During third year, I was not looking forward to my infectious disease rotation in the HIV clinic. I was worried I would only see sick, suffering patients with a complicated and chronic disease who could not be helped. And I decided to become a doctor because I wanted to help. I also wondered what made an HIV clinic different from any other clinic. The disease and treatment options are set… the patients just take hard-to-pronounce antiretroviral medicines and get Pneumocystis pneumonia, right?
Wrong. The HIV clinic was one of my favorite rotations in all of third year. It was often emotional for me. Many uninsured, low-income patients came to the clinic not only for their HIV treatment, but also for comprehensive primary care thanks to the Ryan White program. I performed a Pap test on a patient who was at higher risk of cervical dysplasia due to her HIV infection; she likely would never have gotten a routine Pap test elsewhere due to her socioeconomic status and lack of insurance.
One of my most memorable patient encounters came in the form of a young mother newly diagnosed with HIV. She came to the clinic with her daughter after a screening test and a confirmatory test came back positive for HIV infection. She had been feeling fine with no symptoms, so she was taken aback by the diagnosis. She asked us if we had ever heard of the test being wrong.
She told us that she did not use intravenous drugs or engage in risky sexual behavior–surely, this was a false positive. Just recently, she had moved back in with her mom to escape a bad relationship with her daughter’s father. As she began to believe the tests, she spent a portion of our visit speculating that her exposure must have come from this relationship. I sat and listened to her speculate about her previous partner’s lies about his negative STI screening while her daughter happily played with my stethoscope.
My preceptor eventually and tactfully stepped in to ease some of the stress our patient was feeling. She reminded the patient that our primary goal was not to find out exactly how or when she was exposed in the past, but rather to treat the current infection and keep her healthy going forward. We explained how far HIV therapy has come in recent years: treatment now exists in the form of a single, once-daily pill, and if she takes this pill consistently, there will be no decrease in life expectancy.
Next, we talked about safety and transmissibility. I reassured her that her new HIV diagnosis did not mean she could not kiss and love her daughter the same way she always had. With that allowance, I could see the patient relaxing and preparing herself to conquer this diagnosis. We also confronted her concerns. For instance, she was not thrilled about the size of the pill she had to take for the rest of her life (understandably), so we reinforced the increased risk of opportunistic infections and anti-viral resistance and thus, the need for compliance.
Then, she had a question that neither my preceptor nor I knew how to answer. She described how she usually chewed some of her daughter’s food for her to help her eat and was worried about transmitting the virus this way. A true mother bird. My preceptor and I told her we would look into it while the nurses drew up some labs. After wading through an abundance of literature, I found case reports that showed transmission of HIV attributed to premastication of food. It was likely through a sore or cut in the oral mucosa and the risk was extremely low, but it had happened at least once. I felt defeated as we returned to tell her what we found: the risk was small but real, and we did not recommend she continue to chew up food for her daughter.
For some reason, I found delivering this small piece of news almost as difficult as telling her she had HIV. Our advice affected her maternalism. I realized that I wanted this patient to only have to deal with one bout of bad news that day. I wanted so badly for the rest of the appointment to be filled with reassurance and wins. Fortunately, our patient took it in stride, rubbing her daughter’s head and telling her it was time to be a big girl and eat by herself now. She told her daughter she would be just fine. Or maybe she was telling herself.
It was a long appointment full of ups and downs. Not only did I learn more about HIV than I had ever known, but I also experienced how to deliver news and talk through difficult subjects. Something that sustains me when giving bad news is the thought that, in a way, we are also giving patients the chance to hunker down under the weight of it and show off their strength. Doctors are highly trained bearers of news–good and bad. Even as a medical student, I feel the strain after a long day of telling patients things neither of us wants to hear.
It is truly a wonder that doctors are able to continue practicing for years despite the burden of compassion fatigue. Still, we dedicate many years of our lives to train in the art of medicine and communication. Just as we learn medicine, we also learn how to educate and impart information in the safest way possible while remaining empathetic to our patients. Though my time in the HIV clinic impacted me deeply, it did not necessarily alter the trajectory of my own life. After all, I will never know exactly what my patient felt when receiving the news of her HIV diagnosis, but I will always know how I felt when delivering it.
That visit continues to serve as a pertinent reminder that every time I deliver a biopsy result, listen for fetal heart tones, or check an A1C, I have the potential to change a life. It is not only my job but my duty to accurately and professionally deliver news to patients and to help share the weight of that until they gather the strength to go forth and bear it themselves.