Integrating Infectious Diseases and Preventive Medicine Specialties Into 1 Division: Experience of an Academic Medical Center

Throughout the coronavirus disease 2019 (COVID-19) pandemic, clinicians and researchers with appointments in separate divisions of infectious diseases (ID) and preventive medicine (PM) subspecialties collaborated on multiple projects, programmatic activities, and large-scale interventions at a tertiary academic medical center in the US Midwest. This collaboration was one of the reasons that prompted the integration of these groups into 1 unified academic division. Although this integrated structure is uncommon in the United States, the rationale, circumstances, and culture leading to this realignment may be common to other academic health systems. Therefore, we provide the justification and approach of this integration. Mayo Clinic was established in the 1800s as a multispecialty practice and became a nonprofit organization in 1919. The clinic is a tertiary referral center with a 73,000-person workforce and 3 main destination campuses in Minnesota, Florida, and Arizona as well as a health care system located in the US Upper Midwest. Before integration, the ID division included 31 faculty. The Division of Preventive, Occupational, and Aerospace Medicine included 13 faculty certified by the American Board of Preventive Medicine (ABPM) in the areas of public health and general PM, occupational medicine (OM), aerospace medicine, undersea and hyperbaric medicine, clinical informatics and medical toxicology. Both divisions resided in the larger Department of Medicine. The leadership structure involves a dyad approach that includes a division leader partnering with an administrator. Each division had different clinical administrators, research administrators, and nursing managers. Both divisions had established research and education programs and offered 5 clinical fellowships (general ID, transplant ID, orthopedic ID, public health and general PM, and aerospace medicine). Academic departments and divisions are the building blocks of the administrative structure of most academic hospitals, health systems, universities, and colleges. A medical department or division has the following characteristics: specialized in 1 or more disciplines, run by a board-authorized shared governance, led by an elected or appointed chairperson, and included faculty members who are responsible for academic matters such as curriculum and policies.1Rosowsky D.V. Keegan B.M. The disciplinary trench: what if there were no academic departments? David V. Rosowsky and Bridget M. Keegan explore the possibilities. Insidehighered.com.https://www.insidehighered.com/views/2020/08/18/what-if-there-were-no-academic-departments-opinionDate accessed: October 26, 2022Google Scholar Divisions of ID have become commonplace in academic institutions in the 20th century and are often a part of a larger Department of Medicine. In contrast, the specialties certified by ABPM have more variable academic structures, including being in a dedicated department or division or in a department of another specialty such as internal medicine, family medicine, or community medicine. Although the COVID-19 pandemic was not the only motivation for this merger, the pandemic has highlighted the need for a close working relationship between ID and PM specialties. Examples of these collaborations are presented in Table 1.Table 1Examples of Pandemic-Related Opportunities for Collaboration Between Infectious Diseases and Preventive Medicine Specialties•Developing a framework for sustainable contact tracing and exposure investigation of ∼73,000 health care personnel in 4 states.2Breeher L. Boon A. Hainy C. Murad M.H. Wittich C. Swift M. A framework for sustainable contact tracing and exposure investigation for large health systems.Mayo Clin Proc. 2020; 95: 1432-1444Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar•Coordinating a successful massive vaccination campaign that helped mitigate the effects of the coronavirus disease 2019 pandemic within the health care system.3Swift M.D. Breeher L.E. Tande A.J. et al.Effectiveness of messenger RNA coronavirus disease 2019 (COVID-19) vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a cohort of healthcare personnel.Clin Infect Dis. 2021; 73: e1376-e1379Crossref PubMed Scopus (62) Google Scholar•Leveraging big data to inform operational and clinical management of the pandemic.4Jose T. Warner D.O. O’Horo J.C. et al.Digital health surveillance strategies for management of coronavirus disease 2019.Mayo Clin Proc Innov Qual Outcomes. 2021; 5: 109-117Abstract Full Text Full Text PDF PubMed Google Scholar•Developing a coronavirus disease 2019 risk score to guide decisions on home monitoring.5Nyman M.A. Jose T. Croghan I.T. et al.Utilization of an electronic health record integrated risk score to predict hospitalization among COVID-19 patients.J Prim Care Community Health. 2022; 1321501319211069748Crossref PubMed Scopus (3) Google Scholar•Developing a monoclonal antibody severity score to enhance triage of outpatients for treatments.6Razonable R.R. Ganesh R. Bierle D.M. Clinical prioritization of antispike monoclonal antibody treatment of mild to moderate COVID-19.Mayo Clin Proc. 2022; 97: 26-30Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar•Developing policies and procedures to manage a large number of health care personnel.7Tande A.J. Swift M.D. Challener D.W. et al.Utility of follow-up coronavirus disease 2019 (COVID-19) antigen tests after acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among healthcare personnel.Clin Infect Dis. 2022; 75: e347-e349Crossref PubMed Scopus (7) Google Scholar•Creating rapid clinical guidance about anticoagulation in the early days of the pandemic.8McBane II, R.D. Torres Roldan V.D. Niven A.S. et al.Anticoagulation in COVID-19: a systematic review, meta-analysis, and rapid guidance from Mayo Clinic.Mayo Clin Proc. 2020; 95: 2467-2486Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Open table in a new tab Although medical centers are unique in that biological hazards drive a large component of OM activities,9Russi M. Buchta W.G. Swift M. et al.Guidance for occupational health services in medical centers.J Occup Environ Med. 2009; 51: 1e-18eCrossref PubMed Scopus (14) Google Scholar the connection between ID and OM may not be evident outside medical centers and ID have not been a primary focus of OM in most work settings. For example, although management of infections is essential to the transportation sector,10Mack E.A. Agrawal S. Wang S. The impacts of the COVID-19 pandemic on transportation employment: a comparative analysis.Transp Res Interdiscip Perspect. 2021; 12100470PubMed Google Scholar,11Luke T.C. Rodrigue J.P. Protecting public health and global freight transportation systems during an influenza pandemic.Am J Disaster Med. 2008; 3: 99-107Crossref PubMed Scopus (14) Google Scholar it was not until the COVID-19 pandemic that this link has gained public attention. The pandemic also underscored the dilemmas faced by many frontline workers, with states adopting resolutions allowing the presumption that severe acute respiratory syndrome coronavirus 2 infections are work related, placing the burden of proof otherwise on employers. This in contrast to influenza infection, which has not historically been presumed to be work related. This reframing of infection and postinfectious sequelae as work related has required increased collaboration between ID and OM specialists to navigate administrative programs designed to address work-related illness or injury, return to work, and disability landscape. Predictive analytics and real-time modeling represent another area that gained importance during the pandemic and required close collaboration between ID and PM specialties. Both divisions included personnel with expertise in the field of clinical informatics, which is administered under the auspices of ABPM. Informatics tools provided crucial insights into pandemic activity and supported a targeted approach for testing and personal protective equipment utilization and bridged individual patient care to broader population health concepts. PM faculty also directed one of the Agency for Healthcare Research and Quality evidence-based practice centers, which early in the pandemic created a framework for ongoing synthesis of the published literature to support development of clinical guidelines and algorithms.12Murad M.H. Nayfeh T. Urtecho Suarez M. et al.A framework for evidence synthesis programs to respond to a pandemic.Mayo Clin Proc. 2020; 95: 1426-1429Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Aside from the pandemic, faculty in both divisions acknowledged the potential for a positive academic impact of integration. From an educational perspective, ID fellows often desire additional public health training, but rarely is this training integrated into most ID fellowships. Training in PM subspecialties also requires knowledge of key topics within the ID curriculum. Expanding faculty availability and broadening expertise of educators are expected to improve learning opportunities within graduate medical education across the 5 independent training programs. A positive impact of the integration on research activities also seemed intuitive. Integration facilitates multidisciplinary collaboration to study ID at individual and population levels as well as an expanded pool of research mentors. Although these joint activities could have continued across 2 separate divisions, a compelling rationale to consolidate administrative structures and resources became apparent. Leadership and faculty of both divisions realized that their specialties are at a crucial intersection. The shift, propelled by the COVID-19 pandemic, will drive the ID specialty from a disease management focus to a system- and population-based specialty that incorporates PM core activities and skill sets. Integration is further justified by surveys revealing that the knowledge of health care professionals in public health is insufficient,13Bornstein S. Markos J.R. Murad M.H. Mauck K. Molella R. Improving collaboration between public health and medicine: a timely survey of clinician public health knowledge, training, and engagement.Mayo Clin Proc Innov Qual Outcomes. 2021; 5: 11-22Abstract Full Text Full Text PDF PubMed Google Scholar to the extent that several major medical societies and entities have called for a closer collaboration, if not integration, between public health and medical specialties to improve population health outcomes.13Bornstein S. Markos J.R. Murad M.H. Mauck K. Molella R. Improving collaboration between public health and medicine: a timely survey of clinician public health knowledge, training, and engagement.Mayo Clin Proc Innov Qual Outcomes. 2021; 5: 11-22Abstract Full Text Full Text PDF PubMed Google Scholar,14Integration of primary care and public health (position paper). AAFP.org.https://www.aafp.org/about/policies/all/integration-primary-care.htmlDate accessed: April 5, 2022Google Scholar Not much has been published regarding integration of clinical divisions within academic institutions. The available literature often refers to lateral and vertical integration of medical and surgical specialties into centers that deal with certain conditions, such as spine, transplant, and cancer centers.15Levin S.A. Saxton J.W.F. Johns M.M.E. Viewpoint: developing integrated clinical programs: it’s what academic health centers should do better than anyone. So why don’t they?.Acad Med. 2008; 83: 59-65Crossref PubMed Scopus (12) Google Scholar Nevertheless, such literature provides a strong justification for integration from the perspective of patients, health care professionals, payers, policymakers, and the public.15Levin S.A. Saxton J.W.F. Johns M.M.E. Viewpoint: developing integrated clinical programs: it’s what academic health centers should do better than anyone. So why don’t they?.Acad Med. 2008; 83: 59-65Crossref PubMed Scopus (12) Google Scholar Lessons learned from various integration experiences are not unlike those for any change management effort including the importance of early and clear communication, stakeholder engagement, and transparency.15Levin S.A. Saxton J.W.F. Johns M.M.E. Viewpoint: developing integrated clinical programs: it’s what academic health centers should do better than anyone. So why don’t they?.Acad Med. 2008; 83: 59-65Crossref PubMed Scopus (12) Google Scholar,16Grigsby R.K. Kirch D.G. Faculty and staff teams: a tool for unifying the academic health center and improving mission performance.Acad Med. 2006; 81: 688-695Crossref PubMed Scopus (10) Google Scholar Lack of clarity on organizational goals and mission combined with lack of urgency to prompt changes is identified as a major barrier to integration.15Levin S.A. Saxton J.W.F. Johns M.M.E. Viewpoint: developing integrated clinical programs: it’s what academic health centers should do better than anyone. So why don’t they?.Acad Med. 2008; 83: 59-65Crossref PubMed Scopus (12) Google Scholar,16Grigsby R.K. Kirch D.G. Faculty and staff teams: a tool for unifying the academic health center and improving mission performance.Acad Med. 2006; 81: 688-695Crossref PubMed Scopus (10) Google Scholar The idea of integration was conceived in the summer of 2021. This period included leadership discussions, stakeholder interviews, and planning. The timing for implementation was chosen to occur during the second year of the COVID-19 pandemic after the uncertainty and transmission had declined. Thus, in October 2021, implementation started by inviting volunteer faculty to join the different integration taskforces and providing administrative and project management support. The 2 most critical taskforces that started earliest in the process were one responsible for communication and another charged with the development of a new name, vision, and mission statements. Other taskforces addressed integration of the clinical practice, research infrastructure, educational activities, administrative structure, and activities related to staff well-being, inclusion, and retention. An organizational chart and consolidation of financial activities was done by the end of 2021. The taskforces completed their activities and deliverables by the end of January 2022. The approach started with early meetings that involved all stakeholders and senior leadership. Leadership support and clear vision for what the future would bring was continuous and visible throughout. Grassroot active engagement was pursued (ie, health care professionals and administrative partners at all levels were engaged in the process). Analysis of strengths, weaknesses, opportunities, and threats was performed to guide integration efforts (Table 2). All staff were surveyed repeatedly to reach a consensus on the name, vision, and mission. Transparent and continuous communication of the integration was achieved through a dedicated weekly electronic newsletter that was emailed to all staff as well as through monthly town hall meetings that included staff and senior leadership. Certified project management professionals were instrumental in maintaining organization and movement through defined integration milestones. Anticipating staff concerns about leadership, the new leadership roles included individuals from both divisions. The new division chair was boarded in ID, and the associate chair was boarded by ABPM. Other leadership roles in practice, education, and research were assumed by faculty from both previous divisions.Table 2Analysis of the New Combined Division in Terms of Strengths, Weaknesses, Opportunities, and ThreatsStrengths•Expertise and diverse skill sets in multiple specialty and subspecialty areas•Care and treatment of complex illnesses•International standing•Prolific research faculty•Competitive fellowship programs•Dedicated and motivated allied health staff•Commitment to diversity and inclusionWeaknesses•Disparate skill sets—do not understand each other’s work•Communication lines are still somewhat new and uncertain•Stuck in old ways, “this is how we’ve always done it”•Staff burnoutThreats•Lower reimbursement for virtual care•Increased challenges with payer mix while trying to provide complex differentiated care•Push to see more patients in less time•Weakened US and global economy emerging from the global pandemic•Challenges of national/international patients who travel to Mayo Clinic for complex care•Resistance of staff to embrace an integrated modelOpportunities•Involvement in public health activities at local, state, and national levels•Expand telehealth/virtual/remote care capabilities•Conduct research that leverages the multiple combined skill sets•Prepare the workforce of the future, focusing on professional development and diversity Open table in a new tab We describe the rationale and process for the integration of ID and PM specialties into a single division. Although there are clear benefits of synergistic collaboration, clear challenges exist for integration of clinical specialties. This integration combined clinicians with separate clinical practices, structures, and historical responsibilities. Integration may appear to undervalue or dilute the skill set and importance of an established speciality. Institutional resources, such as blocked administrative time from the clinical practice, project management specialists, and physical space, to allow colocation of clinical practice are also needed. Finally, to detect and prevent unintended adverse effects of integration, it is vital to monitor clinical outcomes and patient satisfaction, and surveil indicators of clinician well-being and burnout.