80% of US Counties Have No ID Specialists

Ken Terry

June 09, 2020

Nearly 80% of US counties have no infectious disease (ID) specialists, and 80% of counties in the top quartile of COVID-19 cases have no ID physicians or a below-average ratio of ID specialists to the population, according to a study published online June 3 in the Annals of Internal Medicine.

Although the majority of these counties are rural, nearly two thirds of Americans live in the 80% of counties that have a below-average ID specialist density or no access to ID physicians at all.

There are no data yet on the association between ID physician care and COVID-19 outcomes, the researchers note. "However, for many other infectious diseases, a robust evidence base supports the association between ID physician intervention and improved outcomes, including lower mortality, shorter length of stay, fewer readmissions, and lower total health care spending," the authors explain.

The national average density of ID specialists was 1.76 ID physicians per 100,000 people in 2017. However, the authors say this distribution "was geographically skewed": Of the 3142 US counties, 331 (10.5%) had above-average ID physician densities and 312 (9.9%) had below-average ID physician densities. Not a single ID physician practiced in the other 2499 counties.

A US map accompanying the study shows the distribution of ID specialists across the country. The areas with the most ID specialists were in the Northeast and Florida. Below-average densities of ID physicians were shown in the Southwest and on the West Coast. Large swathes of the South, the Midwest, and the Mountain West had no ID specialists.

Among the 785 counties with the highest quartile of COVID-19 burden as of mid-May, 147 (18.7%) and 117 (14.9%) had above- and below-average ID physician densities, respectively. More than two thirds (521) of these counties had no ID specialist coverage.

Although the literature does not indicate the "right" ratio of ID specialists to a population, the authors conclude, "our current distribution during pandemic times is probably far too sparse. The deficits in our ID physician workforce today have left us poorly prepared for the unprecedented demand ahead."

The overall shortage of ID specialists is becoming more severe, the researchers note. In 2019 to 2020, ID fellowship programs had fewer than one applicant for every open position, on average. Thirty-eight percent of ID programs were unable to fill their training slots, and 19% could fill no slots at all.

This deficit of interest in the ID field continues a long-term trend. A 2019 Merritt Hawkins report found that between the 2009-2010 and 2016-2017 fellowship matches the number of adult ID programs filling all their positions dropped by 41% and the number of applicants decreased by 31%, according to Medscape Medical News.

The authors tie the decline of interest in the field to the compensation of ID specialists, which is lower than that of procedural specialists. Because their field focuses on cognitive skills, these highly trained physicians are paid about the same as primary care physicians.

Loan Repayment

Young physicians have an average of $200,000 in loans when they graduate from medical school, coauthor Rochelle Walensky, MD, MPH, told Medscape Medical News. With the fellowship training required to become an infectious disease specialist, they fall even further in debt. In effect, they earn less than primary care doctors do, she said.

Consequently, any strategy to bolster the ID specialist workforce should include a government loan repayment program, Walensky explained, adding that perhaps the loan repayment could be tied to practicing in underserved areas where ID specialists are especially needed.

Telehealth is the key to stretching the resources of ID specialists for the duration of the COVID-19 pandemic, she said. "The way to expand [the specialty] in the short run is to reimburse for telehealth."

Walensky is also concerned about the rollback of funding for infectious disease research. "I have a whole corps of researchers…who are really worried about their research future," she said. "These are Harvard scientists who don't know if they'll be funded. If they're not, we could lose a whole generation of researchers, and where will we be 10-15 years from now?"

Walensky is Chief of the Infectious Diseases Division at Massachusetts General Hospital and a professor of medicine at Harvard Medical School, both in Boston.

Frontline Roles

On the front line of fighting COVID-19 today, ID specialists are also critical to the research required to create a vaccine and find new treatments, Walensky explained. They are knowledgeable about current drugs such as hydroxychloroquine and can set up protocols for clinical trials.

At Massachusetts General Hospital, she continued, she and her colleagues developed infectious disease control policies to keep patients and health workers safe; they also triage patients to determine which ones should be tested for COVID-19 and give advice to treating doctors when patients who appear to have COVID-19 test negative. In addition, ID specialists are skilled in the management of complex cases, such as COVID patients who have comorbidities.

"We're not [gastrointestinal] docs or cardiology docs," Walensky noted. "We don't manage a single organ system. We're trained to worry about the entire patient. Given that this disease manifests itself in so many different ways to so many different patients and affects many different organs that nobody was anticipating — that's our sweet spot in terms of how we care for patients."

Walensky reports grants from Steve and Deborah Gorlin MGH Research Scholar Award, outside the submitted work. The remaining authors have disclosed no relevant financial relationships.

Ann Int Med. Published online June 3, 2020.

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