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Now a median of $174,000 per year is hardly chump change, so I don’t expect much in the way of sympathy on these data. On the other hand, someone has to to be last, and note that our income hasn’t increased a bit since the last time I commented on this survey three years ago.

So it’s worth taking a few moments listing the top reasons why infectious disease physicians rank so low, most of them probably as obvious to you as the antibiotic of choice for treatment of syphilis. Then we’ll once again end on a happier note.

Reason #1: Doctors in the USA are paid the most for doing procedures. A famous ID doctor once said, “No one ever got rich from doing a gram stain.” And even though I just made that quote up, it’s definitely true. We ID doctors barely do any procedures, and the few we can do are comparatively low ticket items such as PAP smears, CSF exams, minor wound care, I and D, etc. Some ID/HIV specialists have added various procedures to their practice to offset this deficit, such as screening for anal dysplasia in their HIV positive patients using high resolution anoscopy, doing fecal microbiota transplants for C diff, or providing injections of facial fillers for lipoatrophy — that last one most certainly a cash business. However, these enterprising (and for the first two, strong-stomached) ID docs are the exception, not the rule.

Reason #2: Productivity of doctors is still measured in volume. In a fee-for-service, count-the-RVUs system, the more patients you see the more you get paid. And I suspect there are few cases less amenable to high volume service than those referred to ID/HIV doctors. Consider these: Fever of unknown origin (clinic or hospital/ICU setting). Spinal osteomyelitis/epidural abscess. New HIV diagnosis (especially with advanced disease/complications). Acute endocarditis. Lyme disease (real or imagined). Recurrent UTIs in patients with GU anatomic abnormalities or spinal cord injury. Fever in the returning traveler. Non-tuberculous mycobacterial lung infection. Infectious complication following major surgery. Tuberculosis of any sort. Sexually transmitted infections. Transplant-related infections. And on and on and on …

Reason #3: Many of the time-consuming services ID doctors provide have no billing code. Which means, simply, you can’t charge for your work. Did you spend an hour searching for a critical culture result done at an outside hospital? Maybe it was the orthopedics consult on a patient with a septic hip, now in your hospital with essentially zero information in the chart. And once this patient is treated, who’s going to arrange his/her post-discharge IV antibiotics? The lab test follow-up? The vancomycin levels? That’s right, it’s you, Dr. Bugsndrugs, and not Dr. Breakbone who can bill plenty for the time in the OR, while you can only hope your documentation on the initial consult note meets appropriate complexity criteria for a C4 or C5. (Don’t forget the review of systems.) The rest of the work listed above (aside from that first note) is essentially gratis. On a different case, did you spend an eternity searching for the resistance genotype done in 1999, relegated to the proverbial dust heap — but now it’s absolutely crucial to find it as you try to craft a new HIV regimen for a patient with significant side effects? What’s the billing code for that? And don’t get me started on curbside consults: Just read this.

There are certainly other reasons for the low salary: Low income means you can’t invest in money-making imaging/scanners (just a few have a FibroScan), there’s no ID-drug equivalent to Lucentis, a high proportion of us work on salary for a hospital/clinic rather than in private practice, and many participate in infection control/quality improvement programs that earn points for citizenship but rarely salary.

Yet despite the low revenue, we still seem to be doing great with two key questions — if we had to do it all over again, would we:

Choose to go into medicine (that is, still become a doctor)? Choose the same specialty?

Here, low-ish revenues notwithstanding, we do pretty darn well, finishing second among specialties in question #1, and eighth in question #2. All of which means we’re pretty satisfied with our jobs–— hardly surprising given that we have the privilege of working in such an interesting field. Money isn’t everything.

Paul Sax is an infectious disease physician who blogs HIV and ID Observations, a part of NEJM Journal Watch.