key: cord-0804796-2hcg75km
authors: Jang, Youngeun; Park, Se Yoon; Kim, Bongyoung; Lee, Eunjung; Lee, Seungjae; Son, Hyo-Ju; Park, Jung Wan; Yu, Shi Nae; Kim, Tark; Jeon, Min Hyok; Choo, Eun Ju; Kim, Tae Hyong
title: Infectious Diseases Physician Workforce in Korea
date: 2020-12-07
journal: J Korean Med Sci
DOI: 10.3346/jkms.2020.35.e428
sha: 03ffc363ec543994a8dff50bb1fa3de9da430310
doc_id: 804796
cord_uid: 2hcg75km

This study aimed to evaluate the infectious disease (ID) physician workforce in Korea. We investigated the acquisition of ID physicians from 1992 to 2019 with their current working place in the Health Care System. We defined ID physicians working at general or tertiary-care hospitals as active ID physicians. A total 275 physicians acquired ID as a sub-specialty. Among the 275, 242 were active ID physicians. The density of active ID physicians was 0.47 per 100,000 population. Of all the 17 administrative districts, 11 (64.7%) fell short of 0.47, and 131 medical institutions employed the service of ID physicians. The median number of beds per adult ID physician was 372 (interquartile range, 280–507). It is essential to secure human resources to respond to emerging infectious diseases and perform the inherent work of ID physicians.

We retrospectively investigated sex, workplace (by 17 administrative districts), and type of medical institution (by healthcare delivery system and category of medical institutions) of each ID physician as of June 2020. We investigated physicians' acquisition with ID sub-specialty from 1992 to 2019 for the first time since the sub-specialty was established in Korea. We also investigated the annual number of total specialists and internal medicine specialists between 2009 and 2019. 10 Population data were obtained from the Population Census Division of the National Statistical Office. 10 To calculate the number of beds per ID physician, we investigated data on the number of beds available in each medical institution, based on facility data reported to the Health Insurance Review and Assessment Service. 11 The number of beds calculated excluded those in the delivery room, operation room, and physical therapy clinic.

An ID physician was defined as a physician who has passed the ID board examination recognized by the Korean Association of Internal Medicine. The medical institutions were classified into four subtypes based on their healthcare delivery system: 1) tertiary-care hospital, 2) general hospital, 3) hospital, and 4) medical clinic. Based on the medical service act, the medical institutions were categorized into four subtypes: 1) private/universityaffiliated hospital, 2) public/university-affiliated hospital, 3) private/non-university-affiliated hospital, 4) public/non-university-affiliated hospital. The public hospital criterion was based on lists of current public health care institutions' situations, announced on 31st December 2018 by the Ministry of Health and Welfare. 12 Active ID physicians were defined as physicians working at hospitals, including tertiary-care and general hospitals, except medical clinics or non-clinical services. In this study, we considered ID physicians working at medical clinics as not playing ID physicians' roles; therefore, we excluded them. ID physician density was defined as the number of ID physicians per 100,000 population at the country level.

Statistical analysis was performed using Rex version 3.3.2.3 (RexSoft Inc., Seoul, Korea). We compared annual numbers of total specialists, internal medicine specialists, and ID physicians from 2009 to 2019, using negative binomial regression analyses. Continuous variables were expressed as median (interquartile range [IQR]), whereas categorical variables were expressed as frequencies and percentages. Variables with P values ≤ 0.05 were considered statistically significant.

In total, 275 physicians completed the ID sub-specialty training from 1992 to 2019 (Fig. 1) . The median number of ID sub-specialty physicians acquired each year was 10, ranging from 0 to 21. Among them, 242 were currently active ID physicians, excluding those who were notidentified (n = 11), deceased (n = 5), retired (n = 3), taking time off (n = 2), working at medical clinics (n = 5), and undertaking non-clinical employment (n = 7). Working place of nonclinical employments were governmental agencies (n = 2), pharmaceutical companies (n = 2), non-governmental organization (n = 1), chief executive officer (n = 1), and research institution (n = 1). We observed that 91.8% of ID physicians were employed in tertiary-care or general hospitals. In terms of the category of medical institutions, 47.8% of ID physicians worked in private/university hospitals, followed by 25.9% in private/non-university hospitals ( Table 1) .

The density of ID physicians who were currently active in 2019 was 0.47 per 100,000 population. In terms of geographical distribution, Seoul had the highest density of the Fig. 2 ). The number of ID physicians showed a higher increase rate than total specialists and internal medicine specialties (P < 0.001).

This study showed 242 ID physicians currently in practice: 0.47 ID physicians per 100,000 population and a median of 372 beds per ID physician. Two-thirds of ID physicians worked in the national capital region (Seoul, Gyeonggi-do, and Incheon). Most ID physicians were with 3/6 https://jkms.org https://doi.org/10.3346/jkms.2020.35.e428

Year Acquisition of ID subspeciality per year Commutative ID physicians Among 275 infectious diseases physicians as of 2020, the following were excluded: workplace not confirmed (n = 11), dead (n = 5), retired (n = 3), taken time off (n = 2). general or tertiary-care hospitals when classified by the healthcare delivery system level. Most ID physicians in Korea were clinically active in their role as ID specialists.

Only seven ID physicians were in a non-clinical position. Among them, only two were working for a government institution. Due to the lack of ID physicians in government agencies, policy decisions may not reflect the opinions of ID physicians. Since ID physicians assume many exclusive roles, including education, research, antimicrobial stewardship, hospital infection control, and management of complicated and severe ID, it is reasonable that most ID physicians are seen in large-scale hospitals with sufficient medical resources. However, the field of ID specialty is not limited to clinical work. To effectively deal with emerging and epidemic ID outbreaks, more effort is needed to support non-clinical ID physician workforce, such as ID physician-scientists, journalists, and administrators.

The geographical distribution of ID physicians was uneven. Such uneven distribution was also noted in the distribution of other specialists in Korea. 13, 14 The reasons for uneven distribution might be lack of training hospitals in rural areas or individuals' lifestyle decisions. The factors influencing uneven distribution can be objective and subjective, including income according to regions and lifestyle preferences. Further studies are needed on the causes of uneven distribution of ID physician workforce.

There is no authorized standard of staffing for ID physicians, but a few studies suggest guidelines for optimal numbers. According to the survey of 567 hospitals in 61 countries in Europe, between April and July 2015, the median number of ID physicians/Clinical microbiologists/Infection control physicians was 1.12 per 100 beds (IQR, 0.56-2.13). 7 In hospitals performing regular antimicrobial stewardship programs and infection control activity, the ratio was 1.21 (IQR, 0.56-2.14). 7 A multicenter retrospective study in Korea revealed that each medical institution required 3 personnel per 1,000 beds to review 25% of the hospitalized cases that underwent antibiotic therapy as an antimicrobial stewardship activity. 15 Based on recent research from the US, the national average density of ID physicians was 1.76 per 100,000 4/6 https://jkms.org https://doi.org/10.3346/jkms.2020.35.e428 The number of infectious diseases physicians refer to infectious diseases specialists who are active as of June 2020 and only those who work at the hospital level or higher; b Density of infectious diseases physicians is defined as the number of active infectious diseases physicians per 100,000 people. population in 2017. 9 In Brazil, the number of ID physicians was 3,229, with a density of 16.06 per million inhabitants. 8 Although the number of ID physicians in Korea has been increasing more rapidly than internal medicine and total specialists over the past decade, the current workforce seems to be far lesser (0.47 per 100,000 populations) than in other countries.

We suggest establishing reasonable policies that can attract physicians to choose ID as their specialty is necessary. For example, fair compensation is needed in the economic evaluation of the invisible activities of ID physicians, especially activities of infection control and antimicrobial stewardship. Moreover, as the importance of infection control is more evident due to continuous epidemics of emerging ID, designating the required number of ID physicians according to the number of beds, apart from infection control doctors, might be a strategy to overcome the current situation.

This study had some limitations. The study population was limited to ID physicians treating adults only; therefore, we could not estimate the infection-related specialist workforce, including pediatric ID specialists and clinical microbiologists. Second, we did not assess all aspects of the assignment, such as the actual scope of work, workloads, and compensations. Further studies with in-depth surveillance or interview are needed to overcome these limitations.

The increasing significance, scarcity, and wide regional disparity of ID physicians have been highlighted, emphasizing the current domestic status, particularly with the COVID-19 pandemic. It is crucial to secure qualified experts to properly deal with community and hospital-acquired ID, antimicrobial resistance, and emerging ID, including COVID-19, and execute exclusive tasks of ID physicians.

This study was approved by the Institutional Review Board (IRB) and Ethics Committee of Soonchunhyang University Seoul Hospital (IRB No. 2020-05-016). Informed consent was waived by the board.

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We are grateful to the Korean Society of Infectious Diseases for supporting this study. Supplementary Table 1 

 Supplementary Fig. 2 The number of total specialists, internal medicine specialists, and infectious diseases physicians by year.