HIV and ID Observations

“Vaccinating the Poor”, National Library of Medicine.

Three of my good friends — they’re way more than just colleagues after all this time — in the HIV/ID world have left clinical practice recently.

Abigail (Abbie) Zuger, Joel Gallant, and Chuck Hicks, each of them brilliant in different ways, won’t be caring for people with HIV anymore, something they’ve all been doing since the early days of this epidemic.

And I’m sad.

Sure, I’ll be interacting with them professionally in various capacities — but I’m sad for their patients, for their students, for their readers, and also for what this says about our field of HIV/ID in particular, and outpatient care in general.

Abigail (Abbie) Zuger published a piece in the New England Journal of Medicine last week that should be required reading for all experienced clinicians, not just those in the HIV/ID world. Entitled “Moving On”, it describes beautifully the bittersweet realization that her hospital-based HIV clinical practice isn’t what it used to be.

My health is fine, but my stamina is pretty much gone. Our health care system is not kind to the chronically ill and marginally insured, and it is not particularly kind to their doctors, either … the memories of my patients’ decades of life with a dire disease will become theirs alone. Their old paper medical records are off in storage now, and their digital charts are full of inane computer-speak, cut and pasted into gibberish.

Abbie’s obviously a pro when it comes to putting words together, and you can sense the pain it gives her to see complex medical histories destroyed by our cumbersome electronic medical records.

Because if you want to review that history, that story of their “decades of life with a dire disease”? Good luck.

But now the past is accessible only with a call to a warehouse and a long wait. Though many patients, given the time and encouragement, will eagerly talk about their long journey from sick to well, a 20-minute appointment slot allows for neither.

Joel’s no slouch when it comes to writing himself, and sent a brilliant, on-target, and poignant explanation for his decision to leave practice to all his friends and colleagues.

Many of the same themes (our evolving health care system and awful EMR) figured prominently in his decision too:

For us ancient relics of the pen and paper era, outpatient medicine is not what it used to be. We click boxes on computer screens while doing our best to converse and maintain eye contact with our patients. We provide clinically meaningless documentation so we can satisfy billing requirements and meet required “quality measures.” We fight with insurance companies to get patients what they need. We take mandatory on-line training courses to satisfy administrative requirements. We worry about UDS, MIPS, MACRA, CQM, CQI, PQRS, RSR, FQHC, and PCMH. There’s still medicine in there, but it sometimes feels buried beneath the growing bureaucracy and regulatory burden of modern-day healthcare.

He told me recently that in the last month of his practice, he met with an administrator to review his office notes for compliance reasons. He was criticized for not counseling his patient about smoking cessation.

When Joel pointed out the paragraph in his narrative note that discussed this very topic, he was told — “Yes, but you didn’t click the three required boxes, so it doesn’t count.”

That anecdote alone could be Citation #1 in any review of clinician burnout!

Joel also cited the change to the HIV practice in particular. Not too long ago he was using his encyclopedic knowledge of HIV treatment on a regular basis to help his patients.

Today? Not so much.

With so many patients now on stable HIV therapy, and getting older, he found himself “functioning as a primary care doctor and untrained geriatrician,” focusing on “back pain, knee pain, hypertension, and high cholesterol — all important issues, but neither my passion nor my expertise.”

When Chuck left practice, he picked up another theme that helped push him, one mentioned by both Abbie and Joel — the pain and frustration of seeing medicine as a business drive patient care:

An increasing emphasis on medicine-as-a-business makes wRVU’s and provider productivity measures much more important than quality of care and patient satisfaction. Funds generated by our clinic from welcoming and caring for challenging socio-economically deprived patient groups (for example, 340b money) go not to improve the care of these patients, but instead are used to try to balance ever-growing health system budgets.

Probably everyone who reads this blog already knows this, but let me repeat it since it deserves emphasis — HIV care will never be profitable in a system that values high patient volume and procedures, both of which are impossible for a patient population with its disproportionate share of poverty, addiction, and psychiatric disease.

It’s important to mention that the departures of Abbie, Joel, and Chuck from HIV care are highlighted here because I know them so well, and because they were so public with their decisions.

(Each gave me permission to write this, for the record.)

But they are hardly alone — I could have also mentioned Kate, Cal, Ben, Raphael, Corky, Kim, Harold, Andrew, Richard, and many other smart and experienced HIV doctors and researchers, all of whom decided it was time to move on.

It’s an irony, and a painful one, that in the supplement to Journal of Infectious Diseases on Careers in ID, the one on HIV was written by Joel Gallant.

Ouch.