Thousands of doctors ready to continue their training celebrated Match Day for specialty fellowships on Nov. 30, but one group lamented its results: infectious diseases physicians. Despite its central role in the COVID pandemic, the infectious diseases specialty saw 44% of its training programs go unfilled.

"I'm bummed out," says Dr. Carlos Del Rio, a professor at the Emory School of Medicine and president of the Infectious Diseases Society of America. "I love my field, I love what I do. And it's upsetting to know that my field may not be as attractive to trainees as I would like it to be."

At the University of Washington, which has one of the nation's top-ranked programs, administrators were scrambling to find suitable candidates for two fellowship spots that were still open after the match process. "It feels unsettling," says Dr. Paul Pottinger, director of UW's infectious diseases fellowship training program, "Typically, we match our full eight slots on the first go."

At Boston Medical Center, affiliated with Boston University, none of their three fellowship positions got filled in this year's Match – a "challenging" and unprecedented situation for Dr. Daniel Bourque, who runs their fellowship program: "There was a decrease in the number of applicants this year, and that decrease appears to be a trend."

Becoming an infectious diseases specialist takes years of training. Generally, after four years of medical school, followed by several years in a medical residency, an aspiring ID physician applies to a fellowship program of at least two years. The field hit a low point in recruiting for fellowships in 2016. In the past five years, it was somewhat stable, with around 65%-70% of training programs getting filled.

But 2020 was the exception, when a flood of applicants yielded a record match rate – a phenomenon dubbed the "Fauci effect." As infectious diseases dominated the news, "a lot of us saw it as a [sign of] reinvigorated interest in ID" due to the pandemic, says Dr. Boghuma Titanji, an infectious diseases physician at Emory University. But the slide since then – capped off by this year's "alarming decline" – shows that the pandemic boost may have been a blip in the specialty's long-term struggles.

Despite guiding colleagues and the public through the COVID pandemic and the recent mpox outbreak; despite their lifesaving work in keeping hard-to-treat infections from spreading in hospitals; despite high job satisfaction and a profession that many described to NPR as "never boring": new doctors are not choosing to specialize in infectious diseases.

It's a decline that has the field's top experts searching for explanations.

Training more to get paid less

The most obvious reason is that the pay is low compared with other specialties, says Titanji at Emory University, whose Tweet kicked off a robust discussion about the Match Day results. "We're talking about a six-figure pay difference," she says, citing a 2022 Medscape report that infectious diseases specialists earn an average of $260k a year, which is more than $100,000 less than the average salary for all specialists.

In some cases, doctors who specialize in infectious diseases end up making less than they would have before the extra two to three years of training – for instance, as a hospitalist, which is an internal medicine doctor that sees patients in the hospital. One can become a hospitalist – making between $200,000-$300,000 a year – after completing medical school and residency training, with no additional specialty fellowships required. "I get paid less to work more hours than I did as a hospitalist," Dr. Hannah Nam, an infectious diseases physician at UC Irvine, tweeted. "My student debt isn't going anywhere. Don't regret my choice but don't fault anyone for not choosing it either."

The pay disparities are rooted in the way the U.S. medical system is structured, Titanji and others say. "A lot of the medical compensation system is based on doing procedures or interventions that are highly reimbursed," Titanji says.

Infectious diseases doctors, on the other hand, examine and interview patients and consult with colleagues – "we think for a living," Pottinger, at the University of Washington, says, "Andbecause we don't have a surgery to do, I think that's where this legacy of reduced pay has come from."

Even if the pay is less than other specialties, "it's still very good," Pottinger says. "There's plenty of money in it, both in academic [settings] and in private practice, and our pay is rising over time."

Still, the prospect of getting extra training to take a pay cut deters many from choosing the field. "Medical education in the U.S. is incredibly expensive," says Del Rio from Emory. "If you graduate with a lot of debt, you're not going to go to a specialty that doesn't pay as much as others."

Long hours and public criticism

The relatively low pay is not the only issue, experts say. The field has long been understaffed, leading to long hours – a problem supercharged by the strain of the pandemic. "Every infectious diseases doctorcan tell you that the first year of the pandemic felt like being on call 24/7 because everyone was calling you – and relying on the knowledge that you had – to be able to respond to this," Titanji says.

The current class of doctors largely started their post-graduate residencies in the summer of 2020. All of their training happened during the COVID pandemic, Bourque from Boston Medical Center notes. The long hours and poor work-life balance they observed in ID doctors – and physicians leaving the field in droves due to burnout – may have cut the appeal. "Long hours and low pay are a dreadful combination," del Rio says.

The COVID spotlight also made prominent ID doctors targets for bitter vitriol from people who disagreed with them. "Many of us, myself included, have been attacked in the media and other places," for sharing thoughts on COVID, del Rio says. Dr. Anthony Fauci, a top COVID adviser to President Donald Trump and President Biden, was a lightning rod for criticism – and even death threats. "People [considering the field] realize there's a personal risk. When the chief infectious diseases doctor for the nation has to have bodyguards, that doesn't necessarily make you think 'Oh, this is a great profession," del Rio says.

Loan forgiveness could help

Infectious diseases had a recruiting problem before the pandemic, too: 2016 was an especially disappointing year, recalls Marcelin at University of Nebraska, who was going through her specialty training at the time. That year, 57% of programs went unfilled. "A lot of the conversations that happened then, are happening again now," Marcelin says.

It spawned some soul-searching for the field, with researchers trying to figure out how to attract more doctors. On the money front, medical associations like the IDSA have lobbied Congress for student loan repayment programs, to reduce the medical school debt for doctors who choose the field. They're also advocating for higher reimbursement rates for the work ID doctors do. If the pay gap for infectious diseases decreases, "that may make it more worthwhile for trainees to consider it as a career path," Titanji says.

They've also stepped up their efforts to bring new candidates into the infectious diseases field, with grants and mentorship programs. Still, over the past five years, "despite our recruitment and mentorship efforts, we have made minimal progress in reversing this trend," IDSA leaders wrote to Congress earlier this year. In 2020, a research paper co-authored by Dr. Rochelle Walensky, then chief of the infectious diseases division at Massachusetts General Hospital and now the CDC's director, found that 80% of U.S. counties had no infectious diseases doctors – including most counties that were hit hard by COVID in the first year.

"What I'm learning is that it's a long road ahead," says Marcelin at University of Nebraska.

And the stakes are high, leaving the nation unprepared against outbreaks and health emergencies. "If we don't have enough infectious diseases physicians moving forward, it's going to impact our ability to deal with everything from recognizing and diagnosing a disease, to informing the public, to creating guidance and administering proper treatments," Marcelin says. Then there are the less visible impacts – disease outbreaks in hospitals that could have been prevented in consultation with ID physicians; deaths from infections with treatment-resistant bacteria and viruses that could have been stopped by ID physicians.

That the COVID pandemic hasn't yet inspired more doctors to go into infectious diseases might not be the end of it, says Bourque, looking back at the galvanizing effect the HIV/AIDS crisis had on the field. "There was a point in time where it felt like [infectious diseases] may be a dying subspecialty, and then HIV/AIDS demonstrated the importance of the infectious diseases specialist and really spawned a generation of doctors," including Bourque, to choose it as a career. He says COVID's effects are still unfolding: "COVID has had a tremendous impact on human life, and it continues to have an impact. I do believe that can and should inspire people to pursue careers in infectious diseases."