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, "And because 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 doctor can 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 (PDF) went unfilled. "A lot of the conversations that happened then, are happening again now," Marcelin says.