A situation arose in Canada recently that instigated discussion about personal responsibility if a physician tests positive for HIV - or, ultimately, is suffering from any contagious disease.
Earlier this year, officials of a children's hospital in Quebec learned that one of their surgeons had performed more than 2,500 surgical procedures over more than a decade after she had tested HIVpositive. Although the doctor had informed a hospital committee of her HIV status in 1991 and decisions were made on what surgical procedures she could and couldn't do, the hospital administration didn't learn of her illness until recently. The hospital contacted her patients from the past decade to alert them to the situation and offer HIV tests to the children.
Launched debate
The situation launched public debate in Canada, and the Quebec Medical Association has adopted a policy requiring doctors to inform their employer if they are HIVpositive, while protecting the physician's confidentiality. While the United States recognizes just one case of a health care worker infecting patients - a dentist in Florida - a Canadian HIV expert cites HIV transmission by two surgeons in France and Spain who engaged in what is described as exposure-prone procedures.
What happens north of the border can have implications in the United States down the road, and On Call wondered what dermatologists think about whether physicians have a responsibility to inform either their patients or their employers of their HIV status and when such a responsibility kicks in.
The dermatologists express mixed feelings about where the physician's responsibilities lie - the one thing they agree on is that the questions are not easily answered. Several of the doctors also raised the issue of other illnesses that can be more easily transmitted and, yet, can be nearly as devastating to a person's life.
Scott M. Debates, M.D., Omaha, Neb., outlines some of the difficulties that can arise if a physician were to make a positive HIV status public.
'There is a lot of fear in the marketplace. How many patients would go to a doctor if they knew he or she were HIV-positive - even knowing the reality is that the possibility of transmission is so clinically low on the totem pole?
'In general, the medical transmission of HIV is so very low that bringing it up may actually create more of a fearful mind-set than it probably deserves. It's a difficult issue.'
Dr. Debates, a member of a large multi-specialty clinic that is part of the Methodist Hospital System in Omaha, says the situation changes if there is a chance that transmission has occurred.
'I think there's a personal responsibility of a physician who is HIV-positive that if there would be circumstances where there would be a possibility of transmission, then they would not be silent. There is definitely a moral responsibility of the individual to take responsibility for the potential of transmission if that had happened.
'You would hope that would happen and that the person's moral compass is still working because there are medications that can be used early in the disease process that can really help.
'On the other hand, you would hate to cease providing great health care to people who need it because of unfounded fear they're going to contract HIV.'
Up to the physician
In Seattle, Wash., Rachel A. Carton, M.D., says the lack of legal requirements leaves the decision in the physician's hands.
'Ultimately it's up to each individual physician whether they want to disclose it or not - but each physician needs to consider their specialty and their practice type and determine how much they would be putting their patients at risk.
'I wouldn't favor a law requiring disclosure, but people would, or should, probably feel morally or ethically obligated to disclose it.
'I think it would basically end a physician's career - because, honestly, if a physician did disclose this, I wouldn't expect them to get many patients. Talking to co-workers, they knew of physicians who were HIVor hepatitis C-positive who were either given desk jobs, or were let go'
As Dr. Garton mentions hepatitis in the same breath as HIV, Gerald A. Gellin, M.D., in San Francisco, also raises the issue of other contagious conditions.
'I don't think it's important for a doctor to inform a patient of his or her illnesses.
'It has no relevance to the interaction between the patient and physician, possibly with the exception if the doctor has open tuberculosis. This to me would be more of a public health matter - if a doctor has open tuberculosis and is actively providing medical care.'
Even though physicians prefer to know if their patient is HIV positive because of its effect on medical care, Dr. Gellin says that doesn't happen all the time either.
'I've had patients who waited until I was ready to start surgery and then said, 'by the way, Doctor, I have HIV,' because they thought if they told me beforehand, I would not do the operation. So I think there is more risk to the doctor than there is to the patient.'
Other dermatologists weren't quite so certain.
In Cedar City, Utah, Lancing G. Ellsworth, M.D., agrees the issue is very difficult.
'People in high-risk professions for transmitting HIV - and I wouldn't want to be a judge of exactly who that would be; physicians can fit into that category, but not all physicians - should make it known to their patients that they are HIV-positive. I would think a surgeon would fit and possibly some other specialties.'
Dr. Ellsworth, in private practice for five years, says he has to put himself in the patient's position. He also recognizes that HIV isn't the only condition that raises this issue.
'If I were going to have surgery, I would want to know if the surgeon working on me were HIVpositive. I'm not sure I would support laws requiring disclosure, but I ought to know that as a consumer.
'It's a very hot topic. For example, there is a surgeon in our town who is hepatitis positive, and it is the same sort ofthing. And hepatitis is more transmissible than HIV I don't know if he discloses that to his patients or not, but if I were a patient, I would want to know.
'I support disclosure. I don't know that I would support law. I would hope the surgeon would want to disclose that on his or her own.'
Complicating factors
Dr. Carton agrees that other infectious diseases complicate the issue.
'Hepatitis is as big, if not a bigger issue because it's more easily contracted, but it just doesn't seem to push the buttons HIV does.
'It's not quite as controversial for people who don't know, but really it is. There are probably physicians out there with hepatitis C who need to disclose it, but, ultimately, no one is going to be forced to. Ultimately, it's up to the individual physician. They need to seriously consider the risk to the patient.
'They may not be legally obligated, but they should feel ethically obligated,' Dr. Carton says.
In some ways, Jo-David Fine, M.D., of Nashville, Tenn., almost doesn't think there should be any question.
'My assumption would be that any physician who is performing any procedures that could potentially risk infection to the patient should clearly be obligated to inform the patient prior to doing such procedures that he or she is HIV-positive.
'This is something all physicians should think through and act upon his personal views. The issue is primarily whether he or she could put a patient at risk for receiving the virus from the physician.'
Dr. Fine isn't convinced that it would be absolutely necessary to inform the patient if the physician is wearing gloves and there was no potential risk - unless with major surgical procedures - but he says, 'Even an aggressive dermatologie surgical procedure could certainly expose large open areas in the patient, and a tear in the glove could be a problem.'
Dr. Fine, in practice for 21 years and a professor at Vanderbilt University specializing in blistering diseases, says he can only speak for himself.
'Patients should be informed - that's how I practice. I would rather have 98 percent of my patients walk away from my door if they had concerns than mislead them.
'I can't imagine practicing dermatology without doing biopsies and I guess there's always a theoretical risk that there could be a puncture in my glove. I'd hate to have patients concerned about that. I think I would have to stop doing procedures if anything like that were ever to happen to me.'
Other issues
Other issues enter the picture when the discussion moves to whether physicians would owe it to their employer to disclose an HIV-positive status. The Canadian hospital did decide to track down former patients when the physician's HIV status was discovered. What is the physician's responsibility there? Where does that leave the employer?
Dr. Carton says, 'Physicians probably wouldn't last too long if they disclosed a positive HIV status to their employer, but I guess I think they should - again, just more for patient safety.
'You want people to have their privacy, and their medical condition should not be known. The chance of infecting patients probably isn't very high, but you would probably be opening yourself up and your employer to lawsuits.
'The problem is this extends even to conditions that aren't contagious. What if a person is in the beginning stages of Parkinson's? Should they operate?'
Dr. Debates says the issue of informing an employer is really wide open.
'I don't know anyone's status now, so we may have hired someone who was HIV- positive. I guess with everybody being careful and everybody taking the appropriate measures they're supposed to be taking, you hope to reduce the risk enough that it does not matter. I don't think employers are even allowed to ask that.
'I do wonder if the hospital didn't go overboard in tracking down the patients when there was no indication the disease was transmitted to anyone.'
Physician privacy
Dr. Gellin, a practitioner of 41 years and clinical professor at the University of California, San Francisco, says his patients have ranged from 2 weeks old to 107 years. He thinks that the physician's health status is his or her own business.
'Due to privacy matters, I think it is not necessary or incumbent upon the doctor to tell his employer what diseases he has that have no relevance in the provision of patient care.
'Presumably the employer is not supposed to find out about the illnesses of employees. If the employee voluntarily tells the employer, that is the employee's right to do, voluntarily. The employer is not to ask these specific questions, although I'm not sure much attention is paid to that in too many cases. Privacy takes precedence.'
Dr. Ellsworth agrees with that to some extent.
'I don't think the physician has to disclose that information to their employer, although it still may depend on whether it is a high risk occupation. And I still don't know how you would define high risk. The doctors should also take into consideration that they could be leaving their employer open to liability if they aren't informed.'
Dr. Fine points out that in many cases state medical boards and hospital boards would have policies on disclosure - and when it comes to patient safety, he would have to say that privacy was not the major issue.
'I would think it should be necessary to tell an employer only in situations where physicians could, in any way, put patients at risk for acquiring the disease. It would also depend on the rules of the institution in which the individual works - or the state guidelines of an individual state medical board. My impression from getting licenses in so many states over the years is that state licensing boards all have very rigid policies. If they don't require disclosure then I wouldn't think a physician would have to disclose the information.
'Since I try to adhere to the traditional philosophy of'first do no harm,' I personally believe that patient safety should take precedence over concerns of invasion of a physicians' own privacy. I would want to do nothing (by lack of disclosure) that might negatively impact the relationships I try to foster with my own patients.
'And I would obviously adhere strictly to any written guidelines prescribed by my state licensing board, the state health department, the Centers for Disease Control, or any other appropriate health-related agency.'
[Sidebar]
Karen Nash
What happens north of the border can have implications in the U.S. down the road.
[Sidebar]
'In general, the medical transmission of HIV is so very low that bringing it up may actually create more of a fearful mind-set than it probably deserves. It's a difficult issue.'
- Scott M. Debates, M.D., Omaha, Neb.
[Sidebar]
'The problem is this extends even to conditions that aren't contagious. What if a person is in the beginning stages of Parkinson's? Should they operate?'
Rachel A. Carton, M.D., Seattle, Wash.
[Author Affiliation]
Karen Nash is a print- and broadcast- media medical reporter based in Sioux Falls, S.D.
