The Infectious Diseases (ID) subspecialty of Internal Medicine has been in existence for only about 40 years. Once thought to be the province of epidemic detectives (epidemiologists) sleuthing exotic, rare acquired diseases, the ID specialist has become appreciated over the past 20 years as part of the mainstream of vital assets in defining and managing the more complex and time-critical medical cases, especially within hospitals.
More and more patients and families directly seek consultation with “ID” or request that their physicians do so. The popular TV show “House”, off the air the past few years, was a showcase for that area of medicine called “cognitive” (thinking), as opposed to “procedure-focused”. Though it captured audience attention with the anarchical, irreverent behavior of anti-authoritarian Gregory House, MD. The storyline always culminated with his redemption by intellectually solving the most arcane, ominous problems to the reassuringly best patient outcomes. His performance allowed him to survive another week despite his “anti-hero”, irreverent behavior. For those of us who chose ID as our life’s work, we finally exalted that, despite melodramatic embellishment of Dr. House’s quirks and offenses, the general public would finally see beyond the “sexy” operating rooms or emergency departments, the usual venues of medical entertainment, to the white-hot excitement of an unraveling multi-system infectious disease that threatens to annihilate its host. The fuse set and burning down the timeline to fatality is unforgiving of misdirected diagnostic thinking and action. The dysfunction and dissolution of chemical and biological order in complex organ interactions that define the critically ill patient with a febrile illness challenge the most astute clinician in timely application of life-saving, yet potentially toxic, medications such that when the battle is over there is not just a smoking wasteland remnant of the conflict, but rather an intact patient with an intact life.
It is the allure of mastering the breadth and depth of Internal Medicine, the limitless scope of infections of all manner and from all places, and the orchestrating of such complex, special knowledge that draws doctors to this field. And, because the specialty is not organ-centric (such as Cardiology, Pulmonary, Nephrology, etc), ID docs have always seen themselves as the internist’s internist. Those in the field have always known their value. It has been a long road to recognition by other physicians. After all, for years all doctors had to manage infections as one of the commonest problems of their patients, and still do. “Why do I need an ID specialist? My patient doesn’t have malaria!” Physicians were accustomed to call for help when the case needed a procedure… a scope, a biopsy, a surgical exploration/repair. But, to ask for help from a specialist whose procedure was “cognition”? Thinking? Not on your life.
When I first started in practice in 1981, I was giving talks to physician groups every month to expose them to ID and to educate them on where and when to involve me to improve patient care and outcome. In early summer of 1982, as the first HIV/AIDS cases emerged in San Francisco and New York City, ID specialty awareness got an immediate boost. Since then the specialty has earned its place as a necessity in any hospital that would call itself a fully equipped acute care center, certainly in major urban areas. Immune-suppressed cancer patients, sepsis in the extreme of age, multi-drug resistant bacteria, MRSA, Clostridium difficile colitis, prosthetic and vascular device infections, HIV/AIDS, post-op infections, hepatitis C, TB resurgence, and on and on.
In late 2013, a first-of-its-kind study, “Infectious Diseases Specialty Intervention is Associated with Decreased Mortality and Lower Healthcare Costs”, by Steven K. Schmitt, MD and Daniel McQuillen, MD, finally provided statistics that proved what we ID docs have known for decades; that we significantly create better outcomes for the critically ill. 130,000 hospitalized Medicare patients’ records were reviewed – roughly 50% seen by ID specialists, the other half not. Serious and/or life-threatening infection cases were the target: HIV/AIDS, meningitis, heart valve infections, sepsis, osteomyelitis, artificial joint and vascular device infections, etc.
When an ID subspecialist was involved, 9% less died in the hospital, and 12% fewer died after discharge home. Such patients spent 3.7 fewer days in the intensive care unit and they were less likely to be readmitted within 30 days. The study showed that these benefits were more pronounced when the ID doc was involved early, within 2 days of hospitalization. Overall, ID specialty involvement lowered medical costs by 6%.
At the beginning of the 20th century medical care was dominated by surgeons and surgical procedures. The actual medicines available were few. The first antibiotics weren’t even available until the late 1930’s. Over the past several decades it is fair to say that the medical field has been evolving increasingly to the molecular – immune system modulators, cytotoxic chemotherapy agents, bioengineered molecules, a myriad of anti-infective agents, and many other wondrous modern biological chemicals. It is a medical universe of medicinal molecules, cellular armies, biochemical signals, genetic controls, and foreign cellular invaders or “self” cells gone renegade. This is the turf of the cogitators… non-procedure focused physicians. Their procedure is thinking. The ID specialty is the ultimate expression of this type of medicine. In the decades ahead, the diagnostic and treatment miracles will be showcased by and the territory of such doctors.
Infectious Diseases’ time has come and the numbers show it. Think about it when you or someone important to you needs a diagnostician or a specialist experienced at complexity. Call ID. It will make a difference.
Edward R. Rensimer, MD