Tuesday, September 2, 2014

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Becoming a Physician—By Being a Patient (Part 2)

By Keith E. Loring, MD, MPH, FACEP

Note: Part two of the "Leaning to be a Physician: Experience Gained from being a Patient" article originally published in the June 2014 issue of San Francisco Medicine.

After all the build-up, I was completely unprepared for the emotions that came flooding in when I began taking meds. That's when my HIV infection finally became very real. And reality hit hard. I shed a lot of tears and relied heavily on the counselor I had found through the Episcopal Cathedral congregation in Baltimore. For a good ten days, it was all I could do to stay awake long enough to get through an eight-hour shift. Yet it was in those dark days of starting medication that my spiritual journey finally took off. Suddenly and unexpectedly, I woke up one morning feeling like a kid, fully energized. I was also filled with a profound awareness of just how much my body—and my spirit—had been hijacked by the virus. In that moment of awakening, it was clear to me that I had a great deal to be thankful for, not the least of which was quality of care I was receiving. 

Renewed energy also awakened my inquisitiveness about HIV in general, which in turn heightened my level of anxiety about every little itch and scratch. I began reading obsessively and started pestering Janet with every little worry. She cured my hypochondriasis in one fell swoop by asking me what I was reading. "Harrison's chapter on HIV.” “And who wrote it?” “Anthony Fauci.” "Do you know how many patients Anthony Fauci has seen in the last ten years?” “No.” “The answer is none! Keith, I need you to stop reading for now and let me be your doctor." It was a liberating moment, a release and a relief. I could place my energies elsewhere, trust in my physician, and move forward with my life.

With my fellowship year quickly coming to a close, my heart was set on returning to the Bay Area, which prompted one final referral from Joel: his former residency colleague, Lisa Capaldini, who became my physician here in San Francisco. And like every good doctor before her, she set some very clear expectations: “I have two rules: Number one: If you experience any symptom for more than three days, then I want you to call me. Number two: Every Christmas, you have to send me a card with a picture of your dog. If you don't have a dog, a cat will do." Like Janet before her, when it comes to managing my HIV, I defer to Lisa. And it is all working out just fine.

In that moment when I knew I was exposed to HIV, I knew exactly what I needed to do. My intuition was to go out and get some AZT and start taking it. In 1989, there was no data to back such a move; however, I just knew it would work. In retrospect, my intuition was spot on. But I didn't follow it. I was frozen by shame. I allowed myself to believe in a lesser me who was getting just what he deserved. When I finally was able to gather my courage and reach out for help—as a patient—I was met with nothing but courageous compassion. Was it because I was a physician? Did that make a difference? Perhaps. But looking back at those delicate, angst-filled moments two decades ago, I find it hard to believe how anyone I confided in could see much more than a frightened little boy in need of some direction and a lot of reassurance. Because my caregivers believed in me when I didn't, they showed me how to care for myself, and thereby others, in a very profound way. As a patient, I was taught ever so elegantly by Joel, John, Janet, and Lisa how to be a physician, how to listen with my ears and my heart as the best way to help patients muster the strength and courage they need to find healing in their lives. 

And now, two decades later, thanks to a lot of good fortune and a willingness to follow my intuition, I'm currently participating in a Phase I HIV immunotherapy protocol. Whether it is in the direction of a cure or not, I cannot begin to describe the amount of gratitude I feel to be in a position to participate.

Click here to read part 1 -- Becoming a Physician—By Being a Patient.

Keith Loring, MD, currently practices emergency medicine at the Davies Campus of California Pacific Medical Center. He graduated from the Stanford University/Kaiser Permanente Emergency Medicine Residency Program in 1994 and served as assistant chief of service in the Department of Emergency Medicine at Johns Hopkins Hospital from 1994 to 1995. He then joined the part-time clinical faculty in the Division of Emergency Services at San Francisco General Hospital (1995–2010) and established a full-time clinical practice at St. Mary’s Medical Center (1998–2012), where he served as medical director and chief from 2002 to 2006 and vice chief of staff from 2007 to 2010. 

Becoming a Physician—By Being a Patient

By Keith E. Loring, MD, MPH, FACEP

Note: This article was originally published in the June 2014 issue of San Francisco Medicine.

During the final year of medical school, when hopes and anxiety are expected to run high, when sights are entirely focused on finding the best residency, and when confidence in one's clinical abilities is on a steep upward curve, I seroconverted HIV-positive. I know the exact moment when I was infected: The condom broke. I know the exact day when the seroconversion syndrome occurred: I had just arrived in Southern California for a residency interview. And I will never forget the day when I first heard someone utter the words, "You are HIV-positive." A counselor at an anonymous HIV testing center confirmed my worst fears on January 16, 1991, the day George H. Bush launched Desert Storm. 

I had only recently come out of the closet and stood on shaky ground. I was at odds with my family. And I was still very much at odds with myself. My classmates at Johns Hopkins had been amazingly supportive when I came out, but with this new reality, I froze. I simply kept it to myself, went into complete denial, and headed into residency deeply wounded. It was a lonely, tumultuous, and difficult three years. At one point I was placed on probation for cutting corners with patient care. That woke me up enough for me to pull it together and make it through without any further problems. But it was not enough for me to begin dealing with being HIV-positive. I just did not feel safe enough to pull that trigger. 

Immediately after residency, I gathered the courage to begin dealing with things. I returned to Johns Hopkins for a fellowship in emergency medicine. It was the place of my coming out and, fittingly, it became the place where I would begin to find healing. It was the place where I learned what it really meant to be a physician—by becoming a patient. Clearly, once I chose to seek help, being a physician was hugely advantageous in finding the best resources and negotiating the system. However, what really mattered were the connections that I made: the personal touch of my caregivers who opened up a direct, personal, and unfettered connection with me as a patient. And that is the heart of my story as an HIV-positive physician—the network of caregivers, each of whom contributed to my health by listening to me, answering my questions, counseling, guiding, and firmly directing me when necessary.

My first step was to reach out to Joel Gallant, a friend, who was in charge of the Moore (HIV) Clinic at Johns Hopkins. As soon as I opened up, a flood of questions poured out. Could I safely practice in the ER or did I put my patients at risk? Where could I get lab work done without using my insurance? Who was the best HIV specialist? Would I have to take medications? How would I handle insurance? How would I keep things confidential? He immediately began plugging me into the network of caregivers at Johns Hopkins who quietly cared for a sizable number of HIV-positive health care workers in the Baltimore area.

Joel referred me to three people, each of whom had a profound impact on my well-being. First and foremost, I needed to know if I could safely practice clinical emergency medicine. Being HIV-positive, was I placing patients at risk? At Joel's recommendation, I called on John Bartlett, the chairman of infectious disease, who had just finished serving on a presidential advisory committee tasked with setting policy on this very question. After patiently listening to my story, John described the advisory committee's deliberations in detail. He went out of his way to assure me that I was not placing patients at risk and that I was under no obligation to disclose my status to patients or colleagues. However, he did caution me, "You are placing yourself at risk by practicing in the ER. You need to decide if that is a risk you are willing to accept." I was so relieved. He was so unequivocal that I would not be placing patients at risk. My own risk was of little concern.

The next step was to get a handle on the state of my immune system. I did not want to use my insurance, and I didn't want to go through the hospital lab. So Joel referred me to an HIV research lab on campus. I met with the head of the lab, an MD/PhD and a nonclinician. He agreed to run my lymphocyte panel, but only after sitting down and hearing me out. With one foot still firmly planted in the land of denial, I was anticipating that my CD4 count would be relatively intact and that I would have plenty of time before needing to start on medication. Sitting on a high stool, leaning on one of his cluttered basic science lab benches, he looked me in the eye and gave me two of the most important pieces of medical advice I have ever received: "I can run your labs for you, but you need to figure out what this all means to you in your life; you need to get your head straight. And, when you start on medications, you make sure you start on at least two medications at once." This was long before combination therapy had come to the fore.

It was a lot to swallow, but he was spot-on. My CD4 count was 132. I needed a physician, I needed to start medications, and I definitely needed to get my head straight. Joel's third referral was to Janet Horn, a community internist with a large yet unassuming HIV practice. She became my first doctor. She took me in, led me by the hand, showed me how to be a patient, and helped me negotiate the treacherous waters of managing HIV while staying under the insurance and medical records radar. I established my insurance and official records under my middle name, and we found a clinical trial in which I could start on at least two of three medications and through which I would get all my clinical labs. It was a perfect fit—as long as my CD4 count remained above 100. My enrollment CD4 count came back at 86. That was a dark day; I’d hit rock bottom. But when I called Janet, she didn't skip a beat. "CD4 values fluctuate a lot," she said. "Today is Friday. You go, relax, and have a nice weekend. Stop worrying about this. Come in on Monday and have it redrawn. It will be just fine." Sure enough, the count came in at 112.

Click here to read part 2 - Becoming a Physician—By Being a Patient.


Keith Loring, MD, currently practices emergency medicine at the Davies Campus of California Pacific Medical Center. He graduated from the Stanford University/Kaiser Permanente Emergency Medicine Residency Program in 1994 and served as assistant chief of service in the Department of Emergency Medicine at Johns Hopkins Hospital from 1994 to 1995. Dr. Loring then joined the part-time clinical faculty in the Division of Emergency Services at San Francisco General Hospital (1995–2010) and established a full-time clinical practice at St. Mary’s Medical Center (1998–2012), where he served as medical director and chief from 2002 to 2006 and vice chief of staff from 2007 to 2010. 

SB 492 (Optometrist Scope Bill) Eliminated from Legislative Session

SFMS/CMA has successfully quashed a scope-of-practice bill (SB 492) that originally would have allowed optometrists to perform scalpel and laser surgical eye procedures and medication injections.

This dangerous bill originally proposed such a broad expansion in the scope of services that could be provided by an optometrist that it would have placed patients at risk of significant harm from having medical conditions diagnosed and treated by practitioners who lack the education, training, and experience to safely provide primary medical care.

SFMS/CMA was able to get most of the egregious language in the bill stripped leaving only provisions that would have allowed optometrists to administer flu and shingles vaccines.

Sen. Ed Hernandez, author of the bill, has signaled that he would not push the bill forward for a vote on the Assembly floor. SB 492 is now in the Assembly inactive file.

SFMS/CMA would like to thank all the physicians who took time to call, write and fax their legislators to oppose the bill.

SFMS/CMA strongly believes that simply expanding scope of practice and allowing practitioners to perform procedures they simply aren’t trained to do can only lead to unpredictable outcomes, higher costs and greater fragmentation of care.


Cascade of Bills Out of Appropriations; Many Due for Floor Votes This Week

The Assembly and Senate appropriations committees last week approved hundreds of bills for floor votes, including dozens of health-related ones.

Some of the bills impacting health care are:

  • AB 2533 (Ammiano) and SB 964 (Hernandez) are aimed at ensuring health plans coverage is timely as well as adequate, and requires insurers to pay out-of-network charges for services they don't provide in a timely manner in-network.
  • SB 18 (Leno) would require the Department of Health Care Services to accept a $6 million grant from the California Endowment. The state in May turned down that money -- and its matching $6 million in federal funding -- which is earmarked for Medi-Cal renewal and enrollment assistance.
  • AB 1552 (Lowenthal) would make the Community Based Adult Services program an ongoing Medi-Cal benefit. CBAS is the program providing adult day health care services for frail and elderly Californians.  
  • SB 1052 (Torres) would require the board of Covered California to provide web links on the exchange website to health plans' drug formularies, and to create a search tool on the site for consumers to compare health plans' cost and coverage of particular drugs.
  • SB 492 (Hernandez) was approved, but not before huge chunks of the bill were amended at the urging of CMA/SFMS. SB 492 originally intends to expand scope of practice for optometrists to allow scalpel and laser surgery. The newly amended bill limits optometrists to provide certificates of immunizations. The amended bill text has not yet been released.
  • SB 1054 (Steinberg) brings back grants for the Mentally Ill Offender Crime Reduction program. Those grants are for counties that develop a cost-effective system of prevention, intervention and incarceration for mentally ill offenders.

Source: California Healthline, August 18, 2014.


Legislative Update: SB 492 (Optometry Scope of Practice)

SB 492 (Hernandez) moved out of the Assembly Appropriations Committee on Thursday, only after the CMA advocacy team successfully stripped the most egregious language from the bill. However, SB 492 will still allow Optometrists to administer flu and shingles vaccines.

CMA/SFMS and many physicians expressed grave concerns about the bill, as it allows optometrists to perform scalpel and laser surgical eye procedures and medication injections without training. SB 492 removes accountability and standards in eye care while putting patients at risk. And for these reasons, CMA and SFMS are opposing the bill and urging California legislators to reject this bill.

Click here to view more information on SB 492


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