become obtuse. But in designing a talk, I have to anticipate the problems.

So I become the anti-Allen Iverson, the professional basketball player who notoriously had an outburst about his practices. I practice. I first practiced for 3 weeks and got some very good suggestions. Then again a practiced with different colleagues who pointed out all the assumptions that I should not make in designing the talk. I sent them all an e-mail today:

Thanks greatly for helping me improve my talk. Practice, especially for talks like this one, always help us improve our delivery and help us get the message through to our learners. When we write our talks, especially if we feel like we have some expertise, we get trapped by the curse of knowledge.

I have redone the order of the cases, and hopefully fixed many errors. I did decide to leave out case #6 to allow more time for careful explication.

If you have time to quickly peruse the slides, I would welcome any further

comments. Again, thanks for helping me improve this talk.

I have given talks for over 30 years. I'm told that I give good talks. Practicing always helps me do better. Fortunately I have colleagues who understand that they have an obligation to give specific critiques. They did a great job. Hopefully the talk will go well. If so, I will once again understand the value of practice.

This is related to a wonderful podcast that I listened to today, “How to become great at anything.” We should all value deliberate practice and this podcast explains the concepts beautifully.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Thursday, June 2, 2016

The delusion continues

There's a paper in Clinical Infectious Diseases on the highly anticipated survey of Internal Medicine residents to solve the enigma of why no one is going into infectious diseases. It never seemed to be a mystery to me, but having data is always helpful, providing that you interpret it correctly. And here that caveat concerns me a great deal.

The survey results were divided into 3 groups: those applying or intending to apply to ID fellowship, those interested in ID but deciding not to apply, and those with no interest in ID. Of those who had an interest but didn't apply (the group that we should have some hopes of capturing), the number one reason for not going into ID was salary. Moreover, when asked what is the most important factor to increase interest in ID, all 3 groups said salary. For those going into ID and those who considered it, the percent responding salary was 2-fold higher than the next most commonly cited factor (early exposure to the field of ID).

So, no surprises here. But what was both surprising and alarming to me was that the discussion in the paper and the accompanying editorial both seemed to downplay salary as a factor in the current dearth of applicants to ID. The authors wax eloquently on career choice models, pedagogical techniques, the importance of mentors, etc. Salary is buried in half a paragraph of the eight paragraph discussion. The authors of the editorial even seem somewhat astonished that the top career choice of those who considered ID but didn't apply was general internal medicine, a specialty that they note “is not typically considered a high remuneration specialty.” I think there's no surprise here either for 2 reasons: (1) hospitalists make significantly more money on a per hour basis than most infectious diseases doctors, particularly in the academic setting, and (2) whatever that difference in salaries is, it's magnified by the fact that 2 more years of training (at least) results in a lower salary. That is, you are punished economically for additional training, which many folks find too unpalatable to move beyond.

My bet is that the paper and editorial are nicely in line with IDSA's thinking since IDSA sponsored the study. And I suspect that IDSA will continue to pretend that all is well while the dumpster fire burns away. Once we get the microbiology courses in medical schools to stop making the students memorize so much, the students will come racing to ID!

Carry on then.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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