Valerie Ryan looks at the career path for doctors who want to specialise in infectious diseases
In this country, there are only nine consultant physicians who are specialists in infectious diseases (ID), but the specialty has become firmly established over the last 10 years.
The small number working in the specialty has an impact on training opportunities, according to joint RCPI National Specialty Director Dr Catherine Fleming, who said, obviously, the small number of consultants limits the number of training posts.
She said it is likely that there will be two to three new training positions yearly and Basic Specialist Training (BST) is a prerequisite for getting onto the ID Specialist Registrar programme.
Essentially, infectious disease is a clinical specialty of internal medicine, focusing on the assessment, diagnosis and management of acute and chronic infections. Work in this specialty is constantly evolving and covers everything from new diseases and complications in tropical medicine, to HIV medicine, TB and viral hepatitis.
But it is also involved in new emerging diseases and disease outbreaks, or infectious complications from monoclonal therapies and chemotherapy, resistant community nosomical infections and antimicrobial stewardship programmes.
The number of clinical trainee places available is officially eight, as posts are matched to clinical consultant numbers. However, there are more than 20 specialist registrars (SpRs) in the national programme due to a combination of research, clinical internal medicine and specialty posts, joint RCPI National Specialty Director Prof Colm Bergin pointed out.
Dr Fleming explained that most trainees undertake research during the course of their training. Several of the trainees are integrating their research with clinical commitments and others elect to do research for the final year or years of training.
“Research is highly recommended and we encourage trainees to do an MD or PhD as part of their training. In addition to the obvious academic merit, it allows people to develop a clinical niche and it is often a route to doing further training and getting employment abroad,” she said.
The duration of Higher Specialist Training (HST) in infectious diseases is four years, one year of which may be gained from a period of full-time research. But to get dual certification in infectious diseases and general internal medicine, trainees need to do five years’ training.
Most people usually do five years but some may elect to do longer and that is usually to complete PHD.
And what opportunities exist for doctors to sub-specialise?
It will likely evolve that people will specialise in particular areas as the specialty develops and as the number of specialists increase. However, every trainee is expected to do both HIV care and general infectious diseases.
Dr Fleming added that training is very similar to the US and UK, however in the US there is no requirement for further GIM training. And what are the job prospects?
Dr Fleming said it is hoped that new positions will be created over time. It has to be encouraging that the majority of people who graduate from the programme get jobs as consultants, although they are frequently abroad for a few years.
Prof Bergin said we are still at a relatively early stage in ID and have not yet reached critical mass on consultant numbers. Those who have completed training to date have all been appointed to consultant positions – UK, Northern Ireland, Singapore, and Ireland (locum post).
Looking ahead, he believes, strategically, it is essential for the specialty to evolve in the coming years to a US-style ID model and to extend beyond what was originally perceived as a single-disease specialty (HIV medicine), though this did serve as the impetus to the first appointments in the area.
There will be a need for all partners in ID-related areas to see how coming together will be to the benefit of all, he said. He suggested this could be structured as a partnership across specialties, disciplines and primary and secondary care, with benefits for both patients and partners.
In addition, there will be a need to focus on strategies for disease prevention – vaccinology, public health education and so on, he said.
The overlap with other specialties is not formally structured and varies from place to place but includes areas such as clinical microbiology, pulmonology (especially TB) or hepatology (viral hepatitis). In common with a number of ID colleagues, Prof Bergin’s own training pathway was through dual training in both genito-urinary medicine and infectious diseases, as there was no structured training in ID in this country prior to 2002.
Prof Bergin’s views of working in ID reflect those of other ID consultants. He counts himself lucky to work in the specialty, as he said ID is an evolving and dynamic specialty and he has worked through a time of emerging diseases – SARS, H1N1, MDR TB, zoonotic infections, travelrelated diseases and in a setting of social globalisation and ecological change.
“We play a significant role in patient advocacy for marginalised groups. We are clinically (patient) -focused, working within multidisciplinary teams. We have a great network of consultant colleagues and I have really enjoyed the evolution of training of young colleagues at SHO and SpR level and seeing how many have now joined us for specialty training,” he added.
‛Never a day of boredom’
At present, there are two consultant paediatricians with a special interest in infectious diseases in Ireland.
Training is through the specialty of paediatrics, and there are a number of different training options available, according to Prof Karina Butler, the first consultant paediatrician with a special interest in ID to be appointed in this country. The UK, the US and Australia, she said, are the main countries for training.
While the UK is nearer home, the training scheme is “extremely competitive and is a very academic course”. “It’s a fascinating field to be in,” she said, as her own career coincided with the emergence of the new unfolding disease of HIV.
“There is all of the tragedy and excitement of working with a new disease and the incredible results they have achieved to date.”
She said the real excitement is “in the sense of being able to intervene.
“It is good when the outcomes are so good and sad with the sad outcomes,” she added.
She never saw herself dealing with only one organ, and infectious diseases allows her to spread her skills across all boundaries.
“We are likely to be involved with the sickest children, bone marrow transplants, liver transplant ICU; right across the spectrum and at out-patients, it is so culturally diverse in terms of clientele, it is a very wide spectrum.
“There isn’t one day that I do not see something I have never seen before – there is never a day of boredom,” she added.
Training abroad is essential
Infectious diseases potentially affect every organ and that is one of the biggest attractions of the work; it is one of the few specialties where you need to be a good clinician according to Dr John Lambert, a consultant at Dublin’s Mater Hospital and the Rotunda Hospital.
Internationally, it is a very well established specialty and the opportunities in ID are quite broad, with possibilities of doing HIV medicine, GU medicine, transplant medicine, and hospital epidemiology. It is wide ranging and in Ireland there are a huge range of opportunities, Dr Lambert said.
He said going away for training opportunities is absolutely necessary when you can see more transplant ID complications in a big American teaching hospital in one week than you would in a lifetime in Ireland.
He has found working in the specialty challenging and rewarding and he also believes that continuing new learning, both academically and clinically, is of great benefit for the specialty.
- HST posts: 8 clinical posts
- Annual intake: 2/3
- No. of consultants (adults): 9 (1 part time post) Dublin Mid- Leinster: 3; Dublin North East: 3; South: 2 (1 parttime) and in the West: 1.
- No. of consultants (children): 2
- Specialist registrar’s basic salary: €60,403.78 – €76,071.94
- Consultant pay: (New entrant’s salary) Type A contract starting €184,455, Type B starting at €173,620