Quoted: Scared to work in an HIV clinic

[Doodledog]

I ran into trouble at my institution due to a perceived intolerance toward patients from the GLBT population. As part of remediation, it's likely I will have to spend a couple of weeks over summer rounding in an HIV clinic. It's only 2 weeks but I must admit, this is my worst nightmare in medicine. Although I am interested in infectious disease as a subject, I have always been too terrified to consider pursuing it as a career. Of contagion, that is. I feel like I will be constanstly stressed and worried about my personal well being. It's unlikely to happen, but an angry or mentally unwell patient could ruin your life with just a drop of blood. It would only take a bite, cut, needlestick...they are all potentially death sentences. It doesn't just take a drop of blood even--only a few viral particles.

This isn't all that anonymous. Anyone who knows me or about my situation will know who I am. At this point that's not that important. I am just being up front and honest about this. I feel like this is a somewhat rational fear I have. How can I come to terms with this? I'll consult my family as well. It's 2 weeks but...I really value my life you know? Please be sympathetic with my fears even if they appear exaggerated. When there is a slight risk of death present I believe fear is instinctual.

I would feel okay if I could wear a biohazard suit. But I don't believe this is the case regarding HIV or infectious disease? Surely there are cases every year of doctors contracting HIV or infectious diseases from the front lines. I'm shuddering actually.

I am old enough to have been a physician during the early days of the AIDS epidemic and to remember how afraid, partly rationally, and mostly irrationally, many people were of caring for these patients at that time. Much has changed, but we all have to face our fears about contagion and think about the risks of our profession. I can't provide you much advice other than to seek both clinical experiences, and, if needed, counseling to deal with what I think you know is a very small risk. My guess is that if you start the clinic rotation, you'll soon decrease your fear level, but, this may not be the case. You won't know unless you try.

Still, just like "white knuckle" flyers, we do have these fears and they are common and need to be dealt with, even if they don't stand the test of statistical risk analysis. I think you should become familiar with the most current data about infection transmission for health care workers, not just HIV infections. Consider also if you are ambivalent about your medical career and this has affected your feelings about this issue.

Good luck and we'll see if others have suggestions for you.

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[NotAProgDirector]

You're situation is interesting. Although you have called it a "fear", it's actually more like a "phobia". The statistics suggest that your fear is out of proportion to the risk -- for example, the risk of getting HIV from a needlestick from a needle contaminated with HIV+ blood is thought to be around 0.3%. The chance of some patient willfully attacking you is vanishingly small, and even if it happened you'd have a 99.7% chance of not contracting HIV, and that's without post exposure prophylaxis.

The chance of sticking yourself is based directly on how careful you are, and your career choice (surgery being more dangerous).

Honestly, your chances of getting SARS, XDR TB, Meningococcemia, a viral syndrome leading to GBS, getting killed in an MVA, etc are all much higher than the risk of contracting HIV from a patient. Partof being a physician is accepting some of these risks.

So, perhaps this can be addressed like a phobia with desensitization therapy.

I hate to mention it, but are you sure it's the HIV or is it the GLBT patient population that you have a problem with? This is a serious question, and you should examine it carefully.

 

[NoMind]

Are you trolling or serious?

If you are serious then consider:

Your chance of being seriously injured or killed is far greater driving, crossing a road or skiing than working in an HIV clinic. I will not provide statistics as we are both scientists. I would argue that the ED or psychiatric ward are also much more dangerous and unpredictable.

I suspect you do have a phobia of some sort or perhaps OCD. I would suggest talking to a therapist it could be very helpful.

 

[smq123]

As part of remediation, it's likely I will have to spend a couple of weeks over summer rounding in an HIV clinic. It's only 2 weeks but I must admit, this is my worst nightmare in medicine. Although I am interested in infectious disease as a subject, I have always been too terrified to consider pursuing it as a career. Of contagion, that is. I feel like I will be constanstly stressed and worried about my personal well being. It's unlikely to happen, but an angry or mentally unwell patient could ruin your life with just a drop of blood. It would only take a bite, cut, needlestick...they are all potentially death sentences. It doesn't just take a drop of blood even--only a few viral particles.

I feel like this is a somewhat rational fear I have. How can I come to terms with this? I'll consult my family as well. It's 2 weeks but...I really value my life you know? Please be sympathetic with my fears even if they appear exaggerated. When there is a slight risk of death present I believe fear is instinctual.

I would feel okay if I could wear a biohazard suit. But I don't believe this is the case regarding HIV or infectious disease? Surely there are cases every year of doctors contracting HIV or infectious diseases from the front lines. I'm shuddering actually.

Some points:

• HIV is no longer considered a death sentence by most ID specialists. It's not an easy disease to have, but if someone has a tiny bit of personal responsibility, then they can live with the disease (without giving it to others) for many, many years.
• Fear is instinctual when there is a slight risk of death - but that means that you should be terrified each time you get on a bus or cross a street. Heck, you should have a crippling fear of the bathroom - a lot of people slip and fall in their bathtubs. Since you probably don't live in total fear, I think that you should see a therapist about your fear of contracting HIV. It seems like the fear is far out of proportion of the reality.
• Actually, not a lot of doctors contract HIV from the "front lines." If you're careful, it's an extremely low risk.
• When it comes to HIV, it takes more than "a drop of blood" to ruin your life. HIV is not very infectious, and it's difficult to get HIV from even a needlestick - and post-exposure prophylaxis has been proven to be highly effective. The scenario that you outlined (being attacked by an angry patient) is unusual for an outpatient clinic anyway, unless you work in a mental health or drug rehab clinic.

I hate to mention it, but are you sure it's the HIV or is it the GLBT patient population that you have a problem with? This is a serious question, and you should examine it carefully.

I'm glad that someone else has brought this up. The anonymous post was a little awkwardly worded:

• Do you have a "perceived" intolerance towards GLBT patients? Or do you genuinely feel uncomfortable around them? Or did someone take your comments out of context?
• If you have a "perceived intolerance" towards GLBT patients, then why are they making you volunteer in an HIV clinic? I have shadowed in both an LGBT community center AND at an HIV outpatient clinic.
  
  At the LGBT center, sure, I saw a couple of people with HIV - but most of the patients were there for very mundane things (diabetes, IBD, annual checkups, high cholesterol/HTN management, pap smear, getting an oddly-shaped freckle examined for skin cancer, etc). In fact, the VAST majority of these patients at the LGBT center were HIV negative.
  
  On the flip side, at the HIV clinic, about 40% of the patients there were straight - and for most of the 60%, their sexual orientation never came up so I can't be sure whether they were straight, gay, bi, or whatever. Many, many of those people, in any case, got HIV from IV drug use - NOT from sexual intercourse.
  
  Did your school really make you go to an HIV center, specifically, or did they ask you to go to an LGBT clinic, and you're just couching your fears in a more "acceptable" framework? In other words, are you afraid that people will be harsher if they know that you're afraid of going to an LGBT clinic, and so you're trying to pass it off as a fear of HIV? I'm just curious - because it sounds somewhat odd to me. I'm not trying to be mean or harsh, but I'm really curious.

 

[SoCuteMD]

You sound really scared, and I think that feeling may be coming from your lack of understanding of HIV. As smq123 stated, it's really not a death sentence these days. I've met patients who have lived with HIV/AIDS since a diagnostic test was first available in 1986. They are alive, well, and still working full time.

As a medical student you will be unable to avoid coming into contact with patients with infectious diseases such as HIV and Hepatitis C. Infectious disease clinic is probably one of the SAFEST places you can encounter infectious diseases. You know that patients are infected, they know that they are infected, and it's not like contaminated sharps are floating around waiting to be flung at you. Sure, there is the occasional patient who gets upset when blood is drawn or an IV is started - but generally not in clinic (we never even drew blood in clinic - they all went down the hall to phlebotomy). This is far more of a risk in the emergency department.

HIV is a blood-borne illness. There is no way for you to come into contact with "a few viral particles" without there being blood present. And it takes contaminated blood AND broken skin for there to even be a risk. If your skin is intact, there is pretty much zero risk to you. In the WORST case scenarios, healthcare workers stuck with known infected hollow-bore needles have a 1 in 300 risk of converting to sero-positive HIV status. As I understand it, there are NO documented seroconversions in workers who received HIV prophylaxis within the suggested one hour window.

You mention that you are sure there must be multiple cases of healthcare workers being infected annually, but the numbers are INCREDIBLY low. I worked in a large healthcare system with a significant HIV population. The system I worked in has never had a worker seroconvert after exposure.

This fear is really something you need to work on, as you will be exposed to far riskier (yet still low risk situations) as a clinical medical student. You will assist on traumas and resuscitations in the emergency department on your surgery rotation (most likely). In these situations you will be working with patients who are at high risk for HIV and Hepatitis C (many of our traumas and resuscitations were IV drug users) but have unknown status. You may end up in the OR with these patients for exploratory laparotomy or other cases involving substantial blood loss. You will help in deliveries and C-sections in OB, and will likely know that the patient is HIV positive but will not be excused from the delivery for that reason.

No matter what field you go into, you will be in contact with patients who are HIV positive. In my experience, infectious disease clinic is no riskier than any other specialty, and far less so than the surgical specialties. With that being said, I know surgeons who have practiced in high risk areas geographically, in high risk specialties such as trauma and vascular surgery who have never been stuck with a needle. I also know some third year medical students who have been careless or in a hurry who have been stuck three times since the beginning of their clinical years. That is not to say that all needlesticks are born out of carelessness, but simply to reinforce that we all have a very personal role in protecting ourselves while still caring for ALL patients.