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Voices That Transform: Erin Bonura, MD, MCR

May 3, 2023  |  Posted by ABIM  |  ABIM Governance

Erin M. Bonura, MD, MCR, is Associate Professor of Medicine and Program Director of the Infectious Disease Fellowship at Oregon Health & Science University (OHSU), as well as Director of the Microbiology and Immunology Thread for Undergraduate Medical Education. She is one of the founding members of the Educators’ Collaborative at OHSU and serves as Chair of the Education Committee and Vice-Chair of the Infectious Diseases Society of America’s Medical Education Community of Practice.

Dr. Bonura has served on the ABIM Infectious Disease Board since 2020.

How did you get so heavily involved in medical education as a career path?

Education was always at the center for me; even in college I had thought about being a biochemistry professor. I really loved learning and the role teachers play in unlocking that for students. I didn’t recognize it as a career until I started to have some role models in medical school and beyond, and started to see this role for educators, one of which is running a curriculum for microbiology. I was drawn to infectious disease (ID) and they were some of the best educators we had. Then in residency, we had chief residents and program directors that focused on making us master clinicians. I thought, this is something I could really put all of my passions into.

In fellowship, I sought out opportunities to do more in education. My program director and I started rewriting goals and objectives for the fellowship, completing research projects in education and constructing a mentorship team. That set me up to learn more about education, contribute to the research, and get to know people in the education sphere so that I could put my name out for those education positions.

What interests you most about medical education and infectious disease?

They’re both the most interesting things to me. There are so many things in the field of ID that make the quintessential physician. Infectious diseases have always been around and we’ve always needed people to figure out how to treat afflicted patients. But we need more ID physicians; we need to teach the next generation about this fantastic field. Blending this with my other passion of education was a natural mix. That’s what brings me joy in my career and feels validating.

What has changed in medical education during your career?

We had a big movement of transitioning away from the traditional medical school system that had two years of pre-clinical and two years of clinical, and many of these now-called threads were all siloed. Now they’re integrated across the four years, and that was a big switch that a lot of us had to learn on the fly. Some of our directors called it building the airplane while it was flying. Now we’ve gotten good at it, figuring out how to use the science of learning to make this work.

Other changes in my career were work hours, Accreditation Council for Graduate Medical Education (ACGME) changes to programs and requirements, and at the same time ensuring that we’re making the fellowship program the best for trainees while these changes are happening. Moving residents to an (X+Y) system—not integrating clinic every week but alternating with in-patient weeks—changed how residents interact with subspecialty services (outpatient and inpatient) like ID. As well, most subspecialties are not staffing in-patient wards anymore, so we’re not face-to-face with the learners as much which has been a challenge to workforce recruitment and subspecialty education.

What still needs to change?

Some of the structures probably need to change to better support resident wellness and value. The system is still fairly rigid despite advances though ACGME and many institutions that are working to increase flexibility. We need to give more flexibility to programs to support trainees and that may require some big shifts. There’s a lot of burnout in trainees; they need more support in this very rigorous training environment. So, we need to think about how programs and accrediting agencies can give them that specific support where and when they need it.

Workforce challenges have been highlighted in many subspecialties. What’s your perspective on this point in infectious disease?

I think we need to shift the narrative because we, in ID, have been steadily growing our number of graduates over the years; we’ve also grown the number of new programs. There was a small downshift post-COVID that demonstrates a lack of filled positions, but it is important to note that we actually have more positions than we did many years prior and this likely affected our fill rate. So, in general, it is relatively stable.

Having said that, would we like more ID physicians? Yes, because about 80% of counties in the U.S. don’t have an ID provider. We need to continue to increase our pipeline. We can also shift that number by offering more rural rotations to trainees so they can see what life is like outside of our urban training environments, or by opening that pipeline even more to fill those newly opened programs and continue our upward trajectory.

I published a study with Wendy Armstrong in 2014 evaluating subspecialty career decision-making by internal medicine trainees, and we noticed that people who went into ID were interested in the field even before medical school. We have that chance to get them interested in ID with really solid education skills and good engagement experiences like seeing what it’s like to be an ID provider. Many of them only see a small portion of it, like the in-patient work, but not the public health clinics for HIV care, or outbreak investigations and advocacy. We need to encourage more of that, and in residency, we need to support them and mentor them to limit “leaks” in the pipeline. It requires a multipronged approach to continue to grow the field.

With the rising prevalence of new infectious diseases—and the increasing likelihood of more due to climate change—is there a need to change how students are taught about infectious diseases and epidemics?

I think it’s important for medical schools to stay current and relevant, and adjust to what they see coming down the pike. Some of those shifts can be challenging because educators need to balance STEP content where the pace of change is necessarily slower with current life events. Many schools are integrating the COVID-19 pandemic and other epidemiology concepts into education to stay relevant and ensure all students are prepared. Epidemics/pandemics have always been a part of medical education—events like the 1918 Spanish flu epidemic, for instance—but now it feels more real to the students and it’s hitting home.

What is the Educators’ Collaborative and how did that come together?

The Collaborative came together around the time we were switching from a traditional curriculum to an integrated one. We noticed a lot of educators were siloed in their own departments at the university. Many institutions have educator academies that are hierarchical and honorific. At OHSU, we wanted to develop a more organic network of educators that could really help each other, build curricula, learn from each other and produce research without silos and hierarchy adding extra weight. We started out with the School of Medicine and all departments and divisions were welcome to join. It grew to include all of the schools at OHSU. We also benefit from having a Teaching and Learning Center through the provost’s office that employs MEds and EdDs who support faculty that don’t have as much training in education, and helping them to get their work off the ground.

The Collaborative was meant to bring educators together across campus, and now we’re growing our working groups, grand rounds offerings and scholarship support so faculty, staff and trainees can find value in many different ways.

How did you get involved with the ABIM Infectious Disease Board? What did you want to accomplish when you joined?

After hearing there was an opening, I applied as someone who wanted to bring my skills and voice as an educator to the Specialty Board, and have an impact on decision-making and pathways for diplomates. Having been mostly in the education field, I felt like I could bring value to that. Also, as an early career physician, I wanted to bring that voice because often the specialty boards are perceived as being composed of later career physicians, but there are certain decisions that impact early career physicians and women physicians. I wanted to bring that voice and contribute to the discourse.

What has the experience been like for you?

It’s been fantastic. What I’ve really appreciated is the attention to real-life changes that are happening in the country right now: discussion on Dobbs v. Jackson, HIV antiretroviral therapy, misinformation…these are important discussions to have and the Specialty Board and ABIM take them very seriously. We ask, how is this affecting our diplomates and what do we need to say at this time? Being part of those conversations has been a wonderful experience for me.

More recently, changes to the ACGME requirements for ID was a really important discussion for me as an educator. I brought the voice of a program director from a small to middle-sized program to the table and how the proposed changes impact us as well as others. It was validating to see how the ACGME takes commentary seriously and listens to the specialty boards. At ABIM, these are all relevant discussions and each one is given ample time to examine the nuance.

What is the most important thing you want diplomates to know about the Infectious Disease Board and the work you’re doing?

I want diplomates to know that we are here discussing important topics that impact their daily lives. We’re here to support them in being the best physicians they can be and help them be recognized as the value-add to society that they are. ID physicians have an important role in medicine. We also recognize that needs of diplomates and the field evolve. The Specialty Board and ABIM are dedicated to ensuring our policies and procedures reflect our diplomates’ lived experiences and needs. To have this certificate has meaning, and we work to make sure it retains that value.