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An ongoing dialogue on HIV/AIDS, infectious diseases,
January 8th, 2017
Poll: Should Medicine and Family Practice Residency Programs Have a Dedicated HIV Track?
A few medicine and family practice residency programs around the country have a dedicated track that focuses on HIV care. Though the programs naturally differ somewhat in structure — here are two examples from University of Washington and Yale — they generally involve placing the resident into an HIV clinic for their longitudinal outpatient experience.
We don’t have such a program here, though I’ve been asked about it several times over the years. I can certainly think of advantages and disadvantages to this specialized track.
And since we’re in the midst of residency interview season — plenty of young, bright people wandering around the hospital in dark suits they might not wear again for a couple of years — it seems a good time to consider the issue.
On the plus side for the HIV track:
- Residents with a stated interest in HIV care can get a head start on their career choice.
- There’s a projected shortage of HIV clinicians, and this training will help provide a capable and interested group of young doctors in the field. Residents can skip specialty training in ID and transition right to primary care with a panel of HIV patients.
- Under current training standards, program directors report a high proportion of internal medicine residency graduates are not adequately trained to provide primary HIV care.
- People with HIV are more likely to be poor, from minority or other traditionally marginalized communities (gay men or people with addiction), and having more clinicians sensitive to their needs certainly is a plus.
On the minus side:
- A focused HIV track arguably limits both the breadth of patient experiences and the ambulatory clinical challenges for the resident. Shouldn’t residents get as broad an education as possible at this early stage of their training? This is especially important if they change their minds and choose to do something else.
- If there’s going to be an HIV track, why aren’t there specialty tracks for other diseases? How about more common conditions, such as the primary care needs of cancer survivors, or people with mental illness, or diabetes? Or to choose a couple of problems with comparable numbers in the USA to HIV — how about adults with congenital heart disease, or those with lupus?
- Since so many patients with HIV today are completely stable from the HIV perspective, a dedicated HIV track isn’t necessary. The focus of residency should be learning how to manage problems of aging (hypertension, diabetes, COPD, cancer screening) since these are the most important issues for many HIV patients anyway. Data are emerging that a primary care/specialty collaboration works well — here’s a good recent paper evaluating this issue.
- Doctors who want to manage the most complex HIV issues — multi-class resistance, knotty metabolic abnormalities, opportunistic infections, challenging drug interactions — should do additional subspecialty training Infectious Diseases. In most clinical settings, these situations would prompt a specialty referral regardless of how a resident was trained.
I’m not going to pretend to have the answer to this one. That’s why there’s a poll, and the comments section!