Supporting the Physician-Scientist in Clinical Practice in Infectious Diseases

Abstract

Physician-scientists who work as researchers while practicing as clinicians continue to play a critical role in the conduct of disease-oriented research in infectious diseases. While we have made progress in the coordination of their early clinical and scientific training, we have been less attentive to the exigencies of a hybrid job description along the entire continuum of their academic medical careers. This article considers strategies to support the clinical activities of physician-scientists, honoring our shared commitment to excellent patient care. The approaches described may not be universally applicable. Instead, they are meant to highlight the issues and contribute to an ongoing dialogue in our rapidly evolving field.

Is it a “truth universally acknowledged” [1] that the physician-scientist who practices clinical infectious diseases requires a system of support that differs from other academic clinicians? Most readers would agree that it is not, at least not yet. With the opportunity afforded me by this chapter, I will argue that it should be. In our current clinical and scientific environments, dual mastery (“biomedical bilingualism”) requires a platform for clinical care that recognizes the differences between all of the participating physicians. These physicians may include trainees at all levels and clinical and basic scientists. Because this Supplement focuses on the biomedical physician-scientist in infectious diseases, where possible, I have tailored my comments to specific challenges of this role. However, it will be clear to the reader that much of what I describe applies to all academic physicians with a range of other activities.

The literature discussing any aspect of the physician-scientist in clinical practice is limited [2, 3], and I therefore rely heavily on our own experience with our fellows and faculty at Massachusetts General Hospital (MGH), supplemented by conversations with colleagues outside of our institution.

The potential perils of clinical care delivered by a disaffected physician-scientist have been well described. These physicians have been termed “submarines,” fully submerged in their research activities most of the year, rising a few weeks a year to “behave like doctors.” While the metaphor succeeds by characterizing one extreme, the problem of the distracted academic physician (whether a basic scientist or not) is real. Even decades later, it isn’t possible to read a physician’s account of the illness of a family member in “Who Was Caring for Mary [4]?” without a sense of horror. Which of us cannot identify with the fragmented care of a critically ill patient delivered by “specialists whose actions implied that patient care was of secondary importance.” Subsequent reexamination of the events by the author himself revealed that no one problem accounted for the patient’s clinical course. Nonetheless, the article highlighted many of the challenges inherent to clinical practice in the academic setting.

As important as it is to recognize these potential harms, they must be balanced against the many potential benefits, which have been eloquently described elsewhere in this Supplement. There can be no doubt that physician-scientists help to connect their worlds by signaling and addressing clinically relevant questions and by translating their findings into clinical practice. I would stress one additional benefit, and that is the ability to retain excellent clinicians in the clinical enterprise. In my teaching and mentoring role in our Department of Medicine, I have participated in many years of longitudinal review of our residents. In our residency cohort, physician-scientists demonstrate a degree of engagement and excellence commensurate with that of their nonscientist peers. While only a small number of physicians in any training track become so called “master-clinicians,” all excellent clinicians are important assets to our clinical services. In the best case, the physician-scientist who develops a clinical niche that is closely allied to their research field attracts patients who need their “super-specialized” care, and also teaches trainees and colleagues to deliver that care. When the physician-scientist’s ongoing stake in clinical medicine has an enduring influence on the architecture of their research, patients and society are the beneficiaries.

Before embarking on a discussion of supporting physician-scientists in clinical practice, we should state our shared goal—outstanding patient care, in all settings. This goal is explicit in the mission statements of academic medical centers and, furthermore, is endorsed by the physicians themselves. Our own MGH Physician’s Organization (MGPO) does regular surveys of our practicing physicians. In these surveys, the strongest correlate of satisfaction with clinical practice is the perceived ability to provide excellent care to patients. If the provision of high-quality clinical care is acknowledged to be critical to our mission, why do we fall short? Answers may differ, but the common themes that emerge are familiar. The first theme is that clinical work is not appropriately valued and rewarded by leadership, or even worse, is termed a “distraction” and actively discouraged. Clinical activity makes no meaningful contribution to career advancement. The salary structure for physician-scientists may not include any contribution from clinical revenues, and if it does, their compensation models may not make it transparent. Progress on these issues requires the ongoing efforts of institutional and national leaders at all levels. The second theme is that our divisions fail to acknowledge these divergent job descriptions in the design and support of the accompanying clinical activities. While it is encouraging to see flexible approaches to clinical medicine nascent in dual degree programs and in graduate medical education, we have not yet developed the necessary continuum of approaches through all career stages.

I have been asked to address approaches to the integration of physician-scientists in our clinical infectious diseases practices. It will be evident to the reader that these approaches benefit all practicing clinicians, including those whose academic careers do not encompass basic science. Why then might they be of particular importance to the basic scientist? In reviewing the work of our own faculty, those who work in clinical research or global health are in general more likely to intersect with the clinical realm in their day to day activities. This connection may be more narrow or broad, but it likely provides the physician who works, for example, in global HIV medicine, a tighter connection to clinical care than one who works on basic pathogenesis of HIV infection.

BRIDGING THE EXPERIENCE CHASM

In an era where more and more MD PhDs choose careers outside of internal medicine, we must acknowledge the special requirements imposed by the depth and breadth of knowledge required of infectious diseases physicians. While “super-specialists” in divisional practice areas (eg, opportunistic infections and musculoskeletal infections) may reach their clinical “comfort zone” more rapidly, we must still determine the minimum amount of ongoing clinical activity required for clinical expertise. Acknowledging that this activity may vary with the career phase, we require at least 6 weeks of yearly inpatient attending time on our (very busy) inpatient consult services. Although it was primarily designed as a clinical quality initiative, quantitative divisional expectations for attending follow-up visits help promote hands-on clinical experience. We encourage and support ambulatory practice, and those who maintain a half day a week practice cite the importance of longitudinal care to their clinical development.

EXPANDING PATIENT-FOCUSED LEARNING

Attendance at our patient management conference is required for all faculty on our clinical services, and the conference is well attended by faculty at other times (the lack of teleconferencing to all research sites prevents universal participation of clinically active faculty, which is our goal). The conference is cited by physician-scientists as the single most important activity supporting their clinical work. The conference is choreographed to facilitate active learning through interactive discussions. One specific focus is filling in the gaps for clinicians-scientists by exposing them to the imperatives of daily practice. We emphasize (1) longer-term (including ambulatory) follow-up; (2) challenging diagnostic or management issues that benefit from the input of experienced clinicians; and (3) input from colleagues practicing in the intersecting worlds of clinical microbiology, pathology, neurology, antimicrobial stewardship, and infection control. One of our junior faculty offered the following perspective on how he maximizes the clinical impact of the conference: “I try to imagine being the attending on all of the patients being presented, and decide what I’d do before there is a consensus opinion. In some way, it puts me through the decisions on all of the tougher cases each week when I am not on service. And then, I get the reinforcement, positive or negative, of either a clear answer, or the consensus and dissent of the room. This engages me in a way that makes it even more useful.” An optional conference that is well subscribed and well regarded by junior faculty is our yearly week-long postgraduate course, held in conjunction with Harvard Medical School, “Infectious Diseases of Adults.” We invite our fellows and junior faculty to attend any portion of the course. By charging faculty a nominal administrative registration fee, we are now able to offer them CME (Continuing Medical Education) and MOC (Maintenance of Certification) credit, aligning incentives for their clinical education.

MENTORSHIP IN THE CLINICAL SETTING

Mentorship is more readily available to clinicians in the informal interactions that abound in daily patient care. We have worked to provide this additional clinical mentorship to physician-scientists. Much of this mentoring is done by the experienced clinicians who practice in and administer our clinical practices, including the infectious diseases “super specialty” fields. We have created a so-called “buddy” system to encompass the first 3 years of clinical attending. During that time, all junior faculty members are matched to a mentor. The mentor might be their former clinic preceptor (who knows their clinical trajectory) or someone with whom they share a clinical interest. The junior faculty member is encouraged to discuss the patients under their care, review in detail the particularly challenging ones (which might include bedside review), and to ask for any other support required for the role of infectious disease consultant. When MGH established criteria for the review of clinical competence of new faculty, our existing program met these criteria.

CONTINUITY OF CARE

Here, I refer to informational and relational continuity, for the providers and for their patients. Most of our physician-scientists only care for inpatients. We start by being unambiguous about the timing of transition of their inpatients to the ambulatory setting. On the day of discharge, the outpatient team assumes the care of the patient. This early transition is facilitated by a standard “Infectious Disease Discharge Plan and Sign Off,” instituted over a decade ago. A more extensive version now serves as the OPAT (Outpatient Parenteral Antibiotic Therapy) plan. One important feature of the transition is a single administrative assistant who is the initial contact for the inpatient team, and for the patient and family after discharge. We have always required attending to attending discussions at inpatient transitions, but strongly encourage them between inpatient and outpatient attendings, particularly when medical or psychosocial issues are complex. Relational continuity remains a challenge for all of us in academic medical centers, one without an easy solution. There are patients in whom optimal care requires continuity with an experienced clinician, someone who is well positioned to manage their multidisciplinary care in the inpatient and ambulatory settings. Because our clinical volume requires consultation by attending physicians without fellows, such a patient might be retained by an attending physician organically. Alternatively, this transfer may be engineered through communication between the teams. Relational continuity is also promoted by a forward-thinking program created by our MGPO. Any attending physician who has seen a patient in the last 6 months receives an email alert when they are admitted. One brief visit and conversation between the physician, the patient, and the inpatient team is reassuring to patients and family members, and receives modest compensation.

OUTPATIENT CLINICAL SUPPORT

Our outpatient clinical teams make broader engagement of our physician-scientists possible. In our ambulatory practices, they join clinical teams compromised of several physicians, a nurse, and an administrative assistant. These teams provide support such as same day visits and OPAT monitoring. In return for this support, we require that the physician intersects rapidly with the team and, when needed, with the patient. Though the increasing administrative burden is problematic for all clinicians, physician-scientists are more likely to describe it as the reason they leave ambulatory practice. We have made it a priority to identify, organize, and reassign any clinical work that doesn’t require physicians. Despite our best efforts, however, it seems unlikely that we will ever get ahead of this epidemic curve.

CLINICAL IDENTITY

Despite the advantages we ascribe to the combination of scientific inquiry and clinical medicine, do we help the physician-scientist develop his or her unique professional identity? What are the attributes of clinical practice within that identity? How can we mentor physician-scientists during medical school, residency, and fellowship so that they are better prepared to define and design the clinical roles that fit their career and life stage, and to prepare and negotiate for them? Our physician scientists report that our efforts during fellowship fall short in this regard. They need not only to hear from us, but from those who have “lived that life” about developing their clinical acumen and their clinical careers in infectious diseases. We have begun additional work to ensure that clinician scientists at all stages teach us and teach one another about the requirements of this dual identity. Linking these efforts to those at the level of medical and graduate schools and residencies remains an important goal.

No review of this topic should end without a discussion of resources. Our institutions vary by their size, patient populations, and models of health care delivery and reimbursement. Despite these differences, infectious diseases divisions also share access to certain types of resources. The first resource is revenue for the time our faculty spend in patient care. Optimal patient care and fellow supervision require attending “face time.” Face time is compensated while time in a conference room is not, a notable case of well-aligned incentives. Clinical leadership must ensure the face time needed for patient care and fellow supervision. They must teach faculty optimal billing practices, and regularly review billing at the level of the individual and the division. The second resource is departmental and hospital support for activities that add value and decrease cost. The Infectious Diseases Society of America has emphasized these areas in its education and advocacy, and most infectious diseases divisions have successfully lobbied for support for some, if not all, of these activities. Finally, resource allocation that is allied to the plurality of our physicians requires the input of multiple stakeholders. Our division accomplishes this through regular meetings of a clinical practice committee, comprised of divisional leadership as well as representatives from clinical, basic science, clinical science, and training program spheres. Our clinical revenues accrue to salary support for all faculty, and we emphasize transparency in the design of salary structure for all physicians.

I will end by emphasizing the positive mutual influences between science and clinical care, and the value in supporting the physicians who regularly cross the boundaries between them. If I may be allowed my own metaphor, these physicians would not be submarines but amphibious vehicles, operating clinically at a very high level at some times, while deeply submerged in scientific activity at other times. As leaders in clinical infectious diseases, we must be clear-sighted and judicious in how we support them, and in how we build the remainder of the fleet surrounding them.

Notes

Supplement sponsorship. This work is part of a supplement sponsored by the Ragon Institute of MGH, MIT, and the Harvard University Center for AIDS Research P30 AI060354.

Potential conflicts of interest. The author is on the Board of Directors of Allergan LLC. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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