The Arrivals Gate at Heathrow Airport (2024)

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There's a great opening from Richard Curtis' 2003 film Love Actually (arguably one of the best Rom Coms of all time):

“Whenever I get gloomy with the state of the world, I think about the arrivals gate at Heathrow Airport. General opinion makes out that we live in a world of hatred and greed. I don’t see that. Seems to me that love is everywhere. Often, it's not particularly dignified or noteworthy but it's always there. Fathers and sons, mothers and daughters, husbands and wives, boyfriends, girlfriends, old friends. When the planes hit the Twin Towers, none of the phone calls from people on board were messages of hate or revenge, they were all messages of love. If you look for it, I’ve got a sneaky feeling you’ll find that love actually is all around.”

On 29 November 2023, Infectious Diseases (ID) fellowship program directors and applicants opened their emails to see the results of the ID Fellowship Match. Because our program did not fill on Match Day last year, I was fairly anxious this year to open that email. It was reassuring and inspiring to find out that we matched an amazing group of future ID physicians. Unfortunately, many other programs were not as lucky as we were and the overall results from this year's Match escalated the ID workforce challenges to a new level.

The numbers can be tricky to interpret and it's important to look at the nuances in the data. For me, the number of ID fellowship applicants and the number of ID fellowship positions are the most informative. In 2019, 356 applicants were matched of 401 available fellowship positions. Since then, the number of applicants applying to ID fellowship has remained relatively stable (∼350/year), with an uptick and peak of 404 in 2021 [1]. This is remarkable progress and represents the incredible effort that the Infectious Diseases Society of America (IDSA) and others have put into addressing ID workforce issues. Unfortunately, this year, only 305 people applied to the field [2].

Moreover, the number of applicants has not kept pace with the number of available fellowship positions. This year, there were more ID fellowship positions available than there ever have been in the history of the specialty (another positive milestone that reflects the increasing demand for ID-trained physicians). Unfortunately, with fewer applicants, a larger proportion of positions were unfilled (32%) [2].

When our program did not fill last year for the first time in more than 15 years, the urgency of this issue reached new heights for me personally. Around this time, I discovered the work of Simon Sinek, who has written several books on the art of leadership and understanding how and why people make decisions based on trust and a sense of belonging. I am by no means a behavioral psychologist, but I’ve been trying to better understand what drives people to make certain decisions and choices about their careers.

Sinek describes what he terms “The Golden Circle” in which he explains that successful leaders always start with why they do what they do and not with what they do or how they do it [3]. In other words, it's not what you do that matters but why you do it and what you believe. He gives the example that Martin Luther King, Jr., gave the “I Have a Dream” speech, not the “I Have a Plan” speech. In other words, King articulated his values and vision for equality in his speech rather than presenting a detailed strategic plan on how to make his vision realized. To lead effectively, we need to articulate our passion, our love, and our motivation in a way that resonates with the next generation.

As applied to ID, a traditional approach to talking to trainees about our field would sound something like this:

“In ID, we care for patients with a variety of infections, from human immunodeficiency virus (HIV) to critically ill patients with multidrug-resistant organisms (the what). We obtain detailed histories, perform comprehensive physical exams, and employ an evidence-based and judicious approach to the work-up and treatment (the how). Want to join our field?”

A more inspired approach starts from the inside out. It starts with why. What we do and how we do it stems from our why. An example of this approach might sound something like this:

“In ID, we seek to eliminate injustice and health disparities to improve the lives of the most marginalized patient populations (the why). We obtain detailed histories, perform comprehensive physical exams, and employ an evidence-based and judicious approach to the work-up and treatment (the how) in order to care for patients with a variety of infections, from HIV to critically ill patients with multidrug-resistant organisms (the what). Want to join our field?”

This inside-out approach allows people to form connections and communities with others who have a common set of values and beliefs and thereby establish a sense of meaning and purpose in what they are doing. When we demonstrate our relentless commitment to caring, advocating, and fighting for our patients, we inspire trainees and, perhaps, connect with them on a level that resonates with who they are, what they value, and why they decided to become a physician in the first place. In short, it allows them to feel seen. This is exactly what drew me to the field of ID during my formative years and what continues to fuel my passion and love for the best specialty out there.

I went to college with the intention of majoring in English so that I could be an English teacher. In high school, I had been drawn to works by Maya Angelou, F. Scott Fitzgerald, Zora Neale Hurston, and others because of the way in which they used language to give voice and understanding to the human condition. Because I needed to take a science course to fulfill my college's graduation requirements, I ended up in a class titled “Humans and Viruses” in which I encountered Bob Siegel, an unconventional professor whose enthusiasm for viruses was more contagious than the pathogens he taught about in his lectures. I was so inspired by his energy, passion, and knowledge of virology and its impact on human health that I changed my major, became pre-med, and now, more than 20 years later, I am an ID physician and educator. During these transformative years, I was also moved by books like Infections and Inequalities by Paul Farmer; his stories and experiences inspired me to commit my life's work to addressing health disparities [4]. Bob Siegel, Paul Farmer, and others were early role models for me. Not just in their focus on ID but through their love and devotion to the field and their never-ending quest to improve human health.

I believe that in medical training, we (consciously or subconsciously) incorporate aspects of our teachers into our unique professional identities. I remember rotating on the Medicine Wards at San Francisco General Hospital as an intern where I was taking care of an incredibly sick patient with advanced HIV. I was struck by how my Attending, Annie Luetkemeyer, advocated for a treatment we were told was too expensive and how, despite this, she continued to collaborate with experts at our institution and beyond to obtain the life-saving therapy he needed. When we found him fevering and rigoring on rounds, she placed ice packs behind his neck and positioned his fan in a way that helped to cool him without drying out his lips. I hadn’t thought about this experience until just a few months ago when I was seeing one of my long-term patients who needed a simple procedure to restore his vision. Had he been rich, well-insured, health literate, and from a background of privilege, I could have easily clicked a few buttons in the electronic health record to get him set up for the procedure. But he was not any of these things. And so, I found myself on a mission to get this patient the procedure he needed, advocating up the chain of command in our health system to make it happen. When my patient was followed up in clinic and told me that he could finally see me, I teared up. And I had the realization that my patient advocacy stemmed from the examples of teachers like Dr. Luetkemeyer (and so many others) who have profoundly impacted me.

I think about this impact when I am working with trainees or talking with them about a potential future career in ID. I tell them that being an ID physician is not easy. We do what we do because we are driven to relieve the suffering of patients often marginalized by society. We never tire of building histories with our patients (double meaning intentional), exuding empathy, solving mysteries, and striving to deepen our cultural humility. And I tell them that despite the challenges, I LOVE my job. It sounds cliché, but caring for people with HIV and teaching the next generation of ID physicians is a calling, a privilege, and an honor. I cannot imagine deriving this much meaning and purpose from any other field.

My personal anecdote is just an N of 1. And although I am a data- and evidence-driven person, I am the first to admit that narratives carry the day when it comes to impacting human behavior. We all want to be seen. We want to feel like what we do means something. We want to feel like we belong and that we can contribute. When we belong to a community with a shared set of common values and beliefs, we can crystalize our own identities, take risks, and achieve self-efficacy.

Recently, the IDSA and its leadership have laid out a plan to realize a vision of the ID workforce as a “robust, diverse, and innovative community that advances scientific discovery and protects and heals the world” [5]. Many incredible people are doing really important work at the federal and local levels to address compensation, loan forgiveness, work–life balance, and diversity in the ID workforce. This work is essential, and I commend the IDSA for prioritizing this important topic. Although change can be frustratingly slow, I am confident that we will continue to see more and more positive benefits from these efforts over time. I’m also open to more extreme efforts such as those proposed by Brad Spellberg, who encourages ID to align with market forces by carving out crucial patient care services that only ID specialists are allowed to perform (eg, interpreting complex microbiologic diagnostic tests, prescribing specialized antimicrobials) [6].

But based on my personal experiences as well as expertise from Sinek and others in the business world, I would suggest that we continue to devote time and effort as a community to discovering, articulating, and communicating our why and our love for our field with students and trainees. We should continue to emphasize how much of our work centers around topics that are incredibly important to the next generation such as health disparities, social justice, and climate change. We should highlight the incredible range of ID careers out there—clinical scientist, laboratory scientist, clinician educator, public health officer, global health leader, and on and on. I believe this approach will inspire students and draw trainees to our field as we concurrently address compensation and other related challenges.

Paraphrasing Simon Sinek, people don’t care what you do, they care why you do it. At the end of the day, people want to be inspired, feel like they belong, and have a sense that what they are doing with their lives does in fact matter. When addressing the ID workforce issue, remember the arrivals gate at Heathrow Airport. If you look around our specialty, you will see that it is filled with the smartest, most compassionate, and most inspiring people I know. And the love that we have for the work that we do can move mountains.

So, what's your why?

References

Author notes

Potential conflicts of interest. D. W. reports speaking honoraria paid directly to the author from Clinical Care Options, Vindico Medical Education, and eHIV Review DKBMED; paid leadership or fiduciary role on Scientific Advisory Board for ViiV Healthcare. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.

© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.

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