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.