6 Questions: What's it Like to Work in Infectious Disease?

By Hadiyah Brendel

Physician: Retired Army Colonel (Dr.) Paige Waterman

Retired Army Colonel (Dr.) Paige Waterman, Professor of Medicine  and Vice Chair for Clinical Research at USU's School of Medicine, Department of Medicine. (Photo credit: Tom Balfour, USU)
Retired Army Colonel (Dr.) Paige Waterman, Professor of Medicine
 and Vice Chair for Clinical Research at USU's School of Medicine,
Department of Medicine. (Photo credit: Tom Balfour, USU)

Title: Professor of Medicine, Interim Chair of Department of Medicine at the F. Edward Hebert School of Medicine, Vice Chair for Clinical Research at the F. Edward Hebert School of Medicine, Department of Medicine, at the Uniformed Services University (USU)

Years in Infectious Disease: 13 years

Special Interests: Antimicrobial Resistance (AMR), antibiotic stewardship, molecular diagnostics, access to care, innovative and comprehensive surveillance of infectious diseases/human health/social determinants of health and bioecomony (the convergence of disciplines around biology and using what we already have to source other things). 

Favorite Accolade: My selection as Chief Resident in my residency class. That was cool for a lot of reasons because there hadn’t been a lot of women Chief Residents, at least none in the prior ten years. I was ecstatic and that year, although hard, was probably the favorite year of my career.  

Q: Why did you decide to specialize in Infectious Disease and Antimicrobial Resistance?

Waterman: [Because of] clinical care and taking care of patients, whether in an inpatient or outpatient role, or both. My first love was with HIV and the clinical and immunologic complexity it presents. My second centered on antibiotic resistance and antimicrobial stewardship. We only have so many antibiotics and since there is not really a long term market for these antibiotics, we have to think about how we both use them and develop new ones. When compared to diabetes, or another disease that warrants medication for life, the goal of most infectious disease treatments is to finish administering the medicine within a shorter/defined period of time. The model for how we in infectious diseases use medicine is different. There’s a reluctance for people to invest the time and money for development of new antimicrobials because the profits are simply not the same in our current market system. Infectious Disease (ID) doctors, therefore, have to figure out the best way to use these antibiotics so we can retain them and use them when needed. 

Some think of antibiotic stewardship as saying you can’t use antibiotics. Instead, it’s about using all the tools we have to make sure we're using the right ones the first time. In addition, it also involves looking at the evidence of how long we treat people. In the past, informal doctrine was that you’d tell people to take every last pill your doctor prescribed or risk setting yourself up for incomplete recovery. But we now know that the data does not always support that approach. Perhaps we are doing a disservice by treating people so dogmatically without better evidence? Stewardship is more than just saying you can or cannot have an antibiotic. It’s thinking: Are we tracking the prevalence and patterns of these infections and their responses to the antibiotics that we have and use? Are we really employing judicious use of our limited supply of antibiotics?

Consequently, we are working together to allow for an armamentarium of antibiotics to use for a longer term since the pipeline for new ones is not overly robust. 

Q: What does an Infectious Disease Clinician do? 

Waterman: So many exciting opportunities in ID. We can provide direct clinical care, antimicrobial stewardship, infection prevention, education, policy, research and development, and administrative support. Really, the sky's the limit within ID. The global spread of a particularly resistant strain of bacteria caught the DoD, Infectious Disease physicians, and others off guard in the 2000s. It existed for a long time, though not commonly seen. When it did show up, we considered it to be somewhat wimpy. But whenever anything develops marked resistance, it is rarely regarded as being wimpy.  And if it gets anywhere it’s not supposed to be, it’s an even bigger problem. We had trouble finding antibiotics that worked for this bacteria and the problem rapidly spiraled to very concerning levels. And having to resort to using older, more toxic therapies. We were caught off guard because we didn’t expect it. We didn’t expect it, because we weren't looking. Hence, a plug for the benefit of performing regular disease (and in this case, antibiotic resistance) surveillance. 

Surveillance of things that can impact human health, certainly not limited to bacteria, is important. The DoD, initially spearheaded by the Army, came up with the idea to create a centralized molecular lab to perform and enhance existing surveillance for what’s coming next from a bacterial perspective. Whether it was just this particular prevalent strain of bacteria or other ones, the goal was to be able to identify it early enough so we could warn people.  Many have performed similar surveillance for influenza-like infections (think COVID, RSV, and Influenza most recently) for years and while the techniques and approaches are not identical, the strategies and methodologies are similar enough to allow for sharing of capabilities and expertise. It’s not a one-for-one switch, but it’s comparable enough and the laboratory techniques are relatively substitutable.

It was an innovation at the time to set up this network in the United States. Once in place and working, it became easier to expand and broaden to our needs. We first looked at samples obtained from humans with infections. Now, however, people are looking at animals, food residues, wastewater from hospitals and airplanes, and other environmental sources to identify any potentially worrisome signals of rising bacterial drug resistance.

Policy development, education, and research all help answer and guide: How do we practice medicine better?

Team BAMC, as part of learning about inpatient infectious disease, are screening slides of malaria, ascaris, and staph aureus. (Photo credit: William F. Kelly, MD, MACP, FFCP, COL (ret) MC, Professor of Medicine, Clerkship Director, at the USU School of Medicine, Department of Medicine)
Team BAMC, as part of learning about inpatient infectious disease, are screening slides of malaria, ascaris, and staph aureus. (Photo credit: William F. Kelly, MD, MACP, FFCP,
COL (ret) MC, Professor of Medicine, Clerkship Director, at the USU School of Medicine, Department of Medicine)

Q: What is one of the biggest challenges about working in this field?

Waterman: First, at times, the access to advances and innovation is not as good as could be optimally useful. Second, sometimes people approach problems too reactively rather than strategically, which can result in having a number of small projects but fewer well-developed programs. It is often more strategic to look for 5-10 years in advance rather than for 1-2 year funding cycles, as often happens within the federal government. There are a number of good ideas, but linking them to an overarching problem and program can yield more long-term results.. 

I think back to when we set up the centralized molecular lab. Looking around the DoD landscape at the time, there were some efforts where people were doing versions of this on a local scale. These efforts were often internally funded or directed at a specific problem. Therefore, the information remained somewhat siloed. Unfortunately, if you’re doing this great work but are unable to share it, how is it going to help the bigger picture? That’s why having a reference lab for all the DoD was seen as a good idea. The information got out to everybody in a timeframe and with a level of detail that had previously not been seen. 

In academic settings, people are sometimes reluctant to share their findings until after publication of their work. For instance, say I’m working on this great thing, but it takes a while to get it published. By the time it gets published, the early opportunity to help somebody is over. We saw a little improvement with COVID in that some publishers allowed pre-publication access with less impact on final publication acceptance. That approach is both good and bad because it does make data available far earlier, however, it is not as well vetted and consequently led to some premature acceptance of findings. Depending on your area or level of expertise, it is difficult to figure out what is good data and what isn’t, thus limiting the impact of the data.

Q: What aspects of your job do you find most fulfilling?

Waterman: For me, the bottom line is helping people. People have sometimes asked me what I like most about my job – to which I respond, ”I think the times when I'm happiest are when I'm in the hospital taking care of patients.” Ideally, physicians are able to provide some treatment or explanation that will help patients feel better or better understand the approach taken to improve their condition. However, even when a patient is facing imminent death, just being able to share in the experience with the patient and their loved ones to listen, lend an ear of advice or support, or simply be present can be very important for all involved.

I also enjoy being able to help and to mentor people in ways similar to what I experienced. People learn in so many different ways and good mentoring is a valuable part of the learning process. Earlier in my research career, I was fortunate to work with a skilled molecular biologist; he was very good at what he did, though sometimes did seem a bit stuck in the weeds of science. It has been great being able to watch this person evolve over the years to take his detailed scientific knowledge and apply it in a broader way for public health benefit. In a way, it was a change in paradigm for him.  He previously held the academic mindset of publishing first before announcing any findings. In medicine, however, sometimes it’s a public health issue and the publication comes second to the care of the greater good. 

Watching the evolution of that person in particular over time and seeing how he continues to mentor other people to do the same thing is wonderful. Since I never had the same degree of molecular knowledge and he had far less clinical expertise, I like to think we had a symbiotic relationship working together to find and inform potential solutions to medical problems. Although our paths have diverged over time, we still keep in touch, and I see how he has continued to work similarly with others. Apparently, bacteria aren’t the only species that can evolve! 

Team BAMC, as part of learning about inpatient infectious disease, are screening slides of malaria, ascaris, and staph aureus. (Photo credit: William F. Kelly, MD, MACP, FFCP, COL (ret) MC, Professor of Medicine, Clerkship Director, at the USU School of Medicine, Department of Medicine)
Team BAMC, as part of learning about inpatient infectious disease, are screening slides of malaria, ascaris, and staph aureus. (Photo credit: William F. Kelly, MD, MACP, FFCP,
COL (ret) MC, Professor of Medicine, Clerkship Director, at the USU School of Medicine, Department of Medicine)

Q: In your medical studies, what prepared you the most for this profession?

Waterman: Variety in training sites, experiential learning, and other opportunities afforded me with a degree of adaptability that helped prepare me for the unexpected nature of medicine – which is quite similar to the medical students at USU. You are sort of forced to figure out how to make things work – which is a good thing. As with being in the military in general, assignments and jobs change, sometimes with little warning, and yet you have to rise to the occasion to get the job done. 

I certainly learned in the traditional way through didactic classwork. I learned a lot on the job. I also learned from watching people whom I thought did things well.  And I learned from people who worked directly with me. In my training days, we used to say, “See one, do one, teach one.”  I think with a combination of medical staffing models, deployments, and military leadership opportunities, we get exposure to some things earlier in the military than our civilian counterparts. I got the chance to see medical care administered by people who did it well. I got a chance to do it, albeit with supervision, and then I had the opportunity to teach it. 

Teaching is a really wonderful way of learning. If you can explain what you're doing to somebody, it reflects a clear understanding on the part of the teacher. Although the risers in the steps may be a little steeper now for the younger learners, the concept of seeing, learning, and ultimately doing remains part of the medical education model. 

Many schools these days employ small group learning. In medical school, that group project mentality continues. You’re working together with people of different backgrounds to learn the information and USU does that very well with small group learning. Each student brings their own input to a discussion or problem set. The result is that everybody learns from each other, not just individually. There is a lot of value in shared experiences/learning and being able to bounce ideas off people to enhance understanding. That approach turned out to be really valuable for my learning. No doubt, I would have gleaned the information somewhere else, though I don’t know if I would have picked it up quite so quickly. I would have gone through a chunk of my life thinking: I’ve been successful doing it my way, I can continue to do it my way. The small group approach is a useful one – especially in medicine when you work with so many other people. 

Q: What advice can you offer medical students considering this specialty?

Waterman: In 2014 with Ebola, nobody was truly excited, but the infectious disease part of me was very excited. Imagine having learned about something relatively esoteric and then actually applying that knowledge to real life! The book never quite approximates real life where you get to actually see and use the information you have been packing into your brain for so long. Whether Ebola or COVID, simply learning about a pandemic and actually working in one are two different things. I had considered a couple of specialities when I was in school - often procedural specialties. It is gratifying to be able to objectively fix a problem, as with surgery. However, I realized I really like thinking through problems and sorting out the best way to solve them - similar to what one might read in a medical mystery novel. If we can put enough of the pieces together to solve the puzzle, then the problem is surmountable. That’s the part I really enjoy. 

If your calling is patient care, that is absolutely possible. If you want to teach learners, you can do that. Develop policy based upon experiences? Also an option. Research & development to advance science and health care – yes.  Infectious Disease physicians can do all of those things and more. 

So there’s a lot of opportunity, there’s a lot of variety. No one day is the same as the next. Tropical medicine was something that attracted me to the military too. The DoD has a global footprint and mission. For those people attracted to the field of global public health, Infectious Disease is perfect. USU provides an incredible military medical experience and the opportunity to find what pathway best fits your interests – even if it is something different than ID.