Name:
Episode 67: Careers in Infectious Diseases
Description:
Episode 67: Careers in Infectious Diseases
Thumbnail URL:
/images/podcast-microphone-banner.jpg
Duration:
T00H26M42S
Embed URL:
https://stream.cadmore.media/player/f71048e6-20c4-44ae-91ee-e2b4537a542a
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/f71048e6-20c4-44ae-91ee-e2b4537a542a/RTL- Ep 67- Careers.mp3?sv=2019-02-02&sr=c&sig=ig6vWbH0%2F6k2XhAPh2tsBBLhLbdor6gFsZCY7CfoKdA%3D&st=2024-05-06T10%3A14%3A05Z&se=2024-05-06T12%3A19%3A05Z&sp=r
Upload Date:
2022-09-15T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[Dr. Smith] Welcome back to Run the List, a medical education podcast in partnership with McGraw Hill Medical. Our hosts are Dr. Navin Kumar, Dr. Walker Redd, Dr. Emily Gutowski, Dr. Joyce Zhou, and myself, Blake Smith. As a quick disclaimer, this podcast is meant for informational and educational purposes only, and should not be understood as medical advice under any circumstances. [intro music] [intro music] [intro music] [Dr. Smith] I'm really excited to be talking with Dr. Sigal Yawetz, an assistant professor of medicine at Harvard Medical School, and an attending physician in infectious diseases at Brigham and Women's Hospital in Boston.
Her clinical and research interests include the intersection of infectious disease and LGBT health, women's health, including pregnant women with HIV, and she oversees the post-exposure prophylaxis, PEP program at Brigham and Women's Hospital. We're really quite lucky to be talking with her today about her career in infectious diseases, as she's both a leader in the field of ID, and she's a leader for working with and caring for HIV positive patients.
Thank you so much, Dr. Yawetz, for joining us on Run the List. [Dr. Yawetz] Thank you for having me. [Dr. Smith] Great, if we could start, maybe you could begin by telling us a little bit about yourself, and where you did your training. [Dr. Yawetz] So I was born in France, I was raised in Tel Aviv, Israel, where I went to med school right after two years of military service.
And then I followed my husband to Los Angeles, he went there to do a PhD. So as a foreign medical graduate, I had to spend about 15 months in the role of a research fellow in an immunology lab while getting all my licensing, and completing exams to be able to work as a physician in the U.S. And I did my research on HIV.
Then, I did a medical training in the West Los Angeles VA Medical Center, which had a very strong ID presence at the time. And I had some of my greatest mentors there, and came to Boston in '97 to do ID training at the MGH and BWH combined program. And I initially planned to continue immunology lab research here, but then was drawn to HIV clinical care and teaching, which is what I do till this date.
[Dr. Smith] That's amazing. It's really great to hear, kind of from the perspective of, like you said, a foreign medical graduate, and then how you've kind of really pursued your career here in the U.S. So we'll get back to that, but maybe you could be able to describe the field of infectious diseases, and what the training path is like.
[Dr. Yawetz] Yeah, so infectious diseases is a subspecialty of internal medicine, and to be certified in infectious diseases, it requires two years of training beyond general internal medicine. So at our program, like many other programs, the first year is clinical. It involves the rotations on the consult service, clinics, and microbiology lab. And then in the second year, fellows kind of differentiate into two broad directions.
One is more of an investigative path where they do mentored research, and the other is a clinical educator track, which is the one I did. There are some tracks that kind of have an overlap like medical microbiology, hospital epidemiology, infection control, anti-microbial stewardship. And then after two years of training, some people seek clinical positions, and others continue to do research until they become independently funded investigators and can apply for research jobs.
[Dr. Smith] Yeah, definitely. [Dr. Yawetz] So that's what training is like. [Dr. Smith] Thank you for that broad overview. And you began to describe your initial interest in infectious diseases, and how you somewhat chose your specialty, but could you talk more about kind of how you were working in the lab and then you started seeing patients in the clinic in Los Angeles, and how you really honed in on that specialty?
[Dr. Yawetz] Yeah, so I think, I was in med school, and an intern, and as a resident, witnessing the birth of the AIDS epidemic right when I started my life in medicine. And I think like many other infectious diseases doctors of my generation, the AIDS epidemic really shaped our career. So what initially kind of drew me into the field was an interest in basic research, actually, and I wanted to do basic research in a rapidly evolving area.
And then there was this adrenaline rush with a new epidemic, that I think many of us in medicine experience - now with COVID- - [Dr. Smith chuckles] [Dr. Yawetz] -but eventually, instead of doing research, I ended up choosing a clinical career that was almost by chance, when John Brooks, who's a very good friend and a co-fellow, who was supposed to be the clinical fellow at the Brigham, went to the CDC to be an EIS officer, where he's still now a senior medical epidemiologist now actually runs the COVID efforts- [Dr. Smith] Oh, wow.
[Dr. Yawetz] -but he left the HIV clinical educator fellowship spot unmanned, and I kind of very happily and willingly jumped ship from research to the clinical training spot. I think at the time, being a medical student just like you, I witnessed a lot of fear and resistance among healthcare professionals providing care to patients with AIDS. At the same time I saw patients who were young, in fear of dying, seeing their friends die.
I mean I still hear them tell about those stories to medical students when we teach together. They often didn't have their families to lean on, so I kind of felt a sense of duty and urgency to help. And the science was evolving very rapidly and we could take what we learned and apply it to patient care, and see an immediate impact, and it was just a very exciting area at the time, so I felt I could make a difference most doing clinical care, and it seemed like the thing to do at the time.
[Dr. Smith] Yeah, that's a really beautiful response, and kind of incredibly admirable, especially at that point, but even now. And I want to touch on something that you talked about, just how you were a medical graduate who is choosing your clinical specialty around this epidemic boom at that time, and there's been a lot of talk in the past year about individuals, medical students, who are interested in applying to infectious diseases almost kind of surrounding this time and this pandemic.
So what has it been like being an ID physician, both in the '90s and now, and kind of seeing two sides of how a virus has really touched the lives of many people? [Dr. Yawetz] Yeah, I think it's pretty amazing when you do HIV care for those patients, but especially now when you do COVID care to see how a single virus can impact every single aspect of our lives. [chuckles] And I know for COVID it impacted everyone, so I think people can relate to it more.
I think it has the adrenalin rush, as I said, or the excitement of a new evolving field. So on the professional side, it has that aspect. It also has the aspect of the importance of messaging and communicating with patients. And I keep saying, when people talk about trust with COVID, as an HIV clinician sitting with patients, I would always comment to my patients every time- The field was evolving so quickly, we thought, until we saw COVID, and now it seems like it was slowly.
[Dr. Smith] Yeah. [Dr. Yawetz] But when I'm sitting with patients, I just- Every time they came, I tell them almost the opposite of what I told them last time, right? We used one drug, and then two drugs, and then three drugs, and then we switched, and then we told them we only treat people who have severe immune suppression, and then we started treating everyone. And we told them to use condoms, and now we say, "Oh, undetectable means untransmissable." So the message keeps changing, and that could erode trust, or it can build trust, depending on how you relayed it.
So I think you have to have a lot of humility and being able to explain that we can only practice based on what we know, and as we learn things, we message it and change our practice. And I think there's a lot of similarities between COVID and HIV in that regard. [Dr. Smith] Right. [Dr. Yawetz] So I think that's kind of the similarities I can draw.
There are a lot of other similarities, but it will take the entire session, I think, if we talked about them. [both chuckle] [Dr. Smith] Yeah, I really liked that message because I think a lot of clinicians like really being able to say something with primary research backing what they're saying, or kind of clinical guidelines charting the path forward when they're talking with their patients, but as you said, if the disease that you're targeting is emerging, and it's kind of a moving target, it could kind of feel uneasy as the clinician's saying, "You know we did this last time, but we're going to do this differently this time." - [Dr. Yawetz] Yeah. - [Dr. Smith] And so, just pushing a little further with what you were saying, could you talk about how your career has changed over time, both in the patients you see, and kind of, even as you were touching on like how clinical care has changed for your specialty?
[Dr. Yawetz] Yeah, so for me, I came to ID interested in doing basic, and then clinical research, on the personal level, and that's maybe an important message to students who are facing work-life balance. I had a very sick child, and I had to make some career decisions related to that. I wanted to do global work, and having a sick child at home I couldn't travel, so I changed to working on HIV more locally.
And I started by kind of addressing areas that I felt were less informed in HIV. And that's what brought me to post-exposure prophylaxis, and prevention of mother to child transmission. Two areas where even HIV clinicians felt a little hesitant to go into, because there were very little guidelines and very little research. And kind of moved from that, and created a lot of relationships actually with that.
So working on those two areas, I developed great relationships with the OB-GYN folks at our hospital, and with that kind of was pushed almost by them to pick up more of an interest in non-HIV infections in pregnant women, another area that did not have anyone in our hospital that had a specialty in, and now a large component of my practice is non-HIV infectious diseases in women - as it relates to- - [Dr. Smith] Oh, wow.
[Dr. Yawetz] -preconception, counseling, pregnancy, and from that moved to STD, and UTI. And now I have the relationship with our urologist and do a lot of UTI work and I'm on the national committee creating the new guidelines for treatment of UTI. So kind of one thing led to another as far as my career, although 50% of my practice is still HIV and mostly women. So that path over time changed, So that path over time changed, also just HIV care, we started doing a lot of inpatient care, we had an AIDS service, an inpatient AIDS service.
We kind of were on the battlefield, half of the ICU was HIV patients with complications- [Dr. Smith] Wow. [Dr. Yawetz] -and gradually changed to the outpatient practice, in the outpatient practice it kind of initially was managing complications, toxicities, drug interactions. We were neurologists when there was neuropathy, we did mitochondrial toxicity, we were endocrinologists with interactions with steroids.
And now HIV treatment is very easy if you take it, so now we kind of do longitudinal care for HIV. So from treating wasting, I now treat obesity. It's kind of very interesting how HIV in the U.S. has changed, in many places in the world it hasn't that much. [Dr. Smith] Yeah. [Dr. Yawetz] So that's also kind of a shift that we've seen. And in the last year also, like many others, the other thing that I kind of took on is co-chairing the ID Division's Diversity, Equity, and Inclusion Committee.
And this was motivated by something we've seen for a long time in HIV, but didn't do as much about, and now is seen with COVID, which is the disparities in COVID-19 and HIV pandemic presentations and outcomes. And also just the recognition with a lot of national events, of how many in our patients, and our hospital community are kind of suffering discrimination. So we've created a committee in our division of diversity and inclusion, trying to advance those issues and hopefully we'll make an impact.
So that's another area that kind of from HIV care - I got into which is- - [Dr. Smith] Wow. [Dr. Yawetz] -more on the policy level. [Dr. Smith] Right, wow. That was such a, I mean, it's so amazing to kind of hear you talk about the last few decades of your career, and how the course of HIV has changed. I really liked how you put it, you were treating wasting at one point, and now you're treating patients with obesity, and kind of the interdisciplinary approach with urologists, with endocrinologists, and how ID intersects with a lot of that.
That's a really cool kind of answer. Can you maybe more broadly cover the different career paths for ID specialists? You know, what types of patients do ID physicians at an academic center typically see? [Dr. Yawetz] So I think one of the things that people who come to ID are really surprised by is the large diversity of patients that we see. I mean, the trainees in ID, they come to us after medical training, so they spent three or four years on the medicine wards, and the consults we get in the hospital are from every service in the hospital.
So new trainees are always shocked, they see orthopedic patients, surgical patients, OB-GYN patients, and they haven't trained in those. So you have to do a lot of fast learning in those fields- [Dr. Smith chuckles] [Dr. Yawetz] -and go back to your anatomy books. [Dr. Smith chuckles] [Dr. Yawetz] But in addition to that, we see a lot of nosocomial infections, highly resistant organisms, we see meningitis, or endocarditis, many other infections that don't respond to therapy.
We see opportunistic infections, not just in HIV which we've talked about, but in transplant patients, and other immunocompromised hosts. And infections in people who use drugs, we see mycobacterial infections, TB, we see endemic fungi, and then we're of course, like Dr. House, right? - We're consulted on- - [Dr. Smith chuckles] [Dr. Yawetz] -mystery patients and unexplained systemic illnesses and often diagnose non-infectious syndromes in those.
And we see travelers, and tropical infections, and tick-borne diseases, and zoonotic diseases, we're the only specialty that knows every pet of every patient we see. [both chuckle] [Dr. Yawetz] And we see diarrheas, and outbreaks and STDs, and HSV, and VZV, and hepatitis B and C we treat in the clinic. And the list goes on, and on, and on, and I didn't even mention COVID.
And then in academic centers we see a lot of MRSA. [chuckles] [Dr. Smith] Right. Yeah, I know, it's an encyclopedia, - it almost seems. - [Dr. Yawetz] I know. [Dr. Smith] And yeah, I mean, as a medical student, I feel like always the mystery cases always ended up being ID. It always ended up being kind of the pet parrot, or one of these strange kind of travel-related diseases, or tick-borne diseases.
So it's really cool to kind of hear you rattle off all of those potential organisms, and viruses, and parasites. [Dr. Yawetz] Only about 1%, right? [Dr. Smith] Right, just scratching the surface. [Dr. Yawetz chuckles] No, but you know, even if it's not an infectious disease, I think you need us to summarize the chart, right? - And the history.
[Dr. Smith] And yeah, it really incorporates a lot of internal medicine, and almost the applications of how different things could present in kind of acute settings, or post-surgical settings, or oncologic settings. That's a really kind of interesting approach. I say this in every career's episode, but I think you sold me on the field. [Dr. Yawetz] Okay, so we'll see you soon.
[both chuckle] [Dr. Smith] Just for our listeners, so it would be helpful, could you maybe describe your time breakdown between academic activities, your clinical practice, and any education and teaching you do? [Dr. Yawetz] Yeah, so I will tell you that every person in ID does it a little bit different. So I think my time might be very different than other people's times.
I'm primarily a clinician- [Dr. Smith] Okay. [Dr. Yawetz] -but in an academic medical center, so I spend a lot of time in the clinic. I have clinics with fellows, and clinic without, and one of my clinics is at the Brigham and Women's Center for Women's Health. So we have a multidisciplinary clinic, and I'm one of the specialists in that.
Also on the inpatient service doing consults, but then about half of my time I spend on other activities. I manage a Ryan White Grant for clinical care for women and youth that we receive. I work on two hospital committees, risk management and the diversity and inclusion. I do a lot of teaching, some writing, and I'm still involved in some research projects, so- [Dr. Smith] You're very busy.
[Dr. Yawetz] -it's about 300% job, yeah. [Dr. Smith chuckles] Right. [Dr. Yawetz] Not to talk about COVID, if you wanted to know what we did then, that would be a whole different story, but in a normal year, that's what I do. [Dr. Smith] I can't even imagine for ID clinicians what this last year has really been like. But, as kind of a forward-looking episode for students who are interested in ID in the future, maybe you could comment on what you love about the ID field as a whole, and maybe what you don't love as much.
[Dr. Yawetz] Yeah, so there's not a lot not to love, but I'll try to find something at the end. [Dr. Smith] I could tell, I could tell you love it. [Dr. Yawetz] You got to love it to do it, but I really love the rapid pace of discovery and change. I mean, this is a year now, like no year to demonstrate that, - I mean- - [Dr. Smith] Right. [Dr. Yawetz] -how to sell ID to anyone.
There's always an opportunity to grow and expand, and there's so many fields, and people can change mid-career if they want. I like the intellectual challenge, it's a very brainy field, I think. I really like my colleagues, I think I have the smartest colleagues in the field of medicine, and that's not only physicians, I mean, we have social workers, nurses, it's really a teamwork.
We were a medical home long before this term was invented, doing this for HIV. I really love the trainees because I think we also have the smartest trainees in medicine. [Dr. Smith chuckles] [Dr. Yawetz] And I don't think my trainees appreciate how much they teach me, and I learn from them. And sometimes when I don't know something, I say, "So what do you think?" And then they know it.
[both chuckle] [Dr. Yawetz] So teaching is also learning. And I absolutely love my patients, I mean I think ID, people laugh at us for our long histories, but during them we really learn amazing life stories, which we wouldn't have learned otherwise. And some of my patients have the most amazing lives. What do I not love? It's very hard work- [Dr. Smith] Yeah.
[Dr. Yawetz] -and while we're very highly appreciated, we're not the best compensated. So, people usually don't come to ID for the money. And I think for those of my colleagues who do research, a lot of it is soft money, you have to keep writing grants, and it's a source of a lot of stress for many of them. But I think if you ask ID doctors, I think almost every single one of them would do it again if they were asked if they would do it again.
[Dr. Smith] Yeah. [Dr. Yawetz] So I think people in ID really come to ID for the love of the field, so they enjoy it. [Dr. Smith] I really love that candid kind of answer, so thank you for that. This next question is interesting, because it's contextualized by this past year, but how do you see the field changing in the future, and kind of how has that been shaped almost by the last year's events?
[Dr. Yawetz] Obviously, the pace of the COVID era was unbelievable for us. [Dr. Smith] Right. [Dr. Yawetz] But you know what COVID, I think, highlighted, is what in ID we knew a long time ago. I mean, I think you're asking me, what do people in ID know? I think a year ago nobody knew what people in ID do. A year ago I would meet someone at a party, and they'd ask me, "What do you do?" and I'd say "Infectious disease," and they said, "Oh, what kind of diseases do you see?" And now there's not one person in the world who doesn't know what we do.
[Dr. Smith] Right. [Dr. Yawetz] So I think COVID highlighted what we always knew, and that's that you can't undermine investment in research and prevention of infectious diseases. And so that's one thing, and the other things are the disparities in healthcare, that certain communities both locally and globally, really bear the brunt of this disease, and the infectious diseases in general.
My worry is that COVID will go away, which it will as a pandemic at some point, and the global burden of infectious diseases will remain high, and the burden of infectious diseases in underserved populations will remain high, and will we learn a lesson or not? So I hope that we will see a lot more funding and research in prevention of infectious diseases. I hope that we've learned that collaboration and sharing information, and use of new technology can bring us to great places.
I mean, it's unbelievable how the genome of COVID was posted within weeks, and within weeks we had treatments, and then vaccines to study. And this is really the collaboration between field and mRNA technology used for cancer treatment has suddenly created a vaccine that is now given to millions of people, and it's been just a year, so, even though it feels slow, it's really fast, and I hope we'll learn from that, the importance of one, investing in disease prevention and research, and two, using technology, and three, global collaboration, because infectious diseases are a global problem and we can't fix them in one place.
And for my field, I hope it will get a lot of young people like you- [Dr. Smith chuckles] [Dr. Yawetz] -interested in ID and wanting to come to ID, and create a lot of opportunities to learn and research, and advance science, and bring that to the bedside. So I think COVID is all of that in a nutshell, but infections will always emerge, so I don't think we'll ever not have work in this field, so- [Dr. Smith] Definitely, and going back to something you said earlier, you've listed off all the many of the diseases you saw, and you didn't even mention COVID, right?
It's only a minor, minor, minor piece of ID, and yet what you also said is it kind of wraps everything up in one, both from prevention to kind of funding and research, to kind of translational therapies and vaccines, that we could develop and kind of in a very public-facing way, in a way that hopefully we carry forward as a society. And I really do hope that kind of one of the positive externalities of this all is kind of funding infectious diseases, and interest.
And I really think there will be no shortage of applicants in the future. So yeah, why don't we end this episode with something we always ask our guests which is, do you have any general advice to current medical students? Students who are kind of in the later stages of training and thinking about residency, and maybe even fellowship? [Dr. Yawetz] One of the things I've learned in my career in medicine that maybe I didn't know coming to medicine is that it's really one of the fewest careers where it takes 100% of your time, that when you go to bed at night, you think about your patients- [Dr. Smith chuckles] [Dr. Yawetz] -or your grant, if you do research.
And so what you choose is what you end up doing for so much of your time, so you really should follow your heart and find something you really have a passion for, that inspires you, so you really enjoy doing it. I think finding good mentors is really, really important to having a successful career. And I think every field in medicine has opportunities within it to change and grow.
I mean, every field in medicine has so many options of what you can do within it. I think infectious diseases is a great field, I hope people would love to come and join us, but I think opportunities are everywhere, and you should just take them as they come. [Dr. Smith] Yeah, thanks for that wisdom. I think as a medical student, people are pulled in so many different directions, but really at the end of the day, thinking hard about what is it that I really, even at that stage of your training, think about, and want to do going forward when deciding where to apply, and into what specialty to apply.
So thank you so much. [Dr. Yawetz] Thank you. [Dr. Smith] This has been such a fun conversation, and so helpful to learn from you and your journey to become an infectious disease physician. We're super lucky, kind of to hear from you because you have a really fascinating focus on HIV patients, pregnant patients, STIs, UTIs, diversity, equity and inclusion incorporation into the hospital.
And you had some really wonderful comments on the field as a whole. So thank you again for joining us in this episode of Run the List. [Dr. Yawetz] Thank you, Blake. [outro music] [outro music]