Clinician front lines need more resources
More patients, more problems; less time/money
Working as an HIV clinician in the United States today is largely about doing more with less.
HIV providers have more medications, more complications, more patient socio-economic problems, and more patients to treat—and they're doing so with less time and fewer resources.
"Without a change in appropriations, we don't have any way of dealing with having more patients who have more complicated issues," says Kathleen Clanon, MD, medical director of HIV Access in Oakland, CA.
Also, HIV clinicians have multiple hidden costs in taking care of HIV-infected patients, says Michael S. Saag, MD, professor of medicine and director of the University of Alabama Center for AIDS Research in Birmingham, AL.
"There are all these things a clinic and provider are required to do, and even for a fully-insured patient those services are totally uncompensated," Saag says. "This includes managing phone calls, accessing compassionate use programs, dealing with prior authorizations for CT scans and MRIs, case management, and psychology services – all of which are not covered."
Even substance abuse counseling often is not covered, Saag says.
"These are services required to provide care to a patient because if someone has depression that's untreated they won't take their medicine and ART won't be successful," he adds.
Perhaps the biggest problem is finding time to provide the care that's necessary to keep patients healthy and adherent.
A decade ago, Clanon would spend an hour with new HIV patients and half an hour with returning patients.
"Now, I have 15 minutes for regular appointments with people and half an hour with new patients," she says.
This type of scheduling is so unrealistic that her lunch hour often is non-existent, and patients might have to wait well past their scheduled appointment time.
"So, for instance, yesterday I had 12 patients for a three-hour clinic session in the morning, and many of them were doing great, but one person was struggling," she says. "This patient had relapsed in her cocaine addiction and had stopped taking her medications, as a result."
So Clanon had to spend additional time talking to her about medication adherence and dealing with her emotional issues.
Then Clanon had a patient who was taking his HIV medications incorrectly because he theorized that if he took extra pills on the days he felt bad and no pills on the days he felt good, it would work best.
"He remembered that we had talked about the importance of taking his medications as the prescription was written, but it didn't make sense to him," Clanon says. "So we tried to get him to agree to do it our way for a month and to get his side effects stabilized so that he could see that he could live with taking the pills once a day."
These cases took more than the allotted 15 minutes.
"So by lunch when I had a conference call, I was three people behind," she says.
Although Clanon caught up with the schedule by skipping lunch and shortchanging the conference call, she encountered a patient crisis in the afternoon session that day.
"We had someone come in who was vomiting, and when we did the labs we saw that she had acute renal failure," Clanon said. "So we had to admit her to the hospital, and it took about an hour to determine what she needed and what the hospital staff would need to do and to write notes for the hospital staff."
This crisis case also took about 1.5 hours of nursing time.
"That's a pretty typical day," Clanon says. "In our clinic, each week, we admit a couple of people, who have some kind of HIV complication, to the hospital."
Also, the HIV clinic had been open on Fridays, which helped providers accommodate the increasing patient load. But because of federal budget cuts, they had to close the clinic on Fridays, Clanon says.
"We have a lot of hope that depending on what new administration we have that we'll end up with more resources devoted to HIV care," Clanon adds. "We'd like to see the same kind of attention that's been paid on the international scene to what's being done domestically."
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