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Screening Physicians for HIV Not Cost-Effective To the Editor: Tlie subject of HIV testing among health care professionals is an emotional one. Much of the emotionahsm results from public misperception and misinformation. Thearticle "Screening for HIV in Physicians: Who Should We Test and What Will It Cost," (NC Med J 1994; 55:136-40) was somewhat disconcerting to me because: 1) It reduces the question of testing among physicians to essentially a risk/cost analysis, and 2) it fails to deal with the true issue, which is not HIV positive rates among physicians but rather the rate of HIV transmission to patients from HIV-positive physicians. As a physician who follows the Centers for Disease Control guidelines for personal testing, I think such discussions are not helpful and are misleading. To quote the American College of Surgeons' "Statement on the Surgeon and HIV Infection:" "to date there have been no documented incidences of transmission of HI V from a surgeon to a patient and no transmission of the virus to a patient in a sterile operating room environment. This area has been investigated carefully, and despite testing of thousands of patients of HIV-infected surgeons, no evidence of transmission has been found...." "The only identified HIV transmission from a health care worker to a patient occurred in a dentist's office in Florida. Although not conclusively proven, it almost certainly occurred from contaminated instruments that were not adequately disinfected and sterilized between patient visits." According to this document, even the CDC guidelines for physician testing "ignored the overwhelming testimony of the scientific community and the fact that all currently available data indicate [that] transmission from provider to patient in a hospital setting is so far a purely hypothetical event." The proper cost/risk analysis to perform would be the cost to detect HIV in health care providers divided by the number of transmissions to their patients, which at present is zero. Therefore, until transmission occurs from HIV-positive health care workers to their patients, it will not be cost-effective to perform HIV testing on physicians in any risk group category. Joseph W. Mulcahy, MD Four County Surgical Associates Vance Medical Arts Bldg, No. 203 1912 Ruin Creek Road Henderson, NC 27536 Forensic Pathology Automatically Exposure-Prone To the Editor: I was surprised to read in "Screening for HIV in Physicians: Who Should We Test and What Will It Cost," (NC Med J 1994;55:136-40) that forensic pathology is regarded as having a low incidence of exposure-prone procedures. This news will comfort me as I perform my next examination on an IV drug-abusing, crack-smoking prostitute found dead in an alley, an itinerant drug peddler from New York City with multiple gunshot wounds, or one of the routine examinations we perform on every North Carolina prison or jail inmate who dies. Forensic pathologists perform autopsies on populations preselected for high risk. There is no prescreening, and we cannot refuse to do an examination on the basis of HIV status. I do not know how many of the consensus panel have attended an autopsy recently, but is there any other procedure in medicine that is more invasive or involves more contact with blood? Sharp knives, scalpels, and needles are used; the prosector isexposed to jagged bone, and, at times, glass and foreign metal objects including non-physician friendly projectiles such as the Black Talon bullet are involved. I thus take exception to the suggestion that forensic padiologists, or any pathologist who performs medico-legal autopsies, has a low likelihood of exposure. I would, however, agree that we have an extremely low risk of transferring HIV to patients since we don't do these high-risk procedures on living individuals. For that reason, I believe that, if our objective is to protect patients, it would not be cost-effective to screen forensic pathologists. John D. Butts, MD Chief Medical Examiner NC DEHNR�Div. of PosUnortem Medicolegal Examination Chapel Hill, NC 27599-7580 Selective Behavior, Selective Care To the Editor: I have been interested in media reports alxjut our soc iomedical problems� lack of hospital insurance, decreased accessibility to physicians, and limited insurability due to a positive family history or a newly acquired disease. One also hears much about who should receive medical care, including the idea of reduced or coverage for alcohol or drug users since their medical problems were "self-imposed." At the same time, we omit other self-imposed problems such as HIV infection from sex or needles, or lung cancers from smoking. The insurance industry and its policies are frequently blamed. I don't argue with the criticisms being published, but ask the question: If the current industry behavior is so bad and is creating such huge problems, why did the legislators not anticipate such problems when they wrote the original entitlement legislation? Or now, after recognizing the problems, why have they failed to attempt any corrective legislation? With the exception of "caps," very litUe has been done. Granted, community morals change with time (look at prohibition, abortion, and homosexuality). But have ourmorals shifted enough that we should criticize those who are behaving within legal constraints as though their h�ehavior was criminally negligent? The criticized behavior of the insurance industry is determined by local legislation; changing it could be accomplished whenever legislators believe that changes are needed. I submit this as an argument to initiate and promote negotiated solutions rather than accept mandated, untested programs, which may be less useful than what are now legislatively permitted. H. William Gillen, MD 2038 Trinity Ave. Wilmington, NC 28405 Contifiued on page 236 210 NCMJ/June 1994.Volume 55 Number 6
Object Description
Rating | |
Fixed Title * | NCHH-17: North Carolina Medical Journal [1940-Present] |
Document Title | North Carolina Medical Journal [1940-Present] |
Subject Topical Other | Public Health -- Periodicals.; Physicians -- North Carolina -- Directory.; Societies, Medical -- North Carolina -- Periodicals. |
Description | Includes Transactions of the Society, -1960; 1961- , Transactions issued separately, bound in.; Includes Transactions of the auxiliary to the Medical Society of the State of North Carolina and Proceedings of the North Carolina Public Health Association. Official organ of the Medical Society of the State of North Carolina, 1940-May 1972; of the North Carolina Medical Society, June 1972-. Vols. for 1940-May 1972 published by the Medical Society of the State of North Carolina; June 1972- by the North Carolina Medical Society. |
Contributor | Medical Society of the State of North Carolina. Transactions.; Medical Society of the State of North Carolina.; North Carolina Medical Society.; North Carolina Medical Society. Transactions.; North Carolina Public Health Association. Proceedings. |
Publisher | [Winston-Salem] : North Carolina Medical Society [etc.], 1940- |
Repository | University of North Carolina at Chapel Hill. Health Sciences Library. |
Host | University of North Carolina at Chapel Hill |
Date | 1994 |
Identifier | NCHH-17-055 |
Form General | Periodicals |
Language | English |
Rights | This item is part of the North Carolina History of Health Digital Collection. Some materials in the Collection are protected by U.S. copyright law. This item is presented by the Health Sciences Library of the University of North Carolina at Chapel Hill for research and educational purposes. It may not be republished or distributed without permission of the Health Sciences Library. |
Digital Collection | North Carolina History of Health Digital Collection |
Sponsor | The North Carolina History of Health Digital Collection is an open access publishing initiative of the Health Sciences Library of the University of North Carolina at Chapel Hill. Financial support for the initiative was provided in part by a multi-year NC ECHO (Exploring Cultural Heritage Online) digitization grant, awarded by the State Library of North Carolina, and funded through the Library Services and Technology Act (LSTA). |
Volume Number | 55 |
Health Discipline | Medicine |
Digital Format | JPEG 2000 |
Print / Download PDF Version | http://archives.hsl.unc.edu/nchh/nchh-17/nchh-17-055.pdf |
Document Sort | all; nchh-17 |
Volume Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/identi/searchterm/NCHH-17-055 |
Title Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/documa/searchterm/NCHH-17 |
Catalog Record link | http://search.lib.unc.edu/search?R=UNCb1306322 |
Revision History | done |
Description
Fixed Title * | Page 210 |
Document Title | North Carolina Medical Journal [1940-Present] |
Subject Topical Other | Public Health -- Periodicals.; Physicians -- North Carolina -- Directory.; Societies, Medical -- North Carolina -- Periodicals. |
Description | Includes Transactions of the Society, -1960; 1961- , Transactions issued separately, bound in.; Includes Transactions of the auxiliary to the Medical Society of the State of North Carolina and Proceedings of the North Carolina Public Health Association. Official organ of the Medical Society of the State of North Carolina, 1940-May 1972; of the North Carolina Medical Society, June 1972-. Vols. for 1940-May 1972 published by the Medical Society of the State of North Carolina; June 1972- by the North Carolina Medical Society. |
Contributor | Medical Society of the State of North Carolina. Transactions.; Medical Society of the State of North Carolina.; North Carolina Medical Society.; North Carolina Medical Society. Transactions.; North Carolina Public Health Association. Proceedings. |
Publisher | [Winston-Salem] : North Carolina Medical Society [etc.], 1940- |
Repository | University of North Carolina at Chapel Hill. Health Sciences Library. |
Host | University of North Carolina at Chapel Hill |
Date | 1994 |
Identifier | NCHH-17-055-0014 |
Form General | Periodicals |
Page Type | all; editorial |
Language | English |
Rights | This item is part of the North Carolina History of Health Digital Collection. Some materials in the Collection are protected by U.S. copyright law. This item is presented by the Health Sciences Library of the University of North Carolina at Chapel Hill for research and educational purposes. It may not be republished or distributed without permission of the Health Sciences Library. |
Filename | ncmed551994junedec_0014.jp2 |
Digital Collection | North Carolina History of Health Digital Collection |
Sponsor | The North Carolina History of Health Digital Collection is an open access publishing initiative of the Health Sciences Library of the University of North Carolina at Chapel Hill. Financial support for the initiative was provided in part by a multi-year NC ECHO (Exploring Cultural Heritage Online) digitization grant, awarded by the State Library of North Carolina, and funded through the Library Services and Technology Act (LSTA). |
Volume Number | 55 |
Issue Number | 6 |
Page Number | 210 |
Health Discipline | Medicine |
Full Text | Screening Physicians for HIV Not Cost-Effective To the Editor: Tlie subject of HIV testing among health care professionals is an emotional one. Much of the emotionahsm results from public misperception and misinformation. Thearticle "Screening for HIV in Physicians: Who Should We Test and What Will It Cost" (NC Med J 1994; 55:136-40) was somewhat disconcerting to me because: 1) It reduces the question of testing among physicians to essentially a risk/cost analysis, and 2) it fails to deal with the true issue, which is not HIV positive rates among physicians but rather the rate of HIV transmission to patients from HIV-positive physicians. As a physician who follows the Centers for Disease Control guidelines for personal testing, I think such discussions are not helpful and are misleading. To quote the American College of Surgeons' "Statement on the Surgeon and HIV Infection:" "to date there have been no documented incidences of transmission of HI V from a surgeon to a patient and no transmission of the virus to a patient in a sterile operating room environment. This area has been investigated carefully, and despite testing of thousands of patients of HIV-infected surgeons, no evidence of transmission has been found...." "The only identified HIV transmission from a health care worker to a patient occurred in a dentist's office in Florida. Although not conclusively proven, it almost certainly occurred from contaminated instruments that were not adequately disinfected and sterilized between patient visits." According to this document, even the CDC guidelines for physician testing "ignored the overwhelming testimony of the scientific community and the fact that all currently available data indicate [that] transmission from provider to patient in a hospital setting is so far a purely hypothetical event." The proper cost/risk analysis to perform would be the cost to detect HIV in health care providers divided by the number of transmissions to their patients, which at present is zero. Therefore, until transmission occurs from HIV-positive health care workers to their patients, it will not be cost-effective to perform HIV testing on physicians in any risk group category. Joseph W. Mulcahy, MD Four County Surgical Associates Vance Medical Arts Bldg, No. 203 1912 Ruin Creek Road Henderson, NC 27536 Forensic Pathology Automatically Exposure-Prone To the Editor: I was surprised to read in "Screening for HIV in Physicians: Who Should We Test and What Will It Cost" (NC Med J 1994;55:136-40) that forensic pathology is regarded as having a low incidence of exposure-prone procedures. This news will comfort me as I perform my next examination on an IV drug-abusing, crack-smoking prostitute found dead in an alley, an itinerant drug peddler from New York City with multiple gunshot wounds, or one of the routine examinations we perform on every North Carolina prison or jail inmate who dies. Forensic pathologists perform autopsies on populations preselected for high risk. There is no prescreening, and we cannot refuse to do an examination on the basis of HIV status. I do not know how many of the consensus panel have attended an autopsy recently, but is there any other procedure in medicine that is more invasive or involves more contact with blood? Sharp knives, scalpels, and needles are used; the prosector isexposed to jagged bone, and, at times, glass and foreign metal objects including non-physician friendly projectiles such as the Black Talon bullet are involved. I thus take exception to the suggestion that forensic padiologists, or any pathologist who performs medico-legal autopsies, has a low likelihood of exposure. I would, however, agree that we have an extremely low risk of transferring HIV to patients since we don't do these high-risk procedures on living individuals. For that reason, I believe that, if our objective is to protect patients, it would not be cost-effective to screen forensic pathologists. John D. Butts, MD Chief Medical Examiner NC DEHNR�Div. of PosUnortem Medicolegal Examination Chapel Hill, NC 27599-7580 Selective Behavior, Selective Care To the Editor: I have been interested in media reports alxjut our soc iomedical problems� lack of hospital insurance, decreased accessibility to physicians, and limited insurability due to a positive family history or a newly acquired disease. One also hears much about who should receive medical care, including the idea of reduced or coverage for alcohol or drug users since their medical problems were "self-imposed." At the same time, we omit other self-imposed problems such as HIV infection from sex or needles, or lung cancers from smoking. The insurance industry and its policies are frequently blamed. I don't argue with the criticisms being published, but ask the question: If the current industry behavior is so bad and is creating such huge problems, why did the legislators not anticipate such problems when they wrote the original entitlement legislation? Or now, after recognizing the problems, why have they failed to attempt any corrective legislation? With the exception of "caps" very litUe has been done. Granted, community morals change with time (look at prohibition, abortion, and homosexuality). But have ourmorals shifted enough that we should criticize those who are behaving within legal constraints as though their h�ehavior was criminally negligent? The criticized behavior of the insurance industry is determined by local legislation; changing it could be accomplished whenever legislators believe that changes are needed. I submit this as an argument to initiate and promote negotiated solutions rather than accept mandated, untested programs, which may be less useful than what are now legislatively permitted. H. William Gillen, MD 2038 Trinity Ave. Wilmington, NC 28405 Contifiued on page 236 210 NCMJ/June 1994.Volume 55 Number 6 |
Digital Format | JPEG 2000 |
Print / Download PDF Version | http://archives.hsl.unc.edu/nchh/nchh-17/nchh-17-055.pdf |
Document Sort | all; nchh-17 |
Volume Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/identi/searchterm/NCHH-17-055 |
Title Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/documa/searchterm/NCHH-17 |
Catalog Record link | http://search.lib.unc.edu/search?R=UNCb1306322 |
Revision History | done |
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