An ongoing dialogue on HIV/AIDS, infectious diseases,
January 8th, 2017
Poll: Should Medicine and Family Practice Residency Programs Have a Dedicated HIV Track?
Typical medical residents, out enjoying themselves in a typical leisure activity.
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!
15 Responses to “Poll: Should Medicine and Family Practice Residency Programs Have a Dedicated HIV Track?”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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There should be a clinical track, but it’s hard to get hired with that training in the big cities. No jobs for HIV providers who don’t have ID boards.
Our entire Ryan White program is staffed by internal medicine docs and NPs and PAs who have received additional training in HIV as part of their general internal medicine training and then subsequently certified as AAHIVSs.
Internal medicine training with additional didactics and clinicals in HIV care is a wonderfully satisfying combination of training for clinicians who hope to practice in community health care settings.
As well as in other cronic conditions, there is a special part of it that consists on counseling. And here is where, in where clinical settings are not multidisciplinary, residents should learn on how to give back a somehow “fearsome” positive result. Counseling a patient with HIV could take plenty of time and as Dr. Sax mentioned, vast mayority of this patients comes from a minority or other traditionally marginalized communities. Therefore, they with get skills that some Universities don´t prepare you for: real patients, real life.
Some primary care residencies I think have offered an HIV fellowship of sorts, an extra year with an emphasis on HIV, but not to the exclusion of other aspects of primary care. This might be a better approach?
I graduated from the HIV Primary Care Track at CU-Denver. Have been working 5 years at Emory/Grady now, 50% in comprehensive AIDS clinic, 50% training residents in both outpatient/inpatient Gen Med. I manage the most complex HIV-related problems independently (plenty of inpatient AIDS as well), and train residents in our Distinction in HIV Medicine. Has worked out well for me, but most of the residents I train go into ID or do Gen Med without much HIV focus. Would love to see more HIV training in FP, IM programs where most residents end up in primary care (unlike Emory, where most do fellowship).
Disease specific training/career makes no sense to “medicine” in general. Many HIV (specific) decisions in the future will be resolved by AI – so theses people also risk career evaporation at some time in the inevitable future. On the other hand there will always be work and rewards for those willing to tend to the poor or otherwise disadvantaged – but they better know about aging, psychiatry, health care models, internal medicine, trauma, cardiology etc etc.
Providing longitudinal care to HIV patients is a great way to learn internal medicine as well as HIV. Since more and more HIV patients are likely to be taken care of by internists and family medicine doctors in the future, we need to be training them in HIV. If the only HIV patients a trainee ever sees are inpatients, they’re unlikely to want to go into the field.
At the University of Colorado Denver we are very proud to offer an HIV track within the Primary Care residency program. Residents may opt into the program their 2nd year after having taken an HIV elective course. They have a longitudinal HIV clinic experience in addition to their general continuity clinic experience. In this way they still experience the breadth of ambulatory clinical experience while obtaining valuable clinical experience with specialists and PCPs involving HIV and underserved care. Residents may then certify with the AAHIV Medicine Certification Exam. We’re proud of our graduates and the many ways in which they care for HIV and underserved populations.
The difficulty filling ID fellowship positions each year while HIV prevalence grows speaks to the need to train generalists in HIV care. While we run a post-graduate fellowship in HIV+Viral Hepatitis here at UMass, I fully support HIV tracks in IM or FM residencies. We need multiple approaches to the HIV care shortage, and ultimately HIV tracks will train far more clinicians than the three non-ID HIV fellowships continuously offered in the U.S. (USC, Boise, and ours). The HIV patients in a resident’s panel will have just as many (actually more) medical comorbidities than their HIV-uninfected counterparts, so I don’t see an HIV focus detracting much from their important generalist training. Furthermore, an HIV track or fellowship graduate would likely bring this expertise into a PCMH setting where they can raise the bar of HIV expertise in their primary care colleagues, amplifying their impact beyond their own panel of patients. While HIV care has been greatly simplified in the last few years for many patients, and HIV primary care should be within the realm of a typical IM or FM graduate, I think we all realize that standard training is often lacking in HIV primary care, and that more advanced HIV care still requires specialized training as one would find in an HIV track or an HIV or ID fellowship.
Believe me: There is no shortage of bread-and-butter primary care internal medicine (CAD, COPD, rheumatology, , psychiatry, derm, metabolic disease, hematology, hepatology, healthcare maintenance………) in longitudinal HIV care, especially as the HIV(+) population is aging. In fact, I probably spend more time on primary care internal medicine than HIV-specific problems, and I practice in a dedicated HIV clinic. Learning outpatient HIV medicine as a resident is only an advantage. Oh, and you would also get better at routine STI diagnosis and treatment, fortunately or unfortunately…….;-).
As someone living with HIV, as well as working within the healthcare field, I believe Residency Programs should expose new physicians to as broad a base of medical conditions they may likely encounter within their professional practice. I would, perhaps, recommend a Fellowship training for those interested post-Residency. I have worked with orthopods who did a Fellowship in spine or joint or orthopedic trauma, general surgeons who did Fellowships in vascular, bariatric, or colorectal surgery, etc. Now, a program that provided lessons on empathy and compassion would be helpful!! Of course, that would apply just to orthopods. LOL!!
Our experience with the HIV Pathway at UW has been very positive. Residents report a broad range of experience and solid general primary care training in addition to experience with HIV management. When we reviewed issues managed by the residents, we found a broad mix of general medicine and HIV-related problems. Some additional data regarding the pathway and the graduates is here, presented as a poster at ID Week: https://idsa.confex.com/idsa/2015/webprogram/Paper53425.html
We have established such a track right here in Boston…
Development and Implementation of a Novel HIV Primary Care Track for Internal Medicine Residents
Published in
JGIM: Journal of General Internal Medicine, October 2016
DOI 10.1007/s11606-016-3878-9
Pubmed ID 27704368
Authors
David A. Fessler, Grace C. Huang, Jennifer Potter, Joseph J. Baker, Howard Libman
I am in a CHC based HIV practice. Currently we have 3 ID trained docs and one FP (me). We have had excellent FP, ID docs as well as great NP and PA’s….the truth is that to do HIV care well one has to want to do it….and it seems not too many folks want to.
We have had an opening for 6 months and until this week have had nobody apply.
Clearly the practice of HIV medicine is changing but workforce remains a challenge. Including HIV pathways in primary care residencies will not detract from training but enhance it in my opinion.
What about increasing value even more with a HIV/HCV track? Given the increasing burden of HCV in the U.S. and that fact that so many people are dying from HCV, wouldn’t that make sense? About a third of HIV patients are co-infected with HCV. GI/ID specialists can’t handle, nor should they in my opinion, all the HCV cases. Only a fraction of patients have been treated yet in this country, and HCV like HIV can be expertly treated by primary care physicians and providers. Their outcomes are just as good. Making an HIV and viral hepatitis track would helpful in improving access not just to HIV patients, but to the many HCV patients as well who are largely underserved.