Later this week, the Centers for Disease Control (CDC) is scheduled to hold a consensus conference to address the difficult issue of developing new guidelines for health care workers, particularly surgeons, who are infected with the Human Immunodeficiency Virus that causes AIDS. The pressure for specific recommendations on the subject was increased recently by the report that a Florida dentist apparently transmitted HIV to three of his patients while performing dental work on them.
It is generally acknowledged that the risk of transmission from surgeon to patient is very low but is not zero. And, of course for those few people who do become infected, it is a tragedy.
In a draft document, the CDC has estimated that perhaps between three and 28 people may have been infected by their surgeons in the past 10 years; during that time, about 1 million operations have been performed by HIV-infected surgeons, according to the CDC.
Some people believe that if there is a risk, no matter how small, patients have a right to know. That way, he or she can decide whether the risk is worth taking. Since a Texas pediatrician lost his patients because they learned he was HIV-infected, even though there was zero risk, fear of AIDS would likely lead all patients to say that they would not take the chance.
The reality is that people who worry about contracting AIDS from their doctor are overlooking the many other potential risks that surgeons can pose to patients during surgery. Physicians are well aware of the other far more serious risks but rarely discuss them with patients.
For example, physicians are often aware of which surgeons are having a substance abuse problem. They know which ones are frankly incompetent or only marginally competent. They recognize that when residents (surgeons in training) perform surgery, that there is indeed a greater risk of harm to the patient -- even with observation or assistance by the surgeon the patient thinks will be performing the operation. Patients are often not told that residents will be assisting or performing the surgery, but after all, how else will surgeons become trained?
These risks are far greater for patients than the extremely remote risk of HIV transmission. Therefore, to put the HIV risk in perspective, I have developed the following questionnaire for patients to give to a prospective surgeon:
The Patient's Right to Know
Dear Prospective Surgeon:
There are some questions I must ask you because I need to know about you before I can accept you as my surgeon. Your answers will be kept in the strictest confidence.
1. How much alcohol do you drink during the week?
2. Have you ever been told you had a problem with alcohol?
3. Do you smoke?
4. If so, do you ever crave tobacco during long operations?
5. How many of your patients die within a week of surgery?
6. How does this compare to other surgeons in your specialty?
7. What percentage of your patients get wound infections?
8. How does this compare to other surgeons in your specialty?
9. How often do you operate with under seven hours' sleep?
10. Are you having mental or financial problems?
11. Have you ever transmitted Hepatitis B to a patient?
12. If you think not, how do you know?
13. Have you had problems with memory or concentration?
14. Do you take any prescription drugs? What are they?
15. When was your last physical exam? Were there any abnormalities? If so, what are they?
16. Have you or your sexual partners ever had an HIV test? What were the results?
17. Are you or any other surgeon operating on me still in training?
Neil R. Schram, an internist, is chairman of the AIDS Task Force of the American Association of Physicians for Human Rights. Second Opinion is a forum for viewpoints on health policy issues.