What Does Academic Infectious Disease Look Like?

Session 90

Dr. Philip Chan is an academic Infectious Diseases physician at Brown University in Rhode Island. He has been out of training now for about 8 years. He talks about his typical day, why he chose this specialty, the training path, and an inside look into this field.

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[01:22] Interest in Infectious Disease

Philip recalls being interested in Infectious Diseases (ID) back during undergrad. With a Major in Microbiology, he was basically interested in bacteria, viruses, infections, and how to solve such problems.

Although Philip’s dad is a cardiologist, he was already interested in fixing things at an early age. So he went to college majoring in Engineering. Then he realized he wanted to go to medical school so he shifted to Biology. However, he thought it was too generic so he then changed to Microbiology, specifically focusing on genetic engineering.

[02:40] Traits that Lead to Becoming a Good Infectious Diseases Physician

Philip says you’ve got to have the ability to think through a problem from top to bottom. You also have to have a particular attention to details. He advises medical students, especially early in their career, is to think about a problem in a timeline. You have to be able to put things together in a timely fashion and think through the different problems and problem-solving critically.

He initially got into the field of HIV early on in his career mainly due to the research aspect of it. But as he progressed, he had gotten so much interested in the intersection of HIV, social justice, and health disparities. A lot of his work is presently focused on public health at the community level and engaging populations across their state.

[04:20] Other Specialties of Interest

During medical school, Philip found everything to be interesting. He loved his surgical rotations as well as OB-GYN, Medicine, Pediatrics, and Oncology. But when he got to residency, he felt he was fully committed to Infectious Diseases. He did consider Oncology due to the genetic research he did at that time. But he eventually landed on his current specialty and he’s happy he did.

What he likes about ID is that it touches every part of the body. There’s a broad overlap of lots of other fields and disciplines. You can actually cure a lot of infection. A lot of medicine now is managing chronic diseases. That’s fine. But one thing that appealed to him about infections is that you can cure a majority of them. You can make people 100% back to normal.

'A lot of medicine now is managing chronic diseases... but one thing that appealed to me about infections is that you can cure a majority of them.'Click To Tweet

[06:00] Types of Patients

Philip categorizes patient care in two types. He does consult in the hospital where he’d be dealing with “bread and butter infectious diseases” These include endocarditis, osteomyelitis, diabetic skin, and tissue infections. They also treat a spectrum of all other infections from malaria to TB and to many other sorts.

Moreover, the outpatient side has become more of his “bread and butter.” This includes HIV care. He started the prep/prophylaxis clinic at their site. He also runs their STD clinic. He didn’t receive enough training in these through fellowship and residency. But the outpatient ID care has taken a lot of his time now.

About a third of the time, there are clear culture data to help guide the decisions. Then a third of the time, they don’t have culture data. Cultures may not be accurate, negative, or they’re not drawn correctly. Then there are also lots of bugs that don’t grow. Philip believes that about a quarter of the time, they’re shooting dark and making their best guess. Then they’re just guided by other aspects of the clinical patients. The other third of their time, they deal with random things that they get called for. Majority of the cases would be fever. For instance, there’s a rising blood count. Others would be taking random questions that may be unclear to the primary care team. 10% of the time would be people getting diseases from other countries like malaria, TB, etc. And a small percent of that time, they’re able to nail the diagnosis of some really random diseases. They give them the appropriate antibiotics and cure them.

'You've given the appropriate antibiotics and you cure them. That's one of the greatest feelings in ID.'Click To Tweet

[09:40] Is His Job Just Like the TV Show House?

Funny how Philip thinks that none of it does look anything like his job. 1 out of every 10 patients, he sees the complete mystery and you try to piece things together. One thing they really love to do as ID doctors is to dive into the social history. This includes the person’s demographics and how you frame them epidemiologic-wise. And just to be clear, there is no housebreaking involved.

'For many parts of medicine, the social history doesn't necessarily matter quite as much. But in ID, the social history can really be everything.'Click To Tweet

[10:45] Academic vs. Community Setting

Philip believes there are pros and cons to each. Basically, it’s about what you like to do. In private practice, there’s incredible flexibility especially if you work for yourself. You can make much more in the private world depending on what you do.

He describes his career as being very academic and research-oriented. He’s also the PI of several NIH grants and other grants, which you can’t do in the private world. For academic ID careers, you can get involved in research and public health. You have the chance to get involved in lots of other different committees and leadership roles and stewardship. You can work for the Department of Health.

'There's a lot of other opportunities in the career of ID to really spread out.'Click To Tweet

[11:50] Doing Research without a PhD

Philip is doing a ton of research at a major Ivy League institution, yet he doesn’t have a PhD. This is concrete proof that it is possible to do research without that PhD. After his undergrad, he got a masters in Genetics. So he has some research experience that he has built on.

What he recommends to students is that if you’re really interested in research, really collaborate. One of the keys to successfully writing NIH grant is he always leads the grant with a PhD person. The NIH loves this as there are two different complementary skill set – one a clinically oriented researcher and the other a PhD-driven researcher.

[13:00] Typical Week

Philip holds clinics on Thursday and Friday afternoons. For about 4-8 weeks of the year, he does inpatient service time where he sees most of the bread and butter disease cases. Then the rest of this time is spread out running various research and the programmatic aspects of what they do. He’s spread across various institutions, pushing different agendas related to HIV and other STDs.

[14:00] Doing Procedures and Taking Calls

Compared to other fields, ID is a less procedure-driven field. But there are a lot of things you can do, which are quite parallel to what an internist does. For instance, they do lumbar punctures, thoracentesis, and other procedures. There are other physicians who feel comfortable doing biopsies.  Nevertheless, they routinely take cultures.

'Compared to other fields, ID is a less procedure-driven field.'Click To Tweet

According to Philip, the beauty of this field is that there’s not many emergencies where you have to go into the hospital ever. Hence, this gives them a very good quality of life in terms of taking calls. He personally takes calls a couple of months where he has to answer phones through the night. However, for academic institutions, there’s a fellow who takes all the calls. And if there’s something they can’t answer, they then refer it to the attending. And this happens to him only about 1-2x  a year. For a lot of the calls, they’d usually give the patient antibiotics and see them in the morning for evaluation.

Philip says he has a good work-life balance. His wife works full-time so he actually does a lot of the childcare in their household especially in the evenings. Although you have flexible time, you have to put in the time to be successful. But you can be flexible in terms of how time is managed. He makes sure he exercises everyday.

'As an academic ID physician, you have the flexibility of your time.'Click To Tweet

[16:55] The Training Path and Competitiveness

Infectious Diseases is a fellowship after internal medicine residency. You go through the traditional 3-year internal medicine residency. In general, you go through a two-year clinical fellowship after that. There are numerous variations such as research-oriented fellowships combined clinical research fellowships for 3+ years. Given that ID is an especially research-driven field, there are lots of places that combine clinical and research together. The typical pathway is two years of ID fellowship. A number of his colleagues come from Med-Peds residencies to do Adult ID and Pediatric ID fellowship over 3-4 years as well. Pediatric ID is a specialty so you can go from a pediatric residency into a pediatric ID fellowship.

The top programs in ID tend to be competitive but there is not as competitive per se as Cardiology or GI. To be competitive, you should do well in residency as a rule of thumb. Be involved in something that really demonstrates your interest. ID is very diverse as there are a lot of people from various backgrounds and experiences that are interested in the field. For instance, there are people interested in infection control, antibiotic management, international health, HIV/STD pathway, etc. So try to explore these through residency. Do research or other projects with a mentor to really show and demonstrate your interest. Or to find out if this is really something you’re interested in and that you want to continue this pathway. Just do something outside of your normal residency duties. If you’re interested in academic medicine, you can get involved in some grants or publications.

[20:45] Subspecialty Opportunities

There are various routes to become certified in HIV care. One is to do a fellowship in Infectious Diseases. As an internal medicine doctor, there are certification programs where you can become a certified medicine physician in HIV care. This is generally a one-year fellowship. Once you’ve become specialized, there isn’t any “next step” in terms of specialty. Those that really take the next level are research experts. These are people who have developed research expertise in drug resistance, for instance or a neurological complication-related to HIV/AIDS. Usually, these are people who have done research on a specific topic of HIV. These are world-renowned experts in a specific aspect of HIV.

Within your typical ID fellowship program, there are usually no specific tracks where you can get certified in. Usually, it’s based on where you spend your time on. There are elective months as well as clinical care. A lot of these are self-directed and self-driven. There are programs, workshops, and courses being offered at academic institutions where you can start to develop specific interest and focus within aspects of infectious diseases.

'Most of what happens in how one develops one's interest and expertise, within infectious diseases, is based on where you spend your time.'Click To Tweet

Alternatively, the people that develop expertise in meningitis or fungal inspection or STDs are people who have developed programs and research portfolios around those different topics.

[24:15] Bias Against DOs

One of Philip’s mentors is a DO who runs infectious control at Rhode Island Hospital. He routinely calls him for pieces of advice. He knows other fantastic mentors who are DOs.

'It's less about the degree after your name and more about what you make of yourself and how your career transpires.'Click To Tweet

[25:10] Working with Primary Care and Other Specialties

Philip also provides primary care himself to his HIV positive patients. The way medicine has gone, as he puts it, is that everything is subspecialized that it’s so impossible to be good at everything. You can’t just keep up with every single aspect of literature or every single disease. He found that through the years, he has become less comfortable managing aspects of diabetes and primary prevention related to cardiovascular disease.

Moreover, there are some diseases like HIV that if you engage all primary care physicians, we would all have the potential to make huge strides in addressing the HIV epidemic. So they’re trying to engage the primary care community in assisting patients with HIV testing and STD testing.

Other specialties ID physicians work the closest with include internists/primary care and hospitalist internists.

[27:22] Special Opportunities Outside of Clinical Medicine

There are tons of opportunities for ID physicians to get involved. He has colleagues across the world who work internationally. There are people who provide care at international sites and those who consult with NGOs and the WHO. Nationally and locally, there are many health departments across the country that have consulting physicians. Some even have full-time physicians for infectious diseases within public health. Personally, Philip consults part-time for the Department of Health aspects related to HIV and STD. There are also opportunities at other outpatient health centers. Some of his colleagues provide consulting services related to Hepatitis C treatment, HIV care, and other aspects of ID care to community health centers, NGOs, etc. A lot of community-based organizations have medical director roles related to substances treatment, AIDS service organizations, STD clinics, etc.

[28:45] What They Don’t Teach in Medical School

For Philip, leadership was something he had to learn on the fly. He currently manages a team of over a dozen people. The business aspect is something they don’t teach you in medical school, as well as how to manage people and how to be a leader.

They train you very well throughout medical school and residency to be a clinician. But for basic business/leadership/managing skill was something he had to learn on the fly. This was something he had to do everyday. That being said, it was something he wished he had formal training with given his current positions.

What he has done though was to find key mentors or people who have been through this time and time again. He’d lean on them heavily and ask them questions about how to navigate different situations.

'Seek out a couple of key trusted people that you can ask confidentially some tricky situations if you ever find yourself in them.'Click To Tweet

[30:50] The Most and Least Liked Things

Philip has gravitated more into the preventative side of infection, which was something he didn’t anticipate through his training. He started their HIV preexposure prophylaxis program. He sees a lot of people that are at risk of HIV and one of his jobs is to keep them negative. He enjoys interacting with young HIV positive people. Preventative care wasn’t something he saw doing 10-15 years ago. But he has now found this to be the most enjoyable aspect.

'I feel like I do a lot of education, counseling, teaching, and mentorship to my patients – guide them through difficult situations, mostly, but not all related to their health.'Click To Tweet

On the flip side, what he likes the least about his practice is the administrative aspect that can become sometimes overwhelming. At some point, the administrative side of medicine may start to weigh heavily on your career. So just set some clear boundaries and structures to help manage that time. In fact, Philip just sat on a panel for physician burnout and found that the EMR is one of the number of causes for physician burnout.

[33:10] Major Changes in the Future

Philip says that for those considering careers in HIV specifically, is to consider places where HIV is affecting people most, including the deep south. A lot of money and resources are now being redirected to such places where HIV is hit the hardest.

In terms of HIV cure, Philip sees an optimistic future in the fact that it can be done. a couple of patients now have received bone marrow transplants with HIV mutations to make them resistant to HIV infections. And when implanted with a bone marrow transplant, these people can now be cleared of HIV. There could still be remnants of HIV but people in the field are considering this as functional care. However, this is not something really applicable to the general HIV population. Reason being is that in order to get a bone marrow transplant, you have to destroy one’s immune system. Bone marrow transplant is for those with leukemia and other blood-borne cancers. Also, there’s a 25% mortality rate with bone marrow transplants. And you wouldn’t want to risk that percentage for putting HIV medication that can keep you controlled for life. All this being said, it has the potential to cure HIV.

Ultimately, Philip would still have chosen to be an ID doctor if he had to do it all over again 110%. His advice to students is to do it early. It’s a fantastic career and he’s 100% glad he did it. There are tons of opportunities with some overlaps with international careers, public health, and public policies.

'Try to explore a career in ID especially if you're interested in public health, social determinants of health, addressing health disparities.'Click To Tweet


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