The last sunlight of the day was slanting through Joseph’s hospital window. As the sun descended, it burned the sky crimson and the mists rolled away, disappearing into Rwanda’s seemingly endless hills. I had just arrived in Kigali for global health work with a goal of medical education and, as I looked out, I felt at peace with my recent decision to apply to an Infectious Disease (ID) fellowship.
Earlier, while I was working on the wards in Rwanda’s largest tertiary care facility, I encountered my first so-called true “superbug.” I always thought my first experience with an antibiotic-resistant microbe would be in the United States, where antibiotic misuse is rampant. But there in sub-Saharan Africa, Joseph (an adult farmer who had been intubated for a multifocal pneumonia) grew pan-resistant Pseudomonas aeruginosa. He was dying. And he had only had two previous health care interactions in his life.
In the bed next to him, a young woman with newly diagnosed HIV, had been admitted for altered mental status and had also required intubation. The care team discovered she had progressive multifocal leukoencephalopathy, a rare and often fatal complication of uncontrolled HIV. A poster graphically depicting Ebola symptoms hung from the entrance door to the ward: a reminder to consider it always in your list of differential diagnoses.
The infectious disease presence in Rwanda is raw, powerful, and motivating. Being in such an environment compels me to urge my fellow residents and medical students to consider ID as they embark on their journeys to sub-specialization. Much like the Rwandan sky’s diverse palette of turquoise blue and crimson hues, the ID palette is filled with vibrant tones of opportunity….
- Unparalleled career diversity: ID is deeply entwined with the social determinants of health — and ID specialists work to make sure communities are as resilient as possible to infectious diseases. ID work allows you to venture into epidemiology and global public health, and work with diverse organizations (such as the Centers for Disease Control, the Food and Drug Administration, and the United States Agency for International Development). You can work in infection control and antibiotic stewardship. You can practice inpatient or outpatient care, or both. You can sub-specialize, e.g., in transplant ID or microbiology. You can work on cutting-edge advances in therapeutics or diagnostics. You can work abroad, or care for those returning from abroad in a travel clinic. You can work in critical care (indeed, some ID training programs even offer combined training in this area). These are just examples of some of the many, many career possibilities.
- Academic curiosity: Microscopic organisms can produce a variety of complex problems involving any organ system. Some patients require only one visit, some are critically ill, some have chronic conditions that require long-term primary care. In the background, the infectious disease landscape constantly changes as diagnostic and therapeutic interventions evolve and new (or old) pathogens emerge (or re-emerge). Unlike other specialties, every case has the potential to truly be a “fascinoma.”
- Curability: Many of the patients are curable. You have the opportunity to see a very sick patient, figure out what’s wrong, and see them get better.
- Global calling: It is a rare day when an infectious disease is not in the news, whether it’s a food-borne illness or an epidemic like Ebola. It is one of the only fields where a threat to someone else’s well-being is a threat to your well-being. Everyone is connected. It is unlikely that a large scale myocardial infarction would threaten humanity but infectious diseases have the potential to cause a real “end of the world” scenario. ID specialists are at the forefront, ready to defend against ongoing threats.
Recently, the New York Times published an article highlighting the scary shortage of infectious disease doctors in a world increasingly filled with virulent organisms. I am always surprised when I read reports of a decline in the number of ID physicians or fellowship applicants. Literature has identified possible reasons for this, including the relatively low pay compared to other subspecialties. I understand student loan debt is unsettling but if money is your true motivator, then there are always opportunities to supplement income (whether it be moonlighting, locum, consulting, acting as an expert witness, etc.). What I have not been surprised to read, however, is that despite the reported pay discrepancies, job satisfaction in ID is high.
The desire to practice in infectious disease is infectious. The field is dynamic and kinetic with unpredictable landscapes layered with innovation and heroism. As I stood next to Joseph’s hospital bed, admiring the sun’s colors against the miles of Rwandan hills and sky, I was not only at peace with my decision … I was eager.
Jesse O’Shea is a graduating Internal Medicine resident at Yale. He will be doing an Infectious Disease fellowship at Emory University.