Campaign to Urge Doctors, Patients to Talk About AIDS

Acknowledging that doctors cannot be counted on to raise the subject of AIDS with their patients, the state’s largest physician group will launch an unprecedented campaign next month urging patients to initiate the discussion themselves.

The plan by the California Medical Assn. was prompted in part by growing evidence that squeamishness is inhibiting not only patients but some physicians from talking about one of the nation’s most pressing public health problems.

“Doctors have an aversion to dealing with uncomfortable things,” said Dr. David E. Dassey of the association’s task force on AIDS and sexually transmitted diseases. “One of the big issues is uncomfortableness with sexuality. The other is fear of contagion.”

Also underlying the campaign is mounting proof that new medical treatments can prolong the lives of people infected with the AIDS virus, as well as evidence that many people are eager to hear AIDS-prevention advice if only their doctors would bring it up.

“Talk to your doctor,” advised Mark L. Madsen, director of the association’s department of physician education. “We know that 79% of Californians visited a physician last year, but only 6% had any discussion about AIDS risk.”

The campaign, to be kicked off in a press conference in early October, is intended to reach the 3.5 million Californians believed to have placed themselves at risk of exposure to the AIDS virus through sex, intravenous drug use and blood transfusions.

Association officials, as well as experts in the field of AIDS, said they knew of no other medical society that has undertaken a comparable campaign.

According to Madsen, the association has research data indicating that patients are often reluctant to talk about AIDS--sometimes out of denial that they might be at risk or because of unwillingness to volunteer information about their sexuality or drug use.

In addition, many patients are simply unaware of which activities might place them at risk of infection with the human immunodeficiency virus (HIV). Madsen blamed societal “censorship” of straightforward AIDS-prevention information for some of that ignorance.

Finally, Madsen cited a growing number of studies that have found that physicians are failing to bring up the subject of AIDS, perhaps out of fear of unwittingly offending a patient, or out of squeamishness about discussing sexuality and drug use.

“I think some are uncomfortable with the topic,” said Dr. Marshall Kubota, chairman of the association’s AIDS task force. “Some assume, and quite wrongly, that there’s nobody at risk in their practice.”

Others offered a harsher interpretation.

“In the first place, physicians don’t like dealing with AIDS,” said Dr. Neil Schram, of the American Assn. of Physicians for Human Rights, a group of gay and lesbian doctors. “They don’t like dealing with sex. And they don’t like dealing with gay and bisexual men.”

“Physicians in general are very uncomfortable in talking about sex,” said Gordon Nary, director of the Physicians’ Assn. for AIDS Care. “This is something that is very, very difficult for them to address. That part has nothing to do with HIV infection.”

Ideally, Schram said, the subject of AIDS risk should be raised “in every encounter between a physician and a patient.” At a minimum, it should be raised with all new patients, in all complete physical exams and with any patient with a sexually transmitted disease.

For example, doctors should take a detailed sexual history from their patients and ask about present and past drug use, physicians said. Likewise, patients might raise the subject by asking the physician about AIDS risk.

However, a recent telephone survey done by researchers at UC San Francisco found that only 15% of the people randomly sampled had ever discussed AIDS with their physician. And only one quarter of those had discussed AIDS risk as it related to sex.

Nevertheless, 60% of those surveyed said they wanted their physician to talk to them about AIDS risk. They reported to the researchers that they viewed their physician as their most credible source on the subject.

“When it comes to AIDS, some physicians feel that the patient will bring up the topic,” Kubota said. “Patients are waiting for their doctor to bring up the topic. Everybody is waiting for the other person to make the first move, and nobody is doing it.”

Kubota suggested that the responsibility often lies with the physician.

“I don’t know too many patients that come in to a doctor’s office and tell them off the bat that they smoke or have a high cholesterol diet,” he said. “It’s not the responsibility of the patient necessarily to do so. We have a responsibility to ask.”

More broadly, some physicians said members of the profession have been reluctant to care for people infected with the AIDS virus. They cited numerous reasons ranging from moral qualms about the behaviors that put people at risk to the fatal nature of the disease.

Not Trained for It

“Physicians have not been trained to deal with young patients dying, with patients who often are demanding, and with patients who at least some of the time know more about the disease and the availability of medications than physicians do,” Schram said.

“And that change in relationship is threatening to physicians,” said Schram, a Los Angeles physician. “Because, like most people, physicians like to be in control. In dealing with AIDS, there is very little control that physicians have.”