Abstract
Infectious disease (ID) specialists play a vital role in diagnosing and treating IDs, managing infection control, implementing antimicrobial stewardship programs, and responding to pandemics. Despite their importance, the number of ID specialists has been declining. This study aimed to identify the factors influencing the choice of ID fellowship among internal medicine residents in South Korea and explore strategies to increase application rates. A nationwide survey was conducted among internal medicine residents in South Korea to investigate the factors influencing their decision to apply for ID specialties. The survey included questions on demographic characteristics, career preferences, perceptions of ID specialties, and areas requiring improvement to increase the number of ID applications. Comparisons of each group used χ2/Fisher’s exact, t test or Mann–Whitney U tests, followed by multivariate logistic regression to identify independent factors associated with intention to apply for ID fellowship. Among the 250 respondents, only 2.4% applied to the ID specialty, 19.2% considered but did not apply, and 78.4% did not consider the specialty. More than 80% of the respondents recognized the diverse roles and importance of ID specialists. Respondents who applied to the ID specialty were more likely to find the medical school ID curriculum to be of high-quality (P = .029). Responders whose career choices were influenced by the medical school ID curriculum were significantly more likely to consider an ID fellowship (adjusted odds ratio [aOR] 3.09, 95% confidence interval 1.61–5.90, P = .001), and those positively influenced by the diverse roles of ID professors showed increased likelihood (aOR 2.62, 95% confidence interval 1.24–5.53, P = .012). Strengthening the compensation system (86.4%) was identified as the most critical factor for attracting more residents to ID specialties. Ensuring adequate educational time (P < .001), expanding research opportunities (P = .008), and increasing salaries (P = .012) were identified as the key factors for attracting more applicants. Enhanced educational experience, mentorship, and improvements in compensation and workload are essential for increasing interest in ID specialties among internal medicine residents, thereby strengthening the ID workforce and ensuring preparedness for future ID threats.
Keywords: Infectious diseases, Infectious disease specialty, Internal medicine residents
Key Points.
The number of ID specialists is declining, and inadequate compensation, workload, and insufficient dedicated time for education and research are major barriers to fellowship applications.
High-quality medical school curricula and mentorship from ID faculty significantly increase residents’ interest in pursuing the specialty.
Comprehensive improvements in education, mentorship, and working conditions are essential to strengthen the ID workforce and future infectious disease preparedness.
1. Introduction
Infectious disease (ID) specialists fulfill diverse and essential roles encompassing the diagnosis and treatment of ID, infection control, antimicrobial stewardship programs,[1] pandemic preparedness and response, as well as education and research. The role of ID specialists has been further emphasized in recent challenges, including multiple pandemics and the growing threat of antimicrobial-resistant pathogens.[2]
According to the annual report of medical subspecialties, the number of newly certified ID specialists in Korea has remained steady at 19 to 21 per year from 2017 to 2019.[3] This number peaked at 29 in 2020 but decreased to 16 in 2021.[4] In contrast to other internal medicine subspecialties that have shown similar or slightly declining trends, the ID subspecialty has experienced a significant decline since 2021.[4] In the United States, the number of internal medicine residents choosing ID fellowship programs has declined since 2010, raising concerns regarding their potential impact on the management of opportunistic infections, antibiotic resistance and stewardship, and ID outbreaks.[5,6] A study investigating factors influencing the selection of ID specialties found that internal medicine residents who chose the field often developed an interest before residency, whereas the relatively low salary of ID compared with other specialties was the most significant negative factor for those who considered but ultimately did not choose ID.[5,6]
In Korea, the role of ID specialists was highlighted during the 2015 Middle East respiratory syndrome (MERS) outbreak and the coronavirus disease 2019 (COVID-19) pandemic. However, the growing burden of medical litigation risks, the collapse of essential healthcare services, and conflicts between the medical community and the government, which have led to widespread resignation among residents, are expected to further reduce the number of newly certified ID specialists in the future. This suggests that the decreasing number of newly certified ID specialists will result in a significant gap in the diagnosis and treatment of IDs as well as in the response to future emerging ID pandemics, management of multidrug-resistant infections, and implementation of antibiotic stewardship. Despite the critical role of ID specialists, applications to ID fellowships have declined, and limited data exist on how residency training experiences and perceptions influence this decision. Therefore, this nationwide survey aimed to identify factors associated with internal medicine residents’ intention to apply for an ID fellowship.
2. Methods
2.1. Study design and population
This nationwide cross-sectional analytic study using a survey investigated factors associated with internal medicine residents’ intention to apply for an ID fellowship. All internal medicine residents in South Korea in 2023 (n = 1817) were considered the target population. The survey link was distributed through professional networks and academic contacts, including the Korean Society of IDs; therefore, the exact number of individuals who received the invitation could not be determined.
A survey link was distributed to this population, and only respondents who provided consent were included in the analysis, while those who did not consent or did not complete the questionnaire were excluded. The survey questionnaire was developed by the authors based on previously published surveys addressing career choice and perceptions of ID specialties,[7,8] with modifications to reflect the local training context. The draft questionnaire was reviewed by ID faculty members and revised to improve clarity and content validity. A pilot study was not conducted because the survey was intended to be distributed simultaneously to the entire target population during a limited survey period. Therefore, internal consistency reliability was not formally assessed. An email encouraging internal medicine residents to voluntarily participate in the survey was sent to the ID staff at hospitals nationwide through the Korean Society of IDs. The email was sent twice at 2-week intervals. An online survey link was forwarded to the residents through text messages. The respondents voluntarily completed the survey, were anonymized, and only a single response per participant was included. To minimize selection bias, survey themes were not disclosed beforehand.
2.2. Survey items
Survey items included the baseline characteristics of respondents, such as age, sex, type of graduation, marital status, and number of children. Additional items covered the place of work, type of working institution, number of hospital beds, and number of ID specialists in the hospital. The survey aimed to explore internal medicine residents’ perceptions, experiences, and career decisions regarding ID as a subspecialty. It covered several key areas, including residents’ perceptions of the role and importance of ID specialists, the timing of career decisions, and factors influencing the choice of career fields, including ID or other subspecialties. Questions related to the medical school curriculum and experiences with ID were also included, such as when residents first began training with the ID program and the influences that shaped their interest during ID residency. Additionally, the survey investigated aspects of ID training programs that residents perceived as needing improvement to increase application rates, as well as specific areas for improvement within the ID residency training programs (Supplemental Table 1).
2.3. Statistical analysis
Categorical variables were compared using the χ2 or Fisher’s exact test, as appropriate. Continuous variables were assessed for normality. Normally distributed variables were compared using the Student t test. For non-normally distributed variables, the Mann–Whitney U test (for two groups) or the Kruskal–Wallis test (for 3 or more groups) was used as appropriate. All tests of significance were two-tailed, and P values < .05 were considered statistically significant. Subsequently, a multiple logistic regression analysis was performed for variables with a P value < 0.1 in the univariate analysis, based on the backward Wald selection method. The results are reported as an odds ratio (OR) with 95% confidence interval (CI). All statistical analyses were performed using SPSS for Windows, version 26 (SPSS Inc., Chicago).
2.4. Ethics statement
This study was approved by the Institutional Review Board of the Uijeongbu Eulji Medical Center, University of Eulji College of Medicine (IRB no.: 2023-09-005-001). Prior to the initiation of the questionnaire, participants were presented with an informed consent statement. Only those who provided electronic consent proceeded to the survey.
3. Results
This study aimed to identify factors associated with internal medicine residents’ intention to apply for an ID fellowship. The results below describe the demographic characteristics of respondents, their perceptions of ID specialists, and factors influencing their career decisions.
3.1. Demographic characteristics of respondents
Of the 1817 internal medicine residents in South Korea in 2023, 250 residents responded to the survey, yielding a response rate of 13.8%, and were included in the analysis. Among the 250 internal medicine residents who participated in the survey, 3 groups were identified: those who applied to the ID fellowship program (n = 6), those who considered applying but did not apply (n = 48), and those who did not consider the ID program (n = 196). The median age of the respondents was similar across the groups (range, 30.0–31.0 years), and there was no significant difference in sex distribution. Among the 3 groups, respondents who applied to the ID fellowship were more likely to have children (50%) than those who considered applying but did not apply and those who did not consider applying (P = .047). The median number of ID specialists at the respondents’ institutions was consistent across all groups, with a median of 4 (Table 1).
Table 1.
Characteristics of respondents.
| Characteristic | Respondents, number (%) | ||||
|---|---|---|---|---|---|
| Applied to ID (n = 6) |
Considered but did not apply (n = 48) |
Not-applied to ID (n = 196) |
Total (n = 250) |
P-value | |
| Respondent factors | |||||
| Age (yr), median, (IQR) | 31.0 (26.7–41.2) | 30.0 (28.3–32.0) | 31.0 (28.0–33.0) | 31.0 (28.0–33.0) | .671 |
| Sex, male | 4 (66.7) | 20 (41.7) | 111 (56.6) | 135 (54.0) | .161 |
| Graduation from a medical school* | 6 (100) | 32 (66.7) | 125 (63.8) | 163 (65.2) | .182 |
| Married | 3 (50.0) | 10 (20.8) | 65 (33.2) | 78 (31.2) | .155 |
| Have children | 3 (50.0) | 5 (10.4) | 35 (17.9) | 43 (17.2) | .047 |
| Place of work | |||||
| Capital region | 4 (66.7) | 34 (72.3) | 140 (71.4) | 178 (71.2) | .958 |
| Non-capital region | 2 (33.3) | 13 (27.7) | 56 (28.6) | 71 (28.4) | .958 |
| Type of medical institution | |||||
| Tertiary-care hospital | 5 (83.3) | 41 (85.4) | 154 (78.6) | 200 (80) | .558 |
| General hospital | 1 (16.7) | 7 (14.6) | 42 (21.4) | 50 (20) | .558 |
| Number of hospital beds | |||||
| ≥1200 | 3 (50.0) | 21 (43.8) | 62 (31.6) | 86 (34.4) | .206 |
| 900–1200 | 1 (16.7) | 10 (20.8) | 54 (27.6) | 65 (26.0) | .221 |
| 600–900 | 3 (50.0) | 13 (27.1) | 50 (25.5) | 66 (26.4) | .406 |
| 300–600 | 0 (0) | 3 (6.3) | 27 (13.8) | 30 (12.0) | .235 |
| ≤300 | 0 (0) | 1 (2.1) | 3 (1.5) | 4 (1.6) | .917 |
| Numbers of ID specialists in the hospital, median (IQR) | 4 (2.8–5.0) | 4 (3.0–5.0) | 4 (3.0–5.0) | 4 (3.0–5.0) | .369 |
Data are presented as the number (%) of responders unless otherwise indicated.
ID = infectious disease, IQR = interquartile range.
The remainder refers to graduate schools of medicine.
3.2. Perception of internal medicine residents on the role and importance of ID specialists
Across all groups, >80% of respondents recognized the diverse roles of ID specialists, including the diagnosis and treatment of IDs, hospital infection control, antibiotic stewardship, and academic activities. Most respondents acknowledged the critical contributions of ID specialists. All respondents recognized that the involvement of ID specialists decreased hospitalization and mortality rates and acknowledged the importance of ID specialists.
Regarding the adequacy of the current number of ID specialists, 85% of participants agreed that the ID workforce was insufficient. Most respondents across all groups agreed that ID specialists’ opinions should be incorporated into national ID policies, including pandemics such as COVID-19, with 100% agreement in the applied group, 93.8% in the considered group, and 89.8% in the not-applied group (P = .512; Table 2).
Table 2.
Perception of internal medicine residents on the role and importance of ID specialists.
| Characteristic | Respondents, number (%) | ||||
|---|---|---|---|---|---|
| Applied to ID (n = 6) |
Considered but did not apply (n = 48) |
Not-applied to ID (n = 196) |
Total (n = 250) |
P-value | |
| An ID specialist diagnoses and treats infectious diseases. | 6 (100) | 47 (97.9) | 183 (93.4) | 236 (94.4) | 0.393 |
| ID specialists play a role in hospital infection control. | 6 (100) | 46 (95.8) | 180 (91.8) | 232 (92.8) | 0.498 |
| ID specialists provide education on infectious diseases and antibiotic use to healthcare professionals and the general public. | 6 (100) | 40 (83.3) | 161 (82.1) | 207 (82.8) | 0.519 |
| ID specialists are responsible for antibiotic stewardship. | 6 (100) | 42 (87.5) | 175 (89.3) | 223 (89.2) | 0.648 |
| ID specialists are involved in academic activities such as student education and research. | 6 (100) | 44 (91.7) | 167 (85.2) | 217 (86.8) | 0.312 |
| The majority of ID specialists perform multiple roles simultaneously. | 6 (100) | 42 (87.5) | 168 (85.7) | 216 (86.4) | 0.586 |
| The compensation for ID specialists seems low. | 6 (100) | 41 (85.4) | 152 (77.6) | 199 (79.6) | 0.220 |
| ID specialists appear tired and stressed. | 6 (100) | 30 (62.5) | 120 (61.2) | 156 (62.4) | 0.156 |
| The involvement of ID specialists in the diagnoses and treatment decreases the mortality rates | 5 (83.3) | 45 (93.8) | 171 (87.2) | 221 (88.4) | 0.419 |
| The role of ID specialists is extremely important. | 6 (100) | 47 (97.9) | 179 (91.3) | 232 (92.8) | 0.226 |
| The current number of ID specialists is adequate. | 2 (33.3) | 10 (20.8) | 26 (13.3) | 38 (15.2) | 0.195 |
| ID specialists’ opinions should be included in national ID policies, including pandemics such as COVID-19. | 6 (100) | 45 (93.8) | 176 (89.8) | 227 (90.8) | 0.512 |
| The opinions of ID specialists are adequately reflected in national policies related to infectious diseases. | 4 (66.7) | 15 (31.3) | 68 (34.7) | 87 (34.8) | 0.230 |
The data represent the number of respondents who answered “yes” to each question.
COVID-19 = coronavirus disease 2019, ID = infectious disease.
3.3. Timing and factors influencing the choice of a career in the ID or other fields
Among the 250 respondents, excluding 89 (35.6%) who had not yet chosen a specialty, 6 (3.7%) chose ID as their specialty. Among those who did not choose the ID specialty, the most commonly chosen specialty was gastroenterology (49.7%), followed by nephrology (21.7%) and cardiology (12.4%). Regarding the timing of career decisions, internal medicine residents who chose ID were evenly distributed across the first, second, and third years, with 2 residents from each year, showing no differences in the timing of their choice (Table 3).
Table 3.
Timing of subspecialty choice of a career in the ID or other fields.
| Characteristic | Respondents, number (%) | ||||
|---|---|---|---|---|---|
| Applied to ID (n = 6) |
Considered but did not apply (n = 48) |
Not-applied to ID (n = 196) |
Total (n = 250) |
P-value | |
| Chosen career field | |||||
| ID | 6 (100) | 0 (0) | 0 (0) | 6 (2.4) | N/A |
| Cardiology | – | 6 (12.5) | 14 (7.1) | 20 (8.0) | .225 |
| Nephrology | – | 7 (14.6) | 28 (14.3) | 35 (14.0) | .958 |
| Pulmonology | – | 2 (4.2) | 2 (1.0) | 4 (1.6) | .124 |
| Gastroenterology | – | 12 (25.0) | 68 (34.7) | 80 (32.0) | .200 |
| Hemato-oncology | – | 1 (2.1) | 6 (3.1) | 7 (2.8) | .716 |
| Endocrinology | – | 1 (2.1) | 4 (2.0) | 5 (2.0) | .985 |
| Allergy and immunology | – | 0 (0) | 1 (0.5) | 1 (0.4) | N/A |
| Rheumatology | – | 2 (4.2) | 1 (0.5) | 3 (1.2) | .039 |
| Yet to be determined | – | 17 (35.4) | 72 (36.7) | 89 (35.6) | .865 |
| When did you first decide on your chosen career field? | |||||
| During medical school, prior to clinical rotations | 0 (0) | 4 (8.3) | 9 (4.6) | 13 (5.2) | N/A |
| During medical school, after clinical rotations | 0 (0) | 1 (2.1) | 9 (4.6) | 10 (4.0) | N/A |
| During the first yr of residency | 2 (33.3) | 6 (12.5) | 32 (16.3) | 40 (1.6) | .408 |
| During the second yr of residency | 2 (33.3) | 9 (18.8) | 26 (13.3) | 37 (14.8) | .274 |
| During the third yr of residency | 2 (33.3) | 11 (22.9) | 47 (24.0) | 60 (24.0) | .853 |
| Yet to be determined | 0 (0) | 17 (35.4) | 72 (36.7) | 89 (35.6) | N/A |
| When did you first begin training in ID? | |||||
| Early first-yr resident | 0 (0) | 16 (33.3) | 54 (27.6) | 70 (28.0) | N/A |
| Late first-yr resident | 2 (33.3) | 10 (20.8) | 43 (21.9) | 55 (22.0) | .784 |
| Early second- yr resident | 0 (0) | 10 (20.8) | 32 (16.3) | 42 (16.8) | N/A |
| Late second- yr resident | 2 (33.3) | 1 (2.1) | 15 (7.7) | 18 (7.2) | .017 |
| Early third- yr resident | 1 (16.7) | 6 (12.5) | 14 (7.1) | 21 (8.4) | .371 |
| Not yet trained in infectious diseases | 1 (16.7) | 5 (10.4) | 37 (18.9) | 43 (17.2) | .379 |
The data represent the number of respondents who answered “yes” to each question.
ID = infectious disease, N/A = not available.
Fig. 1 shows the factors influencing the choice of careers in ID and other fields among internal medicine residents. Expertise (82.4%) was the most frequently reported factor, followed by work–life balance (77.6%) and high salary (74.8%), which served as significant motivators.
Figure 1.
Factors influencing the choice of a career in the ID or other fields. The data represent the percentage of respondents who answered “yes” to each question among all internal medicine residents (n = 250), those who applied to the ID specialty (n = 6), and those who considered but did not apply (n = 48). ID = infectious disease.
3.4. Medical school curriculum, experiences, and career influences in ID residency
The considered group showed significantly higher levels of interest and positive experiences with the ID curriculum during medical school compared with the other groups. Specifically, 70.8% of this group found the ID curriculum interesting, significantly higher than that of the applied (33.3%) and not-applied (40.3%) groups (P = .001). Additionally, 72.9% rated the curriculum as high-quality. Moreover, 52.1% of this group rated case-based discussions on ID as superior (P = .025). During residency, the medical school ID curriculum experience positively influenced interest in the applied group (83.3%), more so than the considered (54.2%) and not-applied (32.7%) groups (P = .002). All 3 groups agreed (100%) that faculty members were passionate teachers. The diverse roles of ID professors positively impacted 66.7% of the applied group and 81.3% of the considered group. Positive mentorship was reported more often by the applied (66.7%) and considered (81.3%) groups than the not-applied group (58.2%; P = .012) (Table 4).
Table 4.
Medical school curriculum, experiences, and career influences in ID residency.
| Characteristic | Respondents, number (%) | ||||
|---|---|---|---|---|---|
| Applied to ID (n = 6) |
Considered but did not apply (n = 48) |
Not-applied to ID (n = 196) |
Total (n = 250) |
P-value | |
| Medical school curriculum and experiences in ID | |||||
| It was interesting to me. | 2 (33.3) | 34 (70.8) | 79 (40.3) | 115 (46.0) | .001 |
| It was of high-quality. | 4 (66.7) | 35 (72.9) | 102 (52.0) | 141 (56.4) | .029 |
| The case-based discussion process was superior compared with other subjects. | 2 (33.3) | 25 (52.1) | 61 (31.1) | 88 (35.2) | .025 |
| Hospital internships with patient exams were better than other subjects. | 3 (50.0) | 20 (41.7) | 61 (31.1) | 84 (32.4) | .266 |
| The laboratory classes were better than other subjects. | 1 (16.7) | 10 (20.8) | 42 (21.4) | 53 (21.2) | .959 |
| This inspired my interest in ID during residency. | 5 (83.3) | 26 (54.2) | 64 (32.7) | 95 (38.0) | .002 |
| The faculty members were passionate teachers. | 6 (100) | 48 (100) | 196 (100) | 250 (100) | 1.000 |
| The ID curriculum influenced my career choice during residency. | 3 (50.0) | 28 (58.3) | 0 (0) | 31 (12.4) | <.001 |
| Questions related to ID residency | |||||
| I developed an academic interest in ID | 5 (83.3) | 41 (85.4) | 92 (46.9) | 138 (55.2) | <.001 |
| Patient care in ID aligns with my skills and interests. | 5 (83.3) | 23 (47.9) | 40 (20.4) | 68 (27.2) | <.001 |
| My knowledge of ID was adequate during the residency. | 1 (16.7) | 11 (22.9) | 10 (5.1) | 22 (8.8) | <.001 |
| I received extensive training from my supervising professor. | 4 (66.7) | 39 (81.3) | 128 (65.3) | 171 (68.4) | .104 |
| I participated in ID conferences. | 5 (83.3) | 33 (68.8) | 118 (60.2) | 156 (62.4) | .311 |
| I participated in research activities, including manuscript writing, poster presentations, and conference attendance. | 1 (16.7) | 9 (18.8) | 24 (12.2) | 34 (13.6) | .489 |
| The research activities I participated in contributed to my career decision. | 2 (33.3) | 10 (20.8) | 23 (11.7) | 35 (14.0) | .103 |
| I was positively influenced by the diverse roles of ID professors, including diagnosis, treatment, consultations, hospital infection control management, antibiotic stewardship, and pandemic response. | 4 (66.7) | 39 (81.3) | 104 (53.1) | 147 (58.8) | .002 |
| I received positive mentorship from my ID professor. | 4 (66.7) | 39 (81.3) | 114 (58.2) | 157 (62.8) | .012 |
The data represent the number of respondents who answered ”yes” to each question.
ID = infectious disease.
To identify independent factors associated with intention to apply for an ID fellowship, a multivariate analysis was conducted comparing residents who had considered applying for ID (Applied to ID, n = 6; Considered but did not apply, n = 48; total n = 56) with those who had not considered applying (Did not apply to ID, n = 196). Residents whose career choices were influenced by the medical school ID curriculum were significantly more likely to consider an ID fellowship (adjusted OR, 3.085; 95% CI, 1.613–5.898; P = .001). In addition, being positively influenced by the diverse roles of ID professors—such as clinical care, consultations, hospital infection control, antibiotic stewardship, and pandemic response—was independently associated with ID fellowship consideration (adjusted OR, 2.620; 95% CI, 1.241–5.532; P = .012) (Table 5).
Table 5.
Multivariate analysis of factors associated with consideration of an infectious disease fellowship among residents.
| Characteristics | Univariate analysis | Multivariate analysis | ||
|---|---|---|---|---|
| Unadjusted OR (95% CI) |
P | Adjusted OR (95% CI) |
P | |
| Medical school curriculum, experiences, and career influences in ID residency | ||||
| It was interesting to me. | 2.962 (1.572–5.582) | .001 | ||
| The ID curriculum influenced my career choice. | 3.832 (2.048–7.171) | <.001 | 3.085 (1.613–5.898) | .001 |
| Questions related to ID residency | ||||
| I received extensive training from my supervising professor. | 2.077 (1.006–4.286) | .048 | ||
| The research activities I participated in contributed to my career decision. | 2.149 (0.990–4.665) | .053 | ||
| I was positively influenced by the diverse roles of ID professors, including diagnosis, treatment, consultations, hospital infection control management, antibiotic stewardship, and pandemic response. | 3.458 (1.685–7.099) | .001 | 2.620 (1.241–5.532) | .012 |
CI = confidence interval, ID = infectious disease, OR = Odds ratio.
3.5. Aspects of ID training programs needing improvement to increase application rates
Fig. 2 illustrates the aspects requiring improvement to increase application rates for the ID specialty, as perceived by internal medicine residents. Across all groups, strengthening the compensation system, including vacation allowances and rewards for pandemic response (86.4%), was the most commonly endorsed factor. A salary increase to a level comparable to or higher than that of other specialties (84.8%) was also highlighted as a critical area for improvement. Other aspects included reduced workload (83.6%), reflecting ID specialists’ opinions on infection policies (83.2%), raising awareness regarding ID specialists’ roles (79.6%), and expanding our understanding of ID specialists’ diverse roles (74.4%).
Figure 2.
Aspects needing improvement to increase the number of applications to the ID specialty. The data represent the percentage of respondents who answered “yes” to each question among all internal medicine residents (n = 250), those who applied to the ID specialty (n = 6), and those who considered but did not apply (n = 48). ID = infectious disease.
3.6. Areas for improvement in the ID residency training program
Ensuring sufficient educational time was a significant concern, as reported by 83.3%, 81.3%, and 51.5% of the applied, considered, and not-applied groups, respectively (P < .001). Expanding opportunities for conferences and research were emphasized by 83.3%, 54.2%, and 36.2, respectively (P = .008). Increasing residents’ involvement in patient care, consultations, and infection control was crucial for 100%, 79.2%, and 51.0% of the applied, considered, and not-applied groups, respectively (P < .001). Among residents who did not choose the ID specialty, some indicated that they might have considered pursuing ID if the salary level had been higher (P = .012) or if pandemics such as MERS and COVID-19 had not occurred (P = .001) (Table 6).
Table 6.
Areas for improvement in the ID residency training program as perceived by internal medicine residents.
| Characteristic | Respondents, number (%) | |||
|---|---|---|---|---|
| Applied to ID (n = 6) |
Considered but did not apply (n = 48) |
Not-applied to ID (n = 196) |
P-value | |
| For all internal medicine residents | ||||
| Ensuring sufficient educational time for residents | 5 (83.3) | 39 (81.3) | 101 (51.5) | <.001 |
| Expanding opportunities for conference and research participation | 5 (83.3) | 26 (54.2) | 71 (36.2) | .008 |
| Increasing resident engagement in active and proactive roles in patient diagnosis, treatment, consultations, and infection control processes | 6 (100) | 38 (79.2) | 100 (51.0) | <.001 |
| For internal medicine residents who did not select ID | ||||
| If the salary had increased, I would have chosen ID over my current specialty | 25 (52.1) | 64 (32.7) | .012 | |
| If the MERS and COVID-19 pandemics had not occurred, I would have considered applying for ID | 15 (31.3) | 23 (11.7) | .001 | |
The data represent the number of respondents who answered yes to each question.
ID = infectious disease, MERS = Middle East respiratory syndrome, COVID-19 = coronavirus disease 2019.
Overall, internal medicine residents demonstrated a high level of awareness regarding the roles and importance of ID specialists. While most demographic characteristics were comparable across groups, respondents who applied to the ID fellowship were more likely to have children. Interest and positive experiences related to the medical school ID curriculum and mentorship were more prominent among residents who considered or applied to ID, and these factors remained independently associated with the intention to apply for an ID fellowship in multivariate analysis. Across all groups, structural factors such as compensation, workload, and educational opportunities were commonly identified as areas requiring improvement.
4. Discussion
In this nationwide survey of 250 internal medicine residents, only 6 residents chose ID as their specialty, illustrating that, despite the widespread recognition of the critical role of ID specialists, application rates remain low. Key deterrents include concerns about work–life balance, low salaries, and high workloads. Although early interest and mentorship increased its consideration, they were insufficient for driving applications. Addressing these barriers through better compensation, workload management, and enhanced training opportunities is essential for attracting more applicants and securing a sustainable ID workforce.
The study’s results confirmed that >80% of internal medicine residents generally recognized the diverse roles and importance of ID specialists. Studies have demonstrated that the involvement of ID specialists in the diagnosis and treatment of ID is statistically associated with reduced length of stay in the intensive care unit, decreased mortality rates, lower 30-day readmission rates, and reduced hospitalization costs in acute care hospitals.[9] Despite the internal medicine residents’ strong awareness of the diverse roles and importance of ID specialists, it is essential to examine the factors contributing to the declining application rates to the ID specialty. Overall, internal medicine residents reported that a high level of expertise, favourable work-life balance, and higher salary were important considerations when choosing a specialty, with 82%, 78%, and 75% of respondents, respectively, identifying these factors as influential in their decision making. However, residents perceived that these factors are lacking in the ID specialty. A previous study that surveyed ID specialists found that they worked an average of 60.5 hours per week from Monday to Saturday. Regarding job satisfaction, only 40% of the respondents expressed contentment with their work. Notably, only 16.5% felt adequately supported by human resources, 9.6% reported receiving adequate financial compensation, and only 8.7% stated that they could effectively balance their work and personal responsibilities.[10,11]
In the United States, the steady decline in the number of applicants to the ID specialty has been attributed to factors such as low remuneration, limited exposure to ID during training, and challenges with work–life balance.[7] To address these issues and enhance recruitment, several areas for intervention have been identified, including improvements in medical school curricula,[7,12,13] strengthened mentorship programs,[7] expansion of career pathways,[7,12,13] and revisions to reimbursement strategies.[13] Exposure to ID curriculum prior to residency or during early ID residency training is a significant factor that influences the decision to pursue a career in this field.[7] However, unlike previous studies, our study found no statistically significant association between the timing of training and the choice of specialty. However, compared with the not-applied group, the applied and considered groups reported more positive experiences with the medical school curriculum, clinical experiences, and residency in the ID specialty. Notably, in the applied group, these factors had a statistically significant positive influence on the decision to pursue ID. Furthermore, we found that early exposure to ID training during medical school and residency positively influenced career interests. Positive medical school experiences, favorable early residency exposure to ID and research activities, and active engagement in the diverse roles of ID physicians were influential in encouraging the pursuit of the ID fellowship. Residents who ultimately applied to the ID specialty reported higher rates of inspiration from the medical school curriculum, quality mentorship, and case-based discussions. In our multivariate analysis, 2 factors were independently associated with residents’ consideration of an ID fellowship during residency: having found the ID curriculum during medical school to be influential in shaping their career choice and being positively influenced by the diverse roles of ID professors. These findings indicate that positive experiences with the ID curriculum in medical school can have a lasting impact, promoting consideration of the ID specialty during residency.
A recent U.S. study emphasized the importance of aligning ID recruitment strategies with the interests of medical students who are passionate about public and global health.[14] The authors suggested that strengthening the connection between ID and public/global health domains could help attract students with such interests. Although our study did not assess participants’ interest in public or global health directly, our multivariate findings suggest that residents who found the ID curriculum during medical school engaging and who were positively influenced by the multifaceted roles of ID professors were more likely to consider pursuing an ID fellowship. These results suggest that enhancing the educational content related to ID in the medical school curriculum, particularly by emphasizing the wide-ranging roles of ID specialists and their critical contributions to public health and society, may foster greater interest in the specialty. Furthermore, for medical students or residents who demonstrate a preexisting interest in public or global health, providing targeted educational opportunities, mentorship, and exposure to related ID activities may be an effective strategy to guide them toward ID as a career path. This reinforces the importance of engaging in high-quality educational experiences to foster an interest in ID as a specialty.
Our findings are consistent with those of previous studies reporting that lower salaries and inadequate compensation compared with those of other specialties discourage physicians from choosing ID as a specialty.[7,8,10] To enhance interest in ID residency, residents identified critical areas for improvement, including strengthening the compensation system (86%), increasing salaries (85%), reducing workloads (84%), and integrating ID specialists’ perspectives into infection policy decisions (83%). Notably, 52.1% of those in the considered group indicated that they would have chosen the specialty if salaries were higher. These findings highlight the need to improve the reimbursement structures to attract more applicants. Given the evolving healthcare landscape, relying solely on professional commitment is insufficient for sustaining ID recruitment. Despite their broad responsibilities in clinical care, research, and public health, ID specialists often receive compensation that does not reflect their expertise adequately. Addressing these disparities through competitive remuneration and workload adjustments is essential not only to increase applicant numbers but also to retain specialists, ensuring the long-term stability of the ID workforce. In this context, despite the elevated public recognition of ID specialists during the COVID-19 pandemic, it is necessary to examine why the number of applicants to the ID specialty has not increased and, in fact, has continued to decline. This paradox may reflect a widening gap between societal expectations and actual working conditions. ID physicians played a nationally critical role during the pandemic, yet this was not accompanied by improvements in authority, compensation, or staffing. Rather, they experienced increased responsibility without adequate institutional support, discouraging potential applicants. In addition, ID entails substantial “hidden work,” such as infection control, antimicrobial stewardship, consultations, and education, which are often overlooked. This invisibility may cause the specialty to appear stagnant or unrewarding to residents. Similar trends have been observed internationally, suggesting that the pandemic may have inadvertently reinforced the perception of ID as an overburdened but undervalued field. These findings highlight the need to close the gap between the heightened importance of ID and the lack of meaningful support. Strategic interventions must move beyond symbolic recognition to tangible reforms in training, compensation, and institutional backing to reverse the declining trend.
In response to these challenges, strategic efforts at the academic society level are also needed to enhance interest in the ID specialty. First, initiatives to improve awareness and motivation among residents are crucial. These may include showcasing the diverse roles of ID specialists through interviews, documentaries, or vlogs, operating training programs for residents from institutions lacking adequate ID exposure, and hosting regular “career talks” on ID pathways. Second, structural improvements should be pursued through continuous dialogue with policymakers to ensure proper reimbursement and manpower allocation reflecting the workload of ID specialists. Third, research and education opportunities can be enhanced through society-sponsored fellowships, overseas training support, and the development of high-quality educational content covering topics such as antimicrobial resistance and emerging infections. Fourth, partnerships with teaching hospitals should be strengthened. This includes identifying successful models, sharing best practices for ID training environments, and introducing an official recognition system for “excellent ID training institutions.” Fifth, public campaigns emphasizing the societal contributions of ID specialists—such as their role during COVID-19, in antimicrobial resistance management, and infection control—can improve the specialty’s perceived value among trainees and the general public. Finally, the academic society should support early-career ID physicians through structured networks and collaboration with basic sciences and interdisciplinary fields to attract talented individuals interested in diagnostics, vaccines, and digital health innovations. These multifaceted efforts may help build a more robust and sustainable ID workforce.
Currently, no specific studies have examined the impact of MERS or the COVID-19 pandemic on the subspecialty choice of internal medicine residents. Several studies have investigated the effects of COVID-19 on healthcare workers in South Korea.[10,11,15] Park et al revealed high rates of burnout (90.4%), depression (17.4%), anxiety (20.0%), and stress (4.3%) among ID physicians, regardless of whether they were directly involved in COVID-19 patient care.[10] In the present study, 31% of participants in the considered group reported that they would have considered the ID specialty if the pandemic had not occurred. However, emerging IDs and the resulting pandemics are inevitable recurring events that follow a certain cycle. In such situations, ID specialists play a crucial role in utilizing their expertise to improve global health and contribute to the management of and response to pandemics. Furthermore, they are essential in preparing for future pandemics and ensuring that the healthcare system is ready to face new challenges. Although responding to a pandemic is undoubtedly demanding and requires immense dedication, it also provides ID specialists with a unique opportunity to have a positive impact on public health, offering both professional fulfillment and the chance to contribute meaningfully to the well-being of society. In studies suggesting that the pandemic can have positive effects, healthcare workers developed coping strategies through adaptation, rational thinking, and support from those around them.[15] Along with these efforts, they also experienced positive emotions, including gratitude, a heightened sense of professional responsibility, and personal growth. Despite these challenges, internal responses contributed to their resilience and sustained commitment to their roles during the crisis.[15] Sharing the positive experiences gained during the pandemic with residents through mentorship in the medical curriculum or during ID training could help address and mitigate the negative perceptions surrounding the specialty. This approach may ultimately increase the number of applicants to the ID specialty by fostering a more positive and realistic understanding of the field.
In addition to the pandemic response, the role of ID specialists is becoming increasingly important in the diagnosis, treatment, and infection control of multidrug-resistant pathogens, as well as in ASP.[1] Consequently, the workload of ID specialists inevitably increases. Nevertheless, the number of applications to the ID specialty continues to decline annually. Given the growing reluctance toward essential healthcare fields and the decreased number of residents owing to the conflict between healthcare professionals and the government in South Korea in 2024, it is expected that the decline in interest in the ID specialty and the subsequent decrease in the number of applicants will worsen in the future.[16] It is crucial to strengthen education and enhance compensation, including salaries, to encourage internal medicine residents to choose ID as a specialty. Moreover, it is essential to retain and support this strengthened workforce to ensure the sustainability and growth of the field.
This study has several limitations. First, the response rate of this survey was relatively low, which may limit the representativeness of the sample. Because participation was voluntary and the survey was distributed through professional networks rather than direct individual invitations, the actual number of residents who received the survey link could not be determined. Future studies may improve response rates by using more direct distribution methods, repeated reminders, or institutional collaboration to encourage broader participation. Second, because this study was based on a survey, it was subject to self-reporting limitations. Third, as this survey was conducted prior to the physician–government conflicts in Korea in 2024, it may not fully reflect the current situation. Fourth, the survey focused solely on adult IDs and did not assess perceptions or interest regarding pediatric IDs, which may have different influencing factors and workforce dynamics. Nevertheless, this is the first study to analyze the factors influencing internal medicine residents’ decisions to choose ID as a specialty in Korea, especially in the context of growing concerns about the decreasing number of ID applicants.
This study has several strengths. First, it was a nationwide survey targeting internal medicine residents across South Korea, allowing for a broad assessment of perceptions and career considerations related to ID specialty selection. Second, the study comprehensively examined multiple domains, including demographic characteristics, perceptions of the role of ID specialists, educational experiences, mentorship, and structural factors such as compensation and workload. Third, by including residents who applied to ID, those who considered but did not apply, and those who did not consider ID, this study provides a nuanced understanding of factors associated with intention to apply for an ID fellowship. Finally, the use of multivariate analysis enabled the identification of independent factors associated with ID fellowship consideration, strengthening the robustness of the findings.
5. Conclusion
In conclusion, only a minority of internal medicine residents pursue ID fellowship programs. Early exposure during medical school and meaningful mentorship from ID faculty were positively associated with interest in the specialty. In contrast, workload, low compensation, and limited institutional support served as major deterrents. These findings highlight the need for targeted reforms in education, mentorship, and systemic support. Strengthening these areas is essential to attract future applicants and to secure a resilient ID workforce prepared for future ID threats.
Author contributions
Conceptualization: Hyo-Ju Son, Kyung Hwa Jung.
Data curation: Hyo-Ju Son, Kyung Hwa Jung.
Formal analysis: Hyo-Ju Son, Kyung Hwa Jung.
Investigation: Hyo-Ju Son, Kyung Hwa Jung.
Methodology: Hyo-Ju Son, Kyung Hwa Jung.
Project administration: Hyo-Ju Son, Kyung Hwa Jung.
Resources: Hyo-Ju Son.
Supervision: Hyo-Ju Son.
Validation: Hyo-Ju Son, Kyung Hwa Jung.
Visualization: Hyo-Ju Son, Kyung Hwa Jung.
Writing – original draft: Hyo-Ju Son, Kyung Hwa Jung.
Writing – review & editing: Hyo-Ju Son, Kyung Hwa Jung.
Abbreviations:
- CI
- confidence interval
- COVID-19
- coronavirus disease 2019
- ID
- infectious disease
- MERS
- Middle East respiratory syndrome
- OR
- odds ratio
The authors have no funding and conflicts of interest to disclose.
All data generated or analyzed during this study are included in this published article (and its supplementary information files).
Supplemental Digital Content is available in the online version of this article (http://dx.doi.org/10.1097/MD.0000000000048818).
How to cite this article: Jung KH, Son H-J. Factors influencing internal medicine residents’ selection of infectious diseases as a specialty in South Korea: A nationwide cross-sectional survey. Medicine 2026;105:21(e48818).
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