PACCARB Public Meeting | August 29, 2024 | Part 1 of 1

>> Paul Plummer: I'd like to welcome everyone this afternoon to the 26th public meeting of the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria. My name is Paul Plummer, and I serve as chair of PACCARB along with my co-chair I'll introduce here in just a minute. Today we have a rather abbreviated meeting to review the report out of a requested report on infectious disease workforce incentives. We have a immediate action subcommittee that's a standing part of PACCARB, and we asked that subcommittee to make some recommendations around this topic. And so today we are here to discuss and deliberate and ultimately vote on the outcome of that report. And so we appreciate the work of the immediate action subcommittee and the discussions that we've had in preparation of this report, all of the subcommittee report's efforts in doing so, and we look forward to discussing those more today. Without further ado, I'm going to turn it over to my co-chair, Dr. Jason Newland, for a couple of brief comments before we jump into discussing that report. Jason? >> Jason Newland: Yeah. Thanks, Paul. Just appreciate the council and the subcommittee on all the great work. I think this is an important topic as we discus ID workforce. If we just think of the current times with the WHO recently talking about the concerns around Mpox, as we see elevation in certain pathogens such as mycoplasma in children, listeria outbreaks, the need for an ID workforce is ever present and is needed, and we know it's troubling when it is as low as it is. So I'd just like to say thank you, thank you, thank you to all of those who have been involved in this important work, and I look forward to our quick and fun discussion. Thank you. >> Payal Patel: Awesome. Thank you, guys. Well, thank you for the introduction, and I'll echo some of Jason's comments on the next slide. >> Sarah McClelland: Really quickly, Payal, I'm going to go over some rules of engagement and roll call. Then we'll hand it over to you. Welcome, everyone. I'd like to thank Doctors Plummer and Newland for bringing us in this afternoon to our 26th public meeting. I'm Sarah McClelland. I am the alternate designated federal officer for this advisory council, and I'd like to thank all of our attendees and stakeholders for joining us today. We also would like to thank and acknowledge those who provided written public comment via our [email protected] mailbox. As always, those comments are shared with our council prior to the meeting. This advisory council was established via executive order in 2014, codified into legislation through the Pandemic and All-Hazards Preparedness and Advancing Innovation Act in 2019, and formally reestablished under the statute in September of 2020. I'd also like to announce that our charter has just been renewed today for another two years. The goal of this council is to give the secretary of health and human services advice and recommendations to improve the programs and policies related to antibiotic resistance that would contribute to the overall health of our country. As a federal advisory committee, we are governed under the Federal Advisory Committee Act. As such, all 15 voting members are considered special government employees, or SGEs. All regular government employees, or RGEs, on the council represent the interests of their respective federal agencies, and both those groups are subject to conflict of interest regulations and vetting. Activities of the advisory council, including information gathering, drafting reports, and recommendation development, are performed by designated working groups. The working groups then report to the full council for deliberation and vote, which is what will be taking place today. As with all of our public meetings, this meeting is being recorded and will be available on our website at hhs.gov/paccarb. As Doctors Plummer and Newland mentioned, today's meeting will focus on deliberating and voting on a resolution letter from the immediate action subcommittee, which advocates for incentives to strengthen the infectious disease workforce. This letter is a continuation of recommendations made in the Pandemic Preparedness Report from 2023 and aims to address urgent need for more ID professionals as highlighted in the Infectious Disease Society of America's presentation during our last public meeting in May. During the deliberation portion of the meeting, I will ask that you please raise your hand to provide comments. Ms. Haley Krem will be sharing the resolution letter and offer live edits should there be any during that time. This is a very tight meeting, so we will need to adhere to the time allotted for deliberation, and we ask that you please prioritize one thought per comment and keep them brief so that we can offer everyone an opportunity to speak. As always, we ask that you please keep your camera on and your line muted unless speaking. I would now like to take the opportunity to thank the team for their efforts to support the working group, the council overall, and in planning this meeting, especially Ms. Haley Krem, Dr. Zanah Francis, Ms. Lauren Plaine, and as always, our logistics guru, Ms. Jennifer Adona. I'll now go through roll call for all of our council members. Please let us know if you are present by stating here. For alternate representative members, please identify yourself and provide the name of the principal you are representing today. Beginning with our voting members, our chair, Dr. Paul Plummer. >> Paul Plummer: Here. >> Sarah McClelland: Our vice chair, Dr. Jason Newland. >> Jason Newland: Here. >> Sarah McClelland: Dr. Stephanie Black. >> Stephanie Black: Here. >> Sarah McClelland: Dr. Claire Burbick. >> Claire Burbick: I'm here. >> Sarah McClelland: Dr. Virginia Fajt. >> Virginia Fajt: Here. >> Sarah McClelland: Dr. Susan Huang. >> Susan Huang: Here. >> Sarah McClelland: Dr. Jennie Kwon. >> Jennie Kwon: Here. >> Sarah McClelland: Dr. Brian Lubbers. >> Brian Lubbers: Here. >> Sarah McClelland: Dr. Lynn Marks. >> Lynn Marks: Here. >> Sarah McClelland: Mr. Armando Nahum. >> Armando Nahum: Here. >> Sarah McClelland: Dr. Payal Patel. >> Payal Patel: Here. >> Sarah McClelland: Dr. Robin Patel. >> Robin Patel: Here. >> Sarah McClelland: Dr. Joni Scheftel. >> Joni Scheftel: Here. >> Sarah McClelland: Dr. Julia Szymczak. >> Julia Szymczak: Here. >> Sarah McClelland: And Dr. Thomas Wittum. >> Thomas Wittum: Here. >> Sarah McClelland: Welcome, all. Moving on to our liaison members, Dr. Carla Huston for the American Association of Extension Vets. >> Carla Huston: Here. >> Sarah McClelland: Dr. Padmini Srikantiah for the Bill and Melinda Gates Foundation. Ms. Emily Wheeler for Biotechnology Innovation Organization. Dr. Francisco Zagmutt for EpiX Analytics. Dr. Lucas Pantaleon for the National Institute for Animal Agriculture. >> Lucas Pantaleon: Here. >> Sarah McClelland: Dr. Elizabeth Dodds Ashley for the Society of Infectious Disease Pharmacists. >> Elizabeth Dodds Ashley: Here. >> Sarah McClelland: And Dr. Timothy Jinks for Wellcome Trust. >> Timothy Jinks: Here. >> Sarah McClelland: Okay. Now for our regular government employees, please be sure to indicate if you are covering for a principal RGE. Do I have any representatives from the USDA? Anyone from the Department of Defense? >> Paige Waterman: Hi. Paige Waterman. >> Sarah McClelland: Welcome, Paige. Moving on to HHS, anyone for ASP or BARDA? AHRQ? >> Susan Henderson: Hi. Susan Henderson for Dr. Melissa Miller. >> Sarah McClelland: Welcome, Susan. CDC? CMS? >> Jasmine Dhindsa: Jasmine Dhindsa for Dr. Shari Ling. >> Sarah McClelland: Welcome, Jasmine. NIH? >> Kyung Moon: Kyung Moon for Dennis Dixon. >> Sarah McClelland: Welcome, Kyung. OGA? FDA? And finally, EPA. Great. With that, that concludes roll call, and I'll hand it over to our immediate action subcommittee co-chairs, Dr. Payal Patel and Lucas Pantaleon. >> Payal Patel: Thank you so much, Sarah. Next slide. So thank you again for everyone making time for working on this and to our committee for reading through and coming up with the recommendation. Next slide. In many of the reports that PACCARB has put together and the talks that we hear about, we often hear about the importance of ID professionals across the spectrum. We've just heard from Dr. Newland some current topics, and those topics are ever changing. Hard to pronounce new viruses. Currently there's a round of encephalitis going on throughout the country. And to fight these different infections, we think it's really important to invest in ID professionals. That can include infection prevention and control program leaders, antimicrobial stewardship leaders, of course, across the one health spectrum, managing emergent and endemic diseases, ID'ing and epi and treatment of zoonotic diseases, and then of course, our most recent report with the pandemic preparedness. Next slide. I thought that this graphic is really important to highlight. If you look at the white area in this graphic, which was actually a paper by Dr. Walensky, this shows that every county with a white spot doesn't have an ID physician in that area. And so it's hard to imagine that most of the country is really sometimes understocked, underutilized by the ID physicians. We're trying to fight this with different ways like telemedicine, but our hope is that we can invest in different ways to build this up and fill in these white spaces. Next slide. The IASC has drafted a resolution letter as a continuation of the PACCARB Pandemic Preparedness Report, and I will hand over to Dr. Pantaleon from here. >> Lucas Pantaleon: Thank you, Dr. Patel, and, you know, really interesting map. And that is really telling about the -- you know, the problem that we have with the lack of ID physicians in the United States. So the recommendation for our subcommittee was based on trying to recommend for the federal government to develop and enact incentives to really promote more ID professionals to enter the workforce and do the important work that they do as ID professionals. Next slide, please. So I wanted to -- next slide, please. So I wanted to point out here the title. We as the subcommittee came up to three recommendations, but these are potential recommendations and incentives. And I want to point out the potential because we really, as a subcommittee, wanted to open the door for future or other potential recommendations that could come along to complement the ones that we are going to be discussing today. And of course, the main one for our subcommittee was to develop new CMS codes to really be able to charge for the services that ID professionals do, and also because there is a lack of filling out some of the residency programs and training programs for ID professionals. So, in order to incentivize professionals going into training, instituting some federal loan forgiveness and repayment programs would be also paramount to improve the ID workforce. And also, we recognize that these incentives need to be sufficient in -- and also sustainable in time, so this is not something that we do, you know, in the short term, but also in the long term and sustainable. So this is about all we have to say, this summary of our recommendations. So now we're going to enter the deliberation and vote section of our meeting, and I'm going to hand back the microphone to Sarah McClelland to lead us through that. And also, as Sarah indicated at the beginning, please feel free to raise your hand and provide your feedback. We are going to be doing live edits during our meeting on the letter draft that we put together. Thank you. >> Sarah McClelland: Thank you. We'll now move to the deliberation portion of the vote. Ms. Haley Krem will go ahead and share her screen for any live edits. And just to reiterate Dr. Pantaleon, please raise your hand if you have any comments. Go ahead, Dr. Plummer. >> Paul Plummer: All right. I just wanted to thank Doctors Payal and Lucas for bringing us this report and for the committee's hard work. The entire PACCARB has received the draft of this, and so really, you know, look forward to the discussion from that. Look forward to your comments and questions. But from my perspective, thank you for the hard work. I'm pleased with where we're starting on this, and so look forward to the continued discussion. So thank you to the committee and our chairs, and now I'll turn it over to Lynn. >> Lynn Marks: Thank you. Yeah, I just wanted to build on the comments about this being a start. I don't think any of us believe that these potential recommendations will solve the problem. I would encourage professional organizations, for example, IDSA, ASM, many others, to look to their membership to understand what kind of additional incentives would be necessary in order to build the workforce. I see this as a ongoing work effort. It won't be solved overnight. The residency programs didn't fill, and that will take some time to turn around. That's a vast map of absence across the country, so this is a journey, not a quick fix. And I would encourage those societies to help us help them by understanding better what would motivate more professionals to enter the field of infectious diseases broadly. Thank you. >> Sarah McClelland: Thank you, Doctors Marks and Plummer. Any other comments? Going once. Please, Dr. Pantaleon. >> Lucas Pantaleon: Yeah, I just wanted to highlight, you know, as a veterinarian, the one health aspect of the letter, and I think it's very important for ID physicians not only to provide the important role that they play in order to provide patient care, but also how we can work together across disciplines with the one health approach. I think that is a very important part of what ID physicians do, and veterinarians as well. So I think we need to keep that from incentive as well. Thank you. >> Sarah McClelland: Thank you for that comment. Any others? >> Susan Huang: This is Susan. I'm sorry, I can't figure out how to raise my hand. But I did put in a suggestion earlier, but it looks like it was not included. And it was an edit to one sentence, the one that says, ''ID physicians are among the lowest-paid physician specialties.'' And then I think there was just a clause that I put into an email that said that they are often lower -- they are lower than primary care. And if we could just institute that, I think it was accepted by email, but I don't see it on this version. >> Haley Krem: Yeah, I'm happy to respond to that, Susan. As part of the discussion that kind of came after the fact, there was some concern about this comparison between ID physicians and other physician specialties, that we didn't necessarily want the finger pointing involved in that, but I'm happy to open it up for a broader discussion. >> Susan Huang: That's -- yes, I just want to clarify what you said. We're not comparing across specialties at all. We're saying that this specialty makes less than primary care, and that means there's no value to go into a -- like, why train further into a specialty when the generalist makes more than you? And it's well documented across -- I mean, like, I think we all receive those Medscape scans. We are -- there's only one or two specialties that are less than primary care, and ID is one of them. So to me, it's very different. We're not pointing fingers. We're saying there's no value to train. You train longer for less pay. And I think it's a really important thing to say, because if someone in the government is just looking at it and says we're lowest paid, what really does that mean to me? The point isn't that compared to other doctors, we're paid less. What we're specifically saying is there is no value to train longer to make less. >> Sarah McClelland: So would -- Susan, would it be appropriate to maybe put that point in as an expansion on this -- >> Susan Huang: Yes. I would urge us to put something there related to that, because it's a very important concept. >> Sarah McClelland: So Haley -- yes. >> Haley Krem: Let's do -- yeah, go ahead, Sarah. >> Sarah McClelland: I was going to say, in that section, we can say, ''ID physicians are among the lowest-paid physician specialties in the U.S.,'' and then something along the lines of, you know, disincentivizing those to kind of join the specialty or -- like, that's the main point, right? >> Susan Huang: I think we should just [unintelligible], so training -- added training to become an ID physician generally results in less pay than generalist salaries. Or you don't -- well, you can fix that last part. But I want to call out the fact that we're talking about spending more time training to get less pay than non-specialty physicians. Can we -- I'm looking at everybody else who's better at English crafting than I am. >> Haley Krem: [laughs] >> Susan Huang: But can we come up with something that would be acceptable and not seen as rude? >> Haley Krem: Comparison. Yeah. >> Susan Huang: You know what I'm saying? >> Haley Krem: Right. >> Susan Huang: I'm trying to be, you know -- >> Sarah McClelland: Well, to your point, it's much more about the kind of cost per training, right? >> Susan Huang: Yes. >> Sarah McClelland: It's a lot more training. >> Susan Huang: The value of training. >> Sarah McClelland: It's a lot more intensive that -- and it doesn't result in an equivalent amount of compensation for that training. >> Susan Huang: Right, so, like, an added trainer, added specialty training in infectious diseases, generally results in lower pay than non-specialty physicians, right? So, you know, something like that. That way, we're not picking on any specialty. >> Sarah McClelland: Yes. >> Susan Huang: We're just saying the training value is insufficient. >> Sarah McClelland: So maybe we begin the sentence with added specialty training? >> Haley Krem: Added specialty training. Lynn, it looks like -- >> Susan Huang: Maybe put a period after U.S. and then create a new sentence. >> Sarah McClelland: Dr. Marks, did you have a comment on this? >> Lynn Marks: Well, first of all, I think it's an incredibly important point, and I don't know if the term sub-specialty would help. In other words, if your specialty is internal medicine, your sub-specialty would be infectious diseases, so there's no value in moving from pediatric primary care as a specialty to the sub-specialty of pediatric infectious diseases. I don't know if that will help. >> Sarah McClelland: Dr. Plummer? >> Paul Plummer: Maybe the way it's in there is okay. I was going to suggest something at the beginning of the sentence like ID physicians or becoming an ID physician requires additional training over that of generalists, and while still being among the lowest-paid physician specialties, or something like that. Trying to draw out the increased training but remaining as the lowest paid, but perhaps the way that we currently have it crafted is better. >> Susan Huang: You could even remove the word added. Sub-specialty training in ID generally results in lower pay than non-specialty physicians, I guess, or I don't know if it's physicians. >> Sarah McClelland: Dr. Zagmutt? >> Francisco Zagmutt: I think that addition makes a lot of sense. I was looking -- from just a numbers perspective, I don't know if it's really true that a general physician will make less money after going into this specialty. I'm thinking as a longitudinal life of one doctor as opposed to on average. >> Susan Huang: Oh, it's well documented. Actually, that's well documented. I don't -- >> Francisco Zagmutt: Okay, so they'll make less money after -- >> Susan Huang: Yes. >> Francisco Zagmutt: Okay. Then it's fair. >> Susan Huang: Starting salaries are lower. Ending salaries are lower. >> Francisco Zagmutt: So you start as a general practitioner making $1, to the specialty, you will make then 90 cents >> Susan Huang: Yes. >> Francisco Zagmutt: Okay. Yeah. Then I think it's accurate to say that. Okay. >> Susan Huang: Well documented. Yeah. >> Sarah McClelland: So as it reads now, we have, ''ID physicians are among the lowest-paid physician specialties in the U.S. Sub-specialty training in ID generally results in a lower pay than non-specialty physicians.'' >> Susan Huang: Maybe get rid of a? >> Sarah McClelland: In lower pay? Okay. Does that sound good to everyone? Do we have any comments or other, you know, wordsmithing on that point? Go ahead, Dr. Marks. >> Lynn Marks: Well, again, it's the non-specialty thing. It may be just -- >> Sarah McClelland: Okay. >> Lynn Marks: I think primary care is where that started. >> Susan Huang: Either generalist or primary care. >> Lynn Marks: Right. >> Sarah McClelland: Okay. Does anyone have objection to including primary care in there? >> Jason Newland: No. >> Sarah McClelland: Great. Dr. Black, I saw your hand was raised. Do you have a comment in relation to this, or was yours a different comment? >> Stephanie Black: It was a different comment. >> Sarah McClelland: Okay. Are we all good to close this point out? Any other comments on these two sentences? Dr. Black, the floor is yours. >> Stephanie Black: I was just going to comment that in highlighting the importance of ID professionals in the program leadership that they play, in addition to infection prevention and control and stewardship, they do lead public health programs. And I think that the spirit of that is captured in managing emerging and endemic diseases. I mean, as people have pointed out with vector-borne disease and having CDC come out, you know, there are infectious disease professionals who are -- have those public health roles. So as a representative of public health, I just wanted to raise that. I -- because we highlight the roles played by -- in infection prevention and control and in stewardship. >> Sarah McClelland: Would you like a specific -- >> Stephanie Black: Talk about two vital operational roles. I thought -- >> Sarah McClelland: Okay. >> Stephanie Black: -- we could consider adding, you know, lead infection prevention and control, you know. You could say infection prevention and control, antimicrobial stewardship, and public health programs, or something like that. >> Susan Huang: Stephanie, the question I have for you is infection prevention and control, usually it's specified that it needs to be an ID professional. Same with antimicrobial stewardship. In public health departments that oversee infectious disease response, is it specified, generally, in most states that it needs to be an ID-trained person? >> Stephanie Black: It does not have to be, but it's certainly a benefit, I think, to have infectious disease professionals in that role over, you know, communicable diseases in those situations. But it is not a requirement. I mean, it's another example, frankly, of infectious disease physicians being paid the same as, you know, that isn't even necessarily recognized with pay. >> Sarah McClelland: I'm going to have to jump in really quickly because we are tight on time. >> Stephanie Black: Okay. >> Sarah McClelland: So I would say if there's a specific edit you would like us to make to the sentence, Stephanie, can you just give it to us kind of word for word so we can quickly pop it in and see if it adheres to -- or everyone else agrees with it? Otherwise, is this something that we can kind of add in additional kind of context later as this letter goes out? >> Stephanie Black: I was just suggesting in the sentence that starts with, ''ID professionals lead infection prevention and control programs,'' that you might list infection prevention and control, antimicrobial stewardship, and public health programs. >> Sarah McClelland: Okay. Does anyone object to the addition of public health programs into this sentence? >> Stephanie Black: Then you would have to add three, potentially, vital operational roles and -- >> Sarah McClelland: That's fine. >> Stephanie Black: -- and that's fine if you all don't think that it rise -- I just wanted to raise the issue. >> Sarah McClelland: Does anyone have an objection to adding that in? >> Susan Huang: I think we need to be careful because it says vital operational roles that are required, so you don't -- antimicrobial stewardship programs and infection prevention are required of all hospitals, but the added of the public health would be in the wrong place. So I wonder if it should be its own sentence or under ''Additionally, ID professionals play a critical role in public health response.'' >> Stephanie Black: Sure. Yeah. >> Susan Huang: Maybe it's there. >> Brian Lubbers: That was going to be my suggestion. >> Stephanie Black: That's great. >> Female Speaker: I agree with that. >> Sarah McClelland: Does that work for everyone? In the comment, Dr. Marks suggested a reference, Susan, for your -- the addition below about pay. That's something we can add after the meeting, but if you could please send us that citation. I think that would help bolster -- >> Susan Huang: Yeah. So for everyone, the ones that I know are the ones that come out every month from Medscape that show the ranking. >> Sarah McClelland: Okay. We can [inaudible]. >> Susan Huang: But I don't know if there is a publication, but are you allowed to cite Medscape? >> Sarah McClelland: We can look into that. All right. We need to move to a vote. Are there any other major comments or changes that we need that anyone would like to raise at this time? Okay. Seeing no other raised hands, we're going to move to the council vote. When I call on your name, please respond yes or no for transmittal of this resolution letter as is to the secretary of HHS. Keep in mind, we will add in the citation as appropriate for the addition we made today. I'll be calling on our SGE members to vote. Are we ready? All right. Our chair, Dr. Paul Plummer, please provide a yes or no on whether you will like to see this transmitted. >> Paul Plummer: Yes. >> Sarah McClelland: Great. Vice-Chair Dr. Jason Newland? >> Jason Newland: Yes. >> Sarah McClelland: Dr. Black? >> Stephanie Black: Yes. >> Sarah McClelland: Dr. Burbick? >> Claire Burbick: Yes. >> Sarah McClelland: Dr. Fajt? >> Virginia Fajt: Yes. >> Sarah McClelland: Dr. Huang? >> Susan Huang: Yes. >> Sarah McClelland: Dr. Kwon? >> Jennie Kwon: Yes. >> Sarah McClelland: Dr. Lubbers? >> Brian Lubbers: Yes. >> Sarah McClelland: Dr. Marks? >> Lynn Marks: Yes. >> Sarah McClelland: Mr. Nahum? >> Armando Nahum: Yes. >> Sarah McClelland: Dr. Payal Patel? >> Payal Patel: Yes. >> Sarah McClelland: Dr. Robin Patel? >> Robin Patel: Yes. >> Sarah McClelland: Dr. Scheftel? >> Joni Scheftel: Yes. >> Sarah McClelland: Dr. Szymczak? >> Julia Szymczak: Yes. >> Sarah McClelland: And Dr. Wittum. >> Thomas Wittum: Yes. >> Sarah McClelland: Excellent. That concludes our deliberation and vote. As it stands, we did not have anyone sign up for public comment. If that has changed, Jennifer, please let me know. >> Jennifer Adona: No public commenters. >> Sarah McClelland: Excellent. I will now hand it back over to Doctors Plummer and Newland to close us out on time. >> Paul Plummer: All right. Well, I appreciate this. Thank you, everybody, for taking 30 minutes to join us here. Seems like a quick time and -- but I think successful because of all the hard work that the immediate action subcommittee put in on this and working to get this prepared. So final thanks to both PACCARB staff and everything from behind the scenes, the committee, our chairs of the committee. And I will turn it over to Jason for his final comments, and look forward to seeing you all at our next meeting. >> Jason Newland: Nothing further. Have a wonderful Labor Day. Thanks, everybody. >> Paul Plummer: Thank you, everybody. Have a wonderful day. >> Female Speaker: Produced by the U.S. Department of Health and Human Services.