W hhen Dr. Harvey Ka- plovitch saw his first AIDS ... ronto family physician, who works in a busy downtown .... Once an FP encounters an. HIV-positive or AIDSĀ ...
I Educa tion
programs help family doctors cope with AIDS CFPC, OMA
Evelyne Michaels
W hhen Dr. Harvey Kaplovitch saw his first AIDS patient 2 years ago, he admits he was surprised. "I'd never seen a case before, and I guess I wasn't expecting it", says the Toronto family physician, who works in a busy downtown group practice. Since then he says he's made a conscious effort to educate himself about the disease, using personal contacts with AIDS specialists and reading about aspects of AIDS diagnosis and management in current journals. Today Kaplovitch has five AIDS patients in his practice three have tested positive for antibodies to the human immunodeficiency virus (HIV) and two have the disease - and while that represents just a tiny percentage of his total patient load, they are not the only patients concerned about the disease. "Every day I get questions from patients - whether they should be tested, what the test results really mean, whether they should worry about a 'fling' they had a few years ago", he says. "I have to help them put all this in perspective based on what's known about AIDS." To help physicians like Kaplovitch deal with the AIDS challenge, the College of Family Physicians of Canada (CFPC) has developed an AIDS education program. Similar projects are also being developed at the provincial level, including one by the OnEvelyne Michaels is a freelance writer living in Toronto.
Kaplovitch: questions every day tario Medical Association (OMA). The philosophy behind these efforts is clear. Although AIDS is now part of the curriculum at every medical school, most family doctors have never seen a case of it and have no established structure for learning what they need to know. However, these same family doctors are on the front lines of AIDS diagnosis and prevention and must also deal with a growing group of patients known as "the worried well", those not infected with HIV but concerned about it. Most experts believe the number of people infected with HIV still hasn't peaked, and more cases will be showing up in family physicians' offices. Educating family doctors so that they can diagnose and treat patients in the early stages of the disease will also ease the load being borne by AIDS clinics and specialists. And because many family doctors have already es-
tablished a good relationship with patients and their families, they are well-positioned to offer support and to encourage patient compliance. Dr. Reg Perkin, executive director of the CFPC, says the college's National AIDS Education Program is aimed at strengthening family doctors' knowledge of the disease and at making them more comfortable in treating patients, offering advice about prevention, dealing with the ethical issues raised by AIDS testing, and participating in the palliative care of AIDS sufferers. The college hopes to open an AIDS resource centre in Vancouver sometime this year, and to establish a toll-free hot line for doctors who have questions about AIDS. Dr. Jay Wortman, a family physician who is associate director of the Division of Sexually Transmitted Diseases with the BC Ministry of Health, is in charge of the CFPC's program. He also directed a pilot project in British Columbia early last year, travelling to 60 centres in the province armed with a multimedia presentation on AIDS that was aimed specifically at FPs. Buoyed by the success of this project, the college, with support from the Canadian Public Health Association, sponsored a workshop on AIDS and the family physician in Vancouver last November. About two dozen doctors from across Canada participated and returned to their home provinces with ideas for setting up regional AIDS seminars. Wortman thinks family doctors are doing their best to cope with AIDS, but need more supCMAJ, VOL. 140, APRIL 15, 1989
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port. He also thinks they have a number of common concerns. "A major issue is AIDS testing how to decide who should be tested for HIV and what a test result implies for a patient", he says. Many FPs don't want to test large numbers of low-risk patients because of concem about both the cost of testing and the devastating effect of false-positive results.
Wortman: initial test only $8
Wortman downplays both concerns: "First we tell them that the number of false positives is very low. Second, the cost of the initial test is around $8, about the same as a pregnancy test. We feel the cost is more than justified if, along with the test, these lowrisk patients also get the proper counselling about prevention. If we can prevent or catch just a few cases of AIDS, the testing will pay for itself." Another issue doctors must
confront, especially in smaller cities and towns, is confidentiality. "This is not like testing someone for hemoglobin levels", says Wortman. "Even at the family doctor level steps must be taken to ensure confidentiality if someone is being tested for HIV, and the doctor must be able to reassure the patient about this." Once an FP encounters an HIV-positive or AIDS patient, other problems may occur. "Many family doctors aren't prepared, 944
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either with proper information or emotionally, to counsel these people", says Wortman. They need to have the appropriate statistics on the disease - what percentage of HIV-positive patients go on to develop AIDS, how long someone who has the disease can live, what effects drug therapy can have on length and quality of life, and so on. Wortman says most physicians are no longer extremely worried about transmission of the virus, but they may need to have their knowledge of infection-control procedures reinforced. The OMA is also working to help FPs, especially those practising outside the province's large centres. Its Task Force on AIDS has set up a visiting clinician program for members; the clinicians, from a group of Toronto specialists in the epidemiology, testing and management of HIV infection, the use of zidovudine (azidothymidine, or AZT), the respiratory and neurologic aspects of the disease, and infection control, are available to speak to family practitioners anywhere in the province. John Krauser, the OMA's associate director of health policy, says the program, which was launched in 1988, is being funded by the OMA's local branch societies. "Not only is this important to those doctors who practise in areas outside the cities where most AIDS specialists are, but it also responds to the patients' desire not to have to leave their homes and seek treatment elsewhere", he explains. The OMA is also developing a clinical traineeship program based at Women's College Hospital (WCH) in Toronto. This would allow family doctors to spend several days or longer observing and working with AIDS patients in clinics or on the wards at large teaching hospitals. Dr. Kathleen Givan, a medical microbiologist at WCH, is working on this program: "We felt that although there were a number of outreach educationaltype programs, what was really needed was a face-to-face opportunity for interested doctors to
gain hands-on experience with AIDS." Givan believes many family doctors still regard AIDS as an extremely complicated disease, one that can only be handled by specialists. "We know that many aspects of AIDS management can, in fact, be handled by a family physician, provided he or she has been given the proper support and has access to specialists once the disease becomes more complicated", she says. Dr. Anita Rachlis, another member of the OMA outreach team, agrees. An infectious disease specialist at Sunnybrook Medical Centre in Toronto, Rachlis says it's reasonable for a family doctor to refer an AIDS patient to a specialist, but she compares this with other types of referral, such as sending a cancer patient to an oncologist. "The specialist may carry out certain treatments and make decisions about future care, but in many cases the primary physician can continue to treat and support his or her patient based on this treatment plan." For example, says Givan, some AIDS patients with Pneumocystis carinii pneumonia can be handled on an outpatient basis. An FP, for instance, can order necessary blood work, provide antibiotics or other medications, and give supportive counselling, although she thinks certain aspects of AIDS management are probably still best left to specialists. For example, the use of zidovudine, which must be closely monitored for toxic side effects, is usually directed by an AIDS specialist, and cases of Kaposi's sarcoma are best handled by an oncologist. Rachlis says many family doctors who have yet to encounter their first case of HIV infection or AIDS may not be receptive to these efforts to educate them. But, she adds, the disease's true impact is usually not felt until their first case. Kaplovitch agrees: "Doctors still think it will never happen to their patients. But the fact is that AIDS can occur in anyone's practice and we have to be ready for it."-