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Author Topic: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors  (Read 11020 times)

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Offline Miss Philicia

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source (and click to read entire article as I only formatted the first part)

In a recent editorial, Dr. Mitchell Katz, a physician with extensive experience in treating patients with HIV and AIDS, argues that HIV/AIDS care should shift from HIV specialists to primary care physicians now that, in his opinion, HIV is essentially a chronic, treatable disease. The editorial comes several weeks after an Institute of Medicine report warned of serious and growing shortages in the HIV healthcare system and also recommended shifting more HIV care to primary care doctors.

“If specialty care is less needed than it used to be for HIV-infected patients, it turns out that primary care is more needed. Owing to the advances in HIV treatment, our patients are no longer dying: they are aging!” wrote Dr. Katz, director of the Los Angeles Department of Health Services.

Dr. Katz argued in the editorial that HIV is now largely a chronic disease with relatively routine care that could be provided by primary care physicians, as is the case with diabetes.

Most people with HIV now begin treatment with Atripla (efavirenz/emtricitabine/tenofovir), a once-daily pill containing three antiretrovirals that has simplified HIV treatment. In addition, viral load testing – which measures the amount of HIV in the blood and allows physicians to measure how effective HV treatment is – has become fairly routine.

Dr. Katz argued that with the newer drugs and monitoring abilities, patients with effectively suppressed viruses are unlikely to develop the opportunistic diseases that made HIV treatment so difficult in the 1980s and 1990s.
“The most common reason for a patient’s condition not being fully suppressed while receiving one of the conventional regimens is non-adherence, a primary care problem if ever there was one,” wrote Dr. Katz.
“The small percentage of patients who do not obtain a good response to a conventional regimen despite being adherent will need referral for specialty care,” he added.

Instead, the primary challenges faced by people with HIV are increasingly caused by other conditions, such as heart disease, bone loss, and other problems – issues which, according to Dr. Katz, are best dealt with by a primary care physician.
"I’ve slept with enough men to know that I’m not gay"

Offline drewm

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #1 on: May 04, 2011, 02:59:42 PM »
Interesting post Miss P.

Dr. Katz argued in the editorial that HIV is now largely a chronic disease with relatively routine care that could be provided by primary care physicians, as is the case with diabetes.

Yes HIV/AIDS is now, basically, a chronic disease but where I have some concern is that there is still a lot that is not known about this disease that ID doctors pay very close attention to, and in fact, specialize in. I have my ID doc as my primary care physician because, in my opinion, he is better suited to affect and help me manage this disease and any ailment that may come along because he understands the disease. Hope this makes sense.
Diagnosed in  May of 2010 with teh AIDS.

PCP Pneumonia . CD4 8 . VL 500,000

TRIUMEQ - VALTREX -  FLUOXETINE - FENOFIBRATE - PRAVASTATIN - CIALIS


Numbers consistent since 12/2010 - VL has remained undetectable and CD4 is anywhere from 275-325

Offline Jeff G

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #2 on: May 04, 2011, 03:31:10 PM »
I'm not convinced this is a good decision at all . I have friends that are Primary Care Doctors and I think they would be the first to admit they do not know all they need to know about caring for and interpreting all the test a HIV poz patient may need .

A few months ago it took a team of respected ID docs to figure out why I didn't respond well to a med change , I would not want a Primary Care Doc handling things like that or having to have referrals to consult an ID doc when things got dicey . I'm not ready to make a switch yet .     

Offline buginme2

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #3 on: May 04, 2011, 03:36:10 PM »
As long as your doctor has the education and experience in treating patients with HIV I believe that is sufficient.  I do not believe that you necessarily have to see an Infectious Disease specialist.  My HIV doctor is not an Infectious Disease doctor, in fact, he is a cancer specialist (oncologist).  He see's patients with HIV as their primary care doctor because he began his practice specializing in HIV related cancers.  I feel very comfortable in his knowledge and advice.  In fact, the HIV clinic that I go to many of the doctors are not Infectious Disease doctors.   I have never been to an Infectious Disease doctor.  In the beginning it kind of worried me a little, now I feel very comfortable in the care I receive.  
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Offline drewm

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #4 on: May 04, 2011, 03:45:28 PM »
If I am reading the responses correctly, I guess it depends on the doctor. While there are primary care physicians who know very little about HIV/AIDS, I am sure there are others who understand it very well. I would be comfortable with that. I guess it's more about what an individual doctor knows than what his title is.
Diagnosed in  May of 2010 with teh AIDS.

PCP Pneumonia . CD4 8 . VL 500,000

TRIUMEQ - VALTREX -  FLUOXETINE - FENOFIBRATE - PRAVASTATIN - CIALIS


Numbers consistent since 12/2010 - VL has remained undetectable and CD4 is anywhere from 275-325

Offline Cliff

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #5 on: May 04, 2011, 03:46:51 PM »
I have hypertension.  I like having one doc focus on HIV and the other focus on everything else, but primarily hypertension.  In the past I've had ID doctors who were my primary docs as well.  While the treated everything, I felt that their attention was primarily focused on HIV and less on my blood pressure.

The only downside is that my two docs don't communicate to each other very well.  They write letters to each other but they only seem to go unread.

Offline Miss Philicia

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #6 on: May 04, 2011, 03:47:01 PM »
My view is that I'd rather see an Internal Medicine GP with an HIV patient load of 500 people, than see an ID specialist that only has five HIV patients.  Other than that there's also a world's difference with a patient that has multi-class resistance issues and one that is newly diagnosed with a simple resistance/non-existent profile.  And I do agree with the article that as one ages you will benefit from the GP familiarity with non-HIV issues.

Overall personally I think a large clinic setting with, for example, most patients seeing non-ID specialists but with a managing ID specialist on staff is the best end result.  But you're probably only going to find that in a city.

It's an interesting issue/article though.
"I’ve slept with enough men to know that I’m not gay"

Offline leatherman

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #7 on: May 04, 2011, 04:00:41 PM »
there's been much discussion of this same issue at my ASO recently as the board and clients determine whether it's worth "expanding" from exclusive HIV-care to general health care. There is something to be said for 1) the financial gain of treating more illnesses and 2) the majority of client care becoming general health care with only limited HIV-care. In just the last few yrs, our ID doctor has gone from working 3 days a week to 1, with a nurse practitioner and nursing staff handling the vast majority of the health care work load at the clinic.

I myself have been "lucky" to have dealt with 20 yrs of only HIV-related illnesses and haven't required a general practitioner to deal with any of the more common side effects (BP, done density, cholesterol, etc much less the regular "side effects" of aging), so I'm a little skeptical of changing the agency's paradigm (my vote has remained "undecided"); but I can understand and acknowledge that quite often now my ASO clinic is dealing with non-HIV or only mildly HIV-related health care issues.

Just like when we hired a new case manager and prevention staffer to deal with the growing Hispanic community in our area, perhaps changing for the future will require our clinic to expand past it's original HIV constraints as HIV is becoming more manageable and our clients age.

It's fascinating, and scary, and a "good thing" to see HIV becoming a chronic manageable disease that no longer requires such intensive specialized care.
leatherman (aka mIkIE)


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Offline drewm

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #8 on: May 04, 2011, 05:13:41 PM »
My view is that I'd rather see an Internal Medicine GP with an HIV patient load of 500 people, than see an ID specialist that only has five HIV patients.  Other than that there's also a world's difference with a patient that has multi-class resistance issues and one that is newly diagnosed with a simple resistance/non-existent profile.  And I do agree with the article that as one ages you will benefit from the GP familiarity with non-HIV issues.

Overall personally I think a large clinic setting with, for example, most patients seeing non-ID specialists but with a managing ID specialist on staff is the best end result.  But you're probably only going to find that in a city.

It's an interesting issue/article though.

I like your thoughts on this. I happen to agree  ;)
Diagnosed in  May of 2010 with teh AIDS.

PCP Pneumonia . CD4 8 . VL 500,000

TRIUMEQ - VALTREX -  FLUOXETINE - FENOFIBRATE - PRAVASTATIN - CIALIS


Numbers consistent since 12/2010 - VL has remained undetectable and CD4 is anywhere from 275-325

Offline mecch

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #9 on: May 04, 2011, 05:35:24 PM »
I think whatever people can manage in their individual situation, given location, insurance, etc, to get good steady medical oversight, is the right way to go. There is no universal solution or recommendation. 
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline Miss Philicia

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #10 on: May 04, 2011, 05:42:39 PM »
I think whatever people can manage in their individual situation, given location, insurance, etc, to get good steady medical oversight, is the right way to go. There is no universal solution or recommendation. 

Did you read the rest of the article in the link? 
"I’ve slept with enough men to know that I’m not gay"

Offline mecch

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #11 on: May 04, 2011, 05:44:47 PM »
sure. why do you ask?
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline pozniceguy

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #12 on: May 04, 2011, 06:01:31 PM »
My  ID  Dr  became  my Primary  care  Dr  15 yrs ago.....  I still have access to a local GP  for  minor issues
 (  flu shots, congestion, allergies ,minor , scrapes  etc))   they have  good communication among themselves,  share  any clinical  issues and send copies of  all test results .  I  like having it  this way,   both  Drs  know  me and what is  happening in terms of Health care/status.

Nick
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Offline mecch

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #13 on: May 04, 2011, 06:05:12 PM »
As long as doctors can speak to each other, consulting when needed.
So many countries face limited resources and its just the most important thing to have consistent medical surveillance.  In this day and age, with HAART and all, its seems a no brainer that the most important thing for a population is to have HIV+ people in the health care system any way possible.  I think GP's are mostly fabulous and its a beautiful occupation.  I have never met a crappy GP.


edit- yeah i just wanted to say again, never.  All GP's i've ever met have been wonderfully helpful people.
« Last Edit: May 04, 2011, 06:23:15 PM by mecch »
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline tednlou2

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #14 on: May 04, 2011, 11:49:39 PM »
I can see where HIV care is often routine and primary care docs could do it.  I know I go to my doc and he tells me my labs and off I go.  It almost seems like I could just get them in the mail and only see him if something changed.  And, my doc only works with HIV patients Monday afternoons only.  The rest of the week, he sees old folks at the VA.  However, I think the head HIV docs review his patients. 

I would be concerned about the knowledge primary care docs have about HIV and HIV meds.  From my limited experience, many know only the basics.  I know my brother-in-law who is a doc doesn't know much more than it is a virus and there are meds.  And, not to beat a dead horse, but I worry about prescribing meds incorrectly as happened with me--giving me Sustiva mono-therapy, which led to the K103N mutation and knocking out first generation NNRTI's. 

But, if they knew what they were doing, I wouldn't have a problem.  But this is still a very different message from what many experts were telling us---that we needed a doc who specializes in HIV or is very experienced with HIV and one who also attends conferences.  But, how many of our docs do that?

Offline denb45

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #15 on: May 04, 2011, 11:59:19 PM »
I had a Primary Care Doctor for the 1st 6 yrs. then he left and went to the VA, he still come around form time to time, and every time he see's me he always remembers me, and says hello to me, now I have a str8 up STD/HIV Doctor, she's ok, but not as good as my last one, but I really don't require much of anything from her anymore other than routine stuff every 4 to 6 months, I see my GI-doctor more now, and he's a GP as well  ;)
"it's so nice to be insane, cause no-one ask you to explain" Helen Reddy cc 1974

Offline denb45

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #16 on: May 05, 2011, 12:03:05 AM »
My view is that I'd rather see an Internal Medicine GP with an HIV patient load of 500 people, than see an ID specialist that only has five HIV patients.  Other than that there's also a world's difference with a patient that has multi-class resistance issues and one that is newly diagnosed with a simple resistance/non-existent profile.  And I do agree with the article that as one ages you will benefit from the GP familiarity with non-HIV issues.

Overall personally I think a large clinic setting with, for example, most patients seeing non-ID specialists but with a managing ID specialist on staff is the best end result.  But you're probably only going to find that in a city.

It's an interesting issue/article though.

AMEN to that miss p  :-*
"it's so nice to be insane, cause no-one ask you to explain" Helen Reddy cc 1974

Offline wolfter

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #17 on: May 05, 2011, 08:09:56 AM »
I'm very fortunate that my ID doctor is also my PCP.  When I switched to this doctor 2 years ago, I was dumbfounded at the thought of only having one doctor.  It was the best decision I ever made concerning my health.  My old PCP had an issue with sharing info with my ID doctor. 
Complacency is the enemy.  ;)  Challenge yourself daily for maximum  return on investment.

Offline denb45

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #18 on: May 05, 2011, 09:13:24 AM »
I'm very fortunate that my ID doctor is also my PCP.  When I switched to this doctor 2 years ago, I was dumbfounded at the thought of only having one doctor.  It was the best decision I ever made concerning my health.  My old PCP had an issue with sharing info with my ID doctor. 

Yeah tell me about that Greg, sharing info and even reading your file, some doctors don't even don't do this  ???
"it's so nice to be insane, cause no-one ask you to explain" Helen Reddy cc 1974

Offline poz91

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #19 on: May 05, 2011, 10:41:14 AM »
Come to think of it, I'm not sure that I've ever been seen by a doc who dealt specifically with HIV/AIDS and only HIV/AIDS...

I've always been seen at clinics where HIV was lumped together with pretty much every other STD and/or infectious and tropical disease (interestingly, several of these clinics also offered prenatal care... though I suppose one could argue that falls under 'sexually transmitted'), or at doctors' offices where HIV/AIDS has been a sideline practice (oncologist, etc).

I'm not even sure what my current doc's specialty is... all I know is that I'm typically half the age of the other patients in the waiting room.

And I've always had a problem with these places being capable of doing anything other than ordering routine blood tests and writing prescriptions for my meds. Their inability to diagnose even simple illnesses common to HIV patients (pneumonia, thrush, shingles) has been my cue over the years that I needed to once again try to find another doc who is hopefully more knowledgeable with my condition than the last...

So I couldn't disagree more with the notion that the treatment of HIV/AIDS should become even more generalized than it already is...

Offline poz91

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #20 on: May 05, 2011, 10:50:06 AM »
...even reading your file, some doctors don't even don't do this  ???

...lol, that reminds me of one of the very first docs I ever saw

After sitting there with him for quite a while discussing the fatigue I was experiencing, he looks down at my chart and goes, "OH! You have HIV..."


Offline PeteNYNJ

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #21 on: May 05, 2011, 10:54:36 AM »
I'm with Miss P on this - I would rather see a PCP who has experience in treating a large population of HIV+ individuals than an ID doctor who has very little experience.  I am fortunate enough to have a PCP who treats a large % of HIV individuals  and gets that being poz is not just about the disease.  In fact, how my mood is effected and lifestyle choices are largely what we spend time talking about as an approach to treating the disease.  That being said, I have been lucky to not have many complications from this disease, but it I did I am confident my PCP would know when it was time to send me to a knowledgeable ID doc.

Offline likinglife

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #22 on: May 05, 2011, 04:57:46 PM »
OMG! I think this is a terrible idea. Perhaps it's because my Primary doc saw me no less that six times over the past few years...with shingles, thrush, UC...and ultimately PCP pneumonia and never once considered testing me for HIV. The ID doctor assigned to me in the hospital was the first to test me. My Primary care physician has no clue what to do with me... all the hints my body gave her over the years... I would be really upset if they told me that she was going to take over my HIV care. I imagine she would make a face too.
PCP 7/15/10
CD4 26 at diagnosis 7/18/10
Started Kaletra & Combivir
CD4 28 9/29/10
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Swap Combivir for Isentress
CD4 126 3/3/11 vl=UD
CD4 99 5/4/2011 vl=UD
CD4...still at 99 as of 8/18/2011 vl=UD

Offline denb45

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #23 on: May 05, 2011, 05:21:19 PM »
OMG! I think this is a terrible idea. Perhaps it's because my Primary doc saw me no less that six times over the past few years...with shingles, thrush, UC...and ultimately PCP pneumonia and never once considered testing me for HIV. The ID doctor assigned to me in the hospital was the first to test me. My Primary care physician has no clue what to do with me... all the hints my body gave her over the years... I would be really upset if they told me that she was going to take over my HIV care. I imagine she would make a face too.

Maybe you should sue  ??? that's horrible what happen to you, does that doctor still have medical license
to practice in your state  ???
« Last Edit: May 05, 2011, 05:23:41 PM by denb45 »
"it's so nice to be insane, cause no-one ask you to explain" Helen Reddy cc 1974

Offline Solo_LTSurvivor

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #24 on: May 05, 2011, 07:00:01 PM »
This is an interesting article, Miss P.  Thanks for posting it.

I just had fond remembrances of many years ago when my primary care doctor (whom I picked because of him supposedly being a learned I.D. specialist) telling me when I constantly complained of GI distress that I should just drink some Metamucil because I needed more fiber.  Of course I fired his ass and switched to an HIV specialist who ran numerous tests and diagnosed me with cryptosporidium.
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____________________________

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Last regimen:  Epzicom, Sustiva (since its inception with NO adverse side effects: no vivid dreams and NONE of the problems people who can't tolerate this drug may experience: color me lucky ::))
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Fun stuff (in the past):  HAV/HBV, crypto, shingles, AIDS, PCP

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Offline tednlou2

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #25 on: May 05, 2011, 08:41:45 PM »
OMG! I think this is a terrible idea. Perhaps it's because my Primary doc saw me no less that six times over the past few years...with shingles, thrush, UC...and ultimately PCP pneumonia and never once considered testing me for HIV. The ID doctor assigned to me in the hospital was the first to test me. My Primary care physician has no clue what to do with me... all the hints my body gave her over the years... I would be really upset if they told me that she was going to take over my HIV care. I imagine she would make a face too.

This is my concern.  They would have to be recommended as PCP's who have more advanced knowledge about HIV and HIV meds than the average doc.  I think any doc can take a weekend course and start doing plastic surgery, right?  Well, I would want my family doc to take a few months courses and have an interest in learning all he/she could about HIV.  It isn't just about the labs.  I know enough now to know what decent labs and bad labs are.  As with you, I would be worried they wouldn't recognize illnesses that can happen--sometimes even with good numbers.  And the meds, meds, meds.  I know a little about meds now and know I could come ask questions here whether a regimen was an appropriate one.  Someone new, probably would just trust the doc.

Offline Miss Philicia

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #26 on: May 05, 2011, 08:50:42 PM »
... wonders again if people commenting bothered to read the entire article ::)
"I’ve slept with enough men to know that I’m not gay"

Offline buginme2

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #27 on: May 05, 2011, 09:26:49 PM »
... wonders again if people commenting bothered to read the entire article ::)

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Offline tednlou2

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #28 on: May 05, 2011, 09:54:23 PM »
... wonders again if people commenting bothered to read the entire article ::)

I read the full article and the part where the author says primary care docs would need more training in HIV and students in school now should get it.  I just don't think many PCP's practicing today are going to be interested in taking courses on HIV.  I suppose this would only work for med students starting family practices in the future and who got HIV training, because I just don't see the average family doc taking the time to learn about HIV--unless they lived in a hard-hit area, or could either see a profit motive or just wanted to take on something more interesting than the average cold.

But from reading about the lack of HIV specialists, I understand it may be something that is necessary and many will just have to deal with it.  

Offline Ann

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #29 on: May 07, 2011, 08:20:15 AM »
I think it's a very good idea to begin having medical students learning more about hiv as a matter of course, just like they do with other "chronic but manageable" conditions like diabetes when they're still in the basic learning stages before they decide if they want to branch out into a speciality instead of general practice. With the growing numbers of hiv positive patients, it only makes sense.

As it stands right now, I use my GP for most things. We've discussed his views on his ability to handle hiv concerns and while he has had positive patients in the past (from the 90s onward), he does not feel confident enough to undertake complete hiv care even in a stable patient.

If he ever has any doubts as to whether or not something I'm experiencing is hiv related, he's straight on the phone to my clinic in Liverpool. He's only needed to do this a few times, but at least he's got his eyes open (meaning he's always on the lookout for anything unusual) and is willing to ask for a consult. That means a lot to me. My hiv doctor keeps my GP in the loop by sending me a summary letter after every visit which I can then take to any GP appointments. They're not sent directly to my GP in case I need to show the summary to another doctor like an eye doctor or dentist. It works for me.   
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HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline wolfter

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #30 on: May 07, 2011, 10:26:34 AM »
... wonders again if people commenting bothered to read the entire article ::)

I didn't realize it was required reading.  I'll try not to make this same mistake in the future....I thought I deciphered the jist of the article without studying.
Complacency is the enemy.  ;)  Challenge yourself daily for maximum  return on investment.

Offline leatherman

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #31 on: May 07, 2011, 12:14:52 PM »
I just don't think many PCP's practicing today are going to be interested in taking courses on HIV
I think it's a very good idea to begin having medical students learning more about hiv as a matter of course, just like they do with other "chronic but manageable" conditions like diabetes when they're still in the basic learning stages before they decide if they want to branch out into a speciality instead of general practice. With the growing numbers of hiv positive patients, it only makes sense.
a huge problem, here in the states, is even though the amount of HIV+ people is slowing rising throughout this epidemic, there are still relatively few HIV+ people. One million out of 307 million is about .3%  (that's Point Three Percent not Three Percent) of the population - while many other diseases, like the aforementioned diabetes which effects more than 8% - effect a much higher percentage of the population. Sadly, with so few patients, it's not hard to see that medical students wouldn't waste (and obviously haven't been wasting) much of their time studying a disease that they are very unlikely to treat.

I would rather see a PCP who has experience in treating a large population of HIV+ individuals than an ID doctor who has very little experience.
since I was discussing the size of the HIV+ population as being part of the problem, I thought that I would point out here that finding a PCP with experience in treating a large HIV+ population also requires living in a large population with high HIV+ numbers. In many rural parts of America (around 25% of the population of America) there are few HIV+ people scattered over great distances with low population bases; while in some urban areas, there are few HIV+ people in small areas with large populations.

I was very lucky to find an ASO with an HIV clinic, when I had to move back to my family. However this ASO has to serve 4 counties (which reach clear down to the middle of the state) and treats just barely over 400 HIV+ patients. Even with that client base, as the HIV portion has become more manageable, my clinic is looking at expanding into non-HIV health care to have enough funding to remain sustainable.

Based on population statistics, the amount of HIV+ patients, funding issues, etc., I think there will always be a problem of teaching medical students about HIV and encouraging them to become ID doctors, or doctors with HIV experience - unless they are already in an area with a high HIV concentration.


Quote
The U.S. Centers for Disease Control and Prevention (CDC) estimates that over 1 million adults and adolescents are living with HIV in the USA, including those not yet diagnosed, and those who have already progressed to AIDS.1 At the end of 2008, an estimated 682,668 people were living with a diagnosis of HIV infection in the 40 states and 5 U.S. dependent areas with confidential name-based reporting.
http://www.avert.org/usa-states-cities.htm
Quote
Total prevalence of diabetes
Total: 25.8 million children and adults in the United States—8.3% of the population—have diabetes.
http://www.diabetes.org/diabetes-basics/diabetes-statistics/

population of America
307,006,550 - Jul 2009
Source: U.S. Census Bureau
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline MitchMiller

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #32 on: May 08, 2011, 05:20:26 PM »
My response is relative to the totally bizarre healthcare system we have in the US.

Given the high percentage of HIV patients that are stable under treatment, I would go one step further and advocate that independent nurse practicioners should be used to monitor stable HIV patients.  If something was amiss in a lab test, the patient could then be referred to either a general MD or an HIV specialist, with the nurse practioner having a lot of input into that decision.

I find it troubling that many cannot get assistance for HIV medications, while others bill a premium appt cost to Medicare or their insurance, for what is really simply a blood draw and and a look at lab results.  The lab results are even lableled if they are out of normal range, so even a layman can spot something that might be an issue.  It seems like using independent nurse practioners is a common sense approach to inject some sanity into our medical care cost structure. 

I fear if we don't move in this direction, we may lose our major public healthcare system, Medicare, altogether.   Costs will overrun it, much like pension costs have killed unions.


Offline MarcoPoz

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #33 on: May 09, 2011, 10:44:05 AM »
This is total and complete bullshit.  It is just more of the spewage coming forth from those more concerned about the cost of care than they are the quality of said care.  These cost-focused providers actually think that we'll all be so much better served by the lovely folks at Federally Qualified Health Centers also.

The idea that HIV is 'chronic and manageable' was pure 100%  bullshit when it was first spewed by those who saw the first rush of poor people overwhelming our Ryan White Services.  Before that, when most of the patients were white gay men with their own insurance--AIDS was an emergency.  Once it became more brown, black and poor, it all of a sudden became 'manageable'.  This has NOTHING to do with medications--it has EVERYTHING to do with racism and classism.

Now can't those poor pozzies just pop one pill per day and everything will be fine?  What a completely uninformed and dangerous viewpoint.

This is just another attempt to ensure that we don't have access to TRAINED and QUALIFIED HIV SPECIALISTS because it cost more than sending us to some GP working at a FQHC.

It's BULLSHIT when these "Experts" write it,; its BULLSHIT when HRSA suggests it; its BULLSHIT when the politicans suggest it and its even BULLSHIT when co-opted PWA's start parroting it.

Doubt me?  OK print an Op-Ed that says that since our cancer treatments have become so advanced for most forms of cancers now, Primary Care Physicians should be able to handle the initial care of people diagnosed with most cancers.

In case I wasn't clear----BULLSHIT!

HIV/AIDS manageable...like Diabetes, high blood pressure etc etc ad infinitum...?  BULLSHIT!
« Last Edit: May 09, 2011, 10:47:34 AM by MarcoPoz »

Offline Ann

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #34 on: May 09, 2011, 12:41:55 PM »

Doubt me?  OK print an Op-Ed that says that since our cancer treatments have become so advanced for most forms of cancers now, Primary Care Physicians should be able to handle the initial care of people diagnosed with most cancers.


Marco, I don't think anyone is recommending the INITIAL care of newly diagnosed poz people should be handled by GPs. From what I understand, they're talking about people who are stable.
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"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline MarcoPoz

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #35 on: May 09, 2011, 12:57:55 PM »
Marco, I don't think anyone is recommending the INITIAL care of newly diagnosed poz people should be handled by GPs. From what I understand, they're talking about people who are stable.

Ann,

Actually some engaged in advocacy around Health Care Reform from the provider and funder side are advocating this.  And according to the new treatment guidleines, there is relatively little thinking involved in intitial treatment.  We're right back to hit hard/hit early.

Even if after a patient has become 'stable' I still think it is a VERY bad idea.  1) What exactly is stable?  2) How long does "stable" last?  Are we ONLY talking CD4, CD4/CD8% and viral load.  In that case many of us who have continued extreme conditions to deal with, yet have 'stable' CD4s, 8s and VLs should be seen as having a 'manageable' condition and NOT need related ID and other specialty care?

Most of us LTSs have ridden the roller coaster of the stability continuum.  I'd even hazard to say that we were most often brought back from crisis, or near crisis levels by trained HIV specialist.  Without whom, how much more sick would we have become?

If they're so geeked to have GPs engaged, then there should be no need for GYNs, Endocrinologists, Gastrointerologists etc. Why have any specialist at all if GP can 'learn' how to do 'basic' care.  I mean its not like HIV is a complex condition or the immune system is a dynamic interconnected system which is interdependent on other vital body systems?  Right?  ;)

ID physicians and Nurses who specialize in HIV. come to this field because they are interested in working with the disease and the people living with it.

If HIV is simply just another chronic and manageable health issue that people live with--and can easily be treated by any General practitioner of Medicine--then WHY should we be spending all this time, money and energy trying to prevent it?
« Last Edit: May 09, 2011, 01:08:06 PM by MarcoPoz »

Offline woodshere

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #36 on: May 09, 2011, 01:48:42 PM »
ID physicians and Nurses who specialize in HIV. come to this field because they are interested in working with the disease and the people living with it.

But that is the problem, as the article stated, they aren't coming to the field:

Quote
The Institute of Medicine (IOM) report, published last month, also recommended shifting more HIV care to primary care doctors, stating that decreasing numbers of HIV specialists, along with a growing HIV-positive population, are placing strains on the current United States healthcare system.
In addition, people with HIV are increasingly moving from urban centers to more rural areas where HIV-care providers are especially scarce.

Quote
Older HIV physicians are leaving the field faster than new physicians are entering,” said Hafford, who was not involved with the report. “Physicians are often not choosing infectious diseases because they can make substantially more money in other specialties,” she added.

Of course there is also that same problem with GPs. Toward the end of the article there are some suggestions to entice med students to pursue a career focussing on HIV and I have those same suggestions being used to increase the number of GPs.

I have been poz for over 5 years.  I started with a specialist but after two years he closed his practice and went to work for the VA.  Except for the WINGS Clinic (an HIV clinic operated through the University of Louisville) he had more HIV patients than any other physician in town.  After calling several specialists who were no longer taking new patients I found one in Indiana.  Not only was it inconvenient to go there but I did not like him.  A poz friend of mine recommended a GP who had a good size case load of HIV+ patients.  I have been with him for 3 years now.  I am very comfortable with him.   He is very knowledgeable.  And if I have a question he can't answer he does research or makes calls while I am in his office.  When he prescribed medication for bipolar disorder he consulted the John Hopkins web site as well as called his wife who is a psychiatrist to check on possible drug interactions.  If things take a turn for the worse I can go back to the HIV specialist who still has my file and take my file from the GP to bring him up to date.
« Last Edit: May 09, 2011, 01:50:26 PM by woodshere »
"Let us give pubicity to HV/AIDS and not hide it..." "One of the things destroying people with AIDS is the stigma we attach to it."   Nelson Mandela

Offline MarcoPoz

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #37 on: May 09, 2011, 02:06:03 PM »
Wood, et al.

I have no doubts that there are many great GPs who work with HIV, however they aren't the norm.  Those that have them are lucky.

I can't get over the idea that all of a sudden we deserve lower quality care by more untrained providers.

The IOM report does in fact say that there are fewer nurses and physicians coming into HIV work, but it also states the importance of changing this trend and gives possible examples for specific methods to deploy to increase the number of newly trained HIV specialists.

Another note on the IOM report--its ALL over the place!  Look who wrote the thing!  I took REAL issue when they put the team together for this panel because they failed to include the direct input of people living with HIV who are receiving care services.  Myself, along with others communicated this directly to the IOM.  In the end, you have a report about us--deciding what our experience is like--should be like and might be like--without having us inform the process at all.

The answer to the dilema of having fewer trained specialists is NOT to dumb down the service.

Offline Hellraiser

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #38 on: May 09, 2011, 06:47:27 PM »
I tend to disagree with this.  To really understand the different drugs for treatment, all the potential OIs, the pitfalls of the disease, etc. etc. etc. it takes focusing a large amount of time on this one disease in particular.  This means in effect the doctor would be specializing in HIV anyway.  There is nothing worse than feeling like you know more than your doctor about your disease.

Offline mecch

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #39 on: May 10, 2011, 03:38:18 PM »
In the global perspective, isn't it a step in the right direction if the model is making sure an HIV+ person has contact with ANY sort of health care professional, who is a conduit to specialists and medical science, as needed, when possible, rather than nothing.

Best case scenario - we HIV+ all have our own ID's, in every country. Is this realistic? It's not the situation now in the USA, is it?
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline joeyg624

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #40 on: May 10, 2011, 10:10:13 PM »
political undertones aside, i think the best approach here is to initially be under the care of an ID specialist after the initial diagnosis of seroconversion.  this helps assure the patient that the best possible treatment and care is started and the ID specialist can monitor the rate at which an hiv+ patient responds to medication (decrease of VL after baseline determination, increase in CD4, other initial responses to meds as indicated by other metabolic indicators).  when the VL becomes undetectable, CD4 levels have gone up to an acceptable number (whatever that may be) for at least a year, and there are no other problems indicated by blood tests, then switching to a PCP may be considered in what could be considered as an "auto-pilot" stage of health management for hiv+ patients.  this should only be considered when the patient has transitioned into an otherwise normal state of health, as agreed upon by both patient and ID specialist.

of course, this also means integrating some level of hiv information into the general practitioner's continuing education, maybe even in the average medical student's medical college career.  i would think a few years of transitioning into this kind of practice may be in order.

just my opinion...
« Last Edit: May 10, 2011, 10:41:42 PM by joeyg624 »
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LabRat

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #41 on: May 11, 2011, 11:27:36 AM »
I've been fortunate to have an internist as my primary care doc.  Although his specialty is cardiology, he also focused on HIV. He has a lot of HIV patients. I've been with him since day one.

He didn't go along with drug holidays and switching meds constantly when that seemed to be the trend. I was kept on a steady course of treatment and we dealt with the side effects. Whenever it became necessary for me to make a change in my drug treatment, he was careful in choosing the best combo for me. He has a great deal of knowledge and experience with HIV. He has an encyclopedic memory concerning drugs, side effects and treatment. I trust him implicitly.

I do not want to be forced to go to a GP who may have some knowledge of HIV and little experience. Of course I wouldn't know until it is too late.


I totally agree with MarcoPoz:

Wood, et al.

I have no doubts that there are many great GPs who work with HIV, however they aren't the norm.  Those that have them are lucky.

I can't get over the idea that all of a sudden we deserve lower quality care by more untrained providers.

The answer to the dilema of having fewer trained specialists is NOT to dumb down the service.

« Last Edit: May 11, 2011, 11:32:43 AM by LabRat »

Offline d-boy86

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #42 on: May 11, 2011, 01:43:44 PM »
I started off with a ID doctor and then got switched over to my PCP once my last two set of labs came back UD and stable.

In my opinion it would be better to have a PCP because HIV/ID only deal with those things specificially. Whenever I suffered from back pain or muscle aches, my ID had no idea what to do but my PCP was able to tell me immediately.

But this is just my two cents.

Offline joeyg624

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #43 on: May 11, 2011, 08:00:35 PM »
i think this ongoing debate regarding who should be in charge of providing care to hiv+ patients is merely a result of the great strides scientific research has made in the last few years, particularly in the area of care and medication.  the progress has been made so quickly, many people are still pleasantly shocked that it now only takes one dose of a pill every day to control (even reduce) viral loads in people who have been unfortunately infected with hiv. 

i mean, let's face it.  those of us who are lucky to still have parents alive - aren't they still surprised by how easy it to control this virus these days? remember that just a generation ago, being infected with hiv meant sure death within a few years, if not months. people with hiv who have been lucky to receive proper treatment nowadays are dying not because their condition have worsened into aids but because of heart attacks, some other organ failure, accidents, and yes, even old age.

maybe it is really time to reconsider how we receive proper care for our health.  certainly, anyone who is initially diagnosed as being hiv+ must first seek help from an ID specialist.  however, if it would mean cheaper health care costs and that as a result of declining costs, care would be available to more people, then moving on to a PCP would be a reasonable step to take once we are sure that our blood tests indicate that everything is reasonably under control.

i am sure this debate will go on for quite some time still.  but speaking as a scientist myself, i would think it will serve us all better to keep an open mind as we examine the astounding evidence of how much hiv/aids research has advanced so far. 
Apr 10 CD4 60 VL 256,000
May 10 CD4 130 VL 724
Aug 10 CD4 188  VL <75
Nov 10 CD4 170  VL <75
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Aug 11 CD4 272 VL <20
Nov 11 CD4 267 VL <20
Mar 12 CD4 297 VL <20
Nov 12 CD4 312 VL <20

Offline Jeff G

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #44 on: May 12, 2011, 10:07:42 PM »
The more I have thought about this topic the more I wish my GP would or could take over my care .

The clinic I go to is a very good one at UAB in Birmingham ... but all the doctors come in on specific days to do there clinics and if you find the need to consult with a Doctor between appointments its extremely difficult . I'm having trouble with a new prescription that I really desperately need to be taking for my horrible lipids and I just cant bring myself to deal with having to navigate that clinic between appointments . I would not have this problem with my GP , he would be on the phone with me within the hour . I'm starting to see where I just might be better off making some changes and not having to see a specialist for every little thing . 

Offline randym431

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #45 on: May 13, 2011, 03:56:13 AM »
I think this is a good idea. It would force GP to get better involved with HIV patients, and the HIV patient would experience more of a "one stop shopping" medical benefit. HIV specialist would no doubt still be there for patients that need more intensive care needs. But its true, now a day the HIV specialist doesn't do much for the average patient who is doing well. And most HIV specialist already turn over related issue concerns, like controlling cholesterol, diet, sleep issues, skin and general health to the GP.
I personally feel my GP has helped me more than my HIV specialist, now that Im stable and basically "normal" lab wise.
My labs are normal, and I see the specialist every 4 months. That should be changed to 6 months. All the specialist does is slap me on the back and say "keep up the good work" i.e. take my meds every day and do not skip a dose.
Then we talk about the weather or the local news or his family. Any issue I mention, like sleeping problems or cholesterol, he asks "doesn't your GP follow that?".

So, yes, it makes sense for the GP to also do the blood/lab work and report the results, write the scripts.
Im all for that!
And it frees up the specialist to devote more time to the patients that need more intensive care.


Ps. I actually think we might get better care from the GP anyway.
Example... if I just happened to have a cold when I had my HIV specialist visit, he would say "Sounds like we have a bit of a cold? Drink juices and take Tylenol".
If I went to my GP with a cold, he say "we better give you some antibiotics and I'll write you a script for some sinus medicine, JUST TO BE SAFE". The GP, knowing I am treated for HIV, seemed much more concerned that my cold did not get worse to move to the chest or lungs. While the HIV specialist was like "take two aspirins and call your GP in the morning".

To me, a doctor isn't any good unless he/she is willing to give out the DRUGS :D
And when HIV is in the mix, the GP is much more cooperative when it comes to writing scripts.

« Last Edit: May 13, 2011, 04:16:51 AM by randym431 »

Offline wolfter

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #46 on: May 13, 2011, 07:04:37 AM »
After following this thread and appreciating all the different viewpoints, I realize there's not an easy answer to this question.  We can all cite our individual experiences to justify our positions.  Whenever I'd visit my "regular doctor" for any issue, he always questioned me about what my ID thought.  He was consistently referring me to the ID doctor for routine issues.  I'm fortunate to have an ID doctor in private practice who can address any issues and has been the best professional I've dealt with through the entire progression of this disease.  He was the one who suggested I allow him to act as my primary care physician.  He has a lot of initials after his name so he wins....lol  

Plus, he is so damn hot!
http://www.andrewmurry.com/andrewmurry.com/STAFF.html
« Last Edit: May 13, 2011, 07:07:32 AM by wolfter »
Complacency is the enemy.  ;)  Challenge yourself daily for maximum  return on investment.

Offline Ann

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #47 on: May 13, 2011, 09:28:35 AM »
He was the one who suggested I allow him to act as my primary care physician.  He has a lot of initials after his name so he wins....lol   

Plus, he is so damn hot!
http://www.andrewmurry.com/andrewmurry.com/STAFF.html

I was wondering what the initials meant, so I looked them up. Of course the MD was a no-brainer and the FACP (Fellow in the American College of Physicians or Fellow in the American College of Psychiatry, probably the former) was easy too, but the CWS?

From Wikipedia, the free encyclopedia

CWS may refer to:

In environment:

    Canadian Wildlife Service, also known as Environment Canada.
    Currumbin Wildlife Sanctuary, Queensland, Australia

In sports:

    Chicago White Sox, Major League Baseball team
    College World Series, college baseball tournament conducted by the NCAA

In misc. technology and companies:

    Calfrac Well Services, oilfield servicing company
    Celebrity Worship Syndrome
    Control Wheel Steering, special autopilot function in aeroplanes
    CoolWebSearch, spyware
    CWS T-1, the first serially built car manufactured in Poland

Other:

    Church World Service, cooperative humanitarian ministry
    Co-operative Group, large consumers' co-operative
    Co-operative wholesale society

I have to wonder if the correct definition in his case is "Celebrity Worship Syndrome". ;D
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"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline wolfter

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #48 on: May 13, 2011, 10:26:53 AM »
I didn't know that one either Ann, so I looked up his credentials.  It's certified wound specialist.  But cock worshipping syndrome works also. ;D
Complacency is the enemy.  ;)  Challenge yourself daily for maximum  return on investment.

Offline Ann

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Re: HIV Experts Recommend Shifting HIV Care To Primary Care Doctors
« Reply #49 on: May 13, 2011, 11:06:47 AM »
I didn't know that one either Ann, so I looked up his credentials.  It's certified wound specialist.  But cock worshipping syndrome works also. ;D

Or Cock Wanking Specialist. Yee-haw! :D
Condoms are a girl's best friend

Condom and Lube Info  



"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

 


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