THE HIV-POSITIVE SURGEON AND YOU

It was a hot summer morning of 1992 when a bright young surgery resident stood up to address the Department of Surgery. The venue was a Government Medical College auditorium in Bombay, and the young resident was going to talk on a new subject: ‘AIDS and the Surgeon’. Listening with curiosity (for AIDS was only just beginning to register in Indian minds) were students, postgraduates and teachers of the Department of Surgery.

The resident talked of the HIV virus and the disease, and turned the topic to something far more interesting. “Given that the risk of getting AIDS through a contaminated needle prick during surgery is very low, how much lower are the chances of an HIV positive surgeon transmitting the disease to his patient? Should an HIV positive surgeon be allowed to operate on patients?, he asked.
That resident was me. Those questions were unanswered then. Today, prompted by Ergo’s post, I will try to answer them.

Look at the issue from a rights perspective. A patient deserves to be informed about his or her risks to be incurred during or after a surgery. For example, if you undergo a bypass surgery, you should know before you sign the papers that there is a risk of a lung infection or bleeding or dying from something else. Would you not like to know if the surgeon you are getting operated on by is HIV positive or not? Not unlike your wanting to know the HIV status of the guy (or girl) you are going to marry.

Looking from the perspective of the surgeon or dentist, any disclosure of a positive HIV status would spell the end of his career, and a major chance of starving to death. Because surgeons are generally not good for anything besides their own craft. Now, how reasonable is it to expect a man to condemn his existence by being honest and truthful to his patients, saying “I would like to operate on your prostate tomorrow, but I would like you to know that I am HIV positive. Don’t worry, I will take care….hey, where are you going? Please come back, lissen, will ya?”
Surprisingly, this has happened in real life. Professor George Browning, an ENT surgeon, was allowed to operate on his patients at a hospital in Glasgow back in the 1990s. His patients were considerate and understanding, and signed consent forms where his HIV positive status was clearly mentioned. He was the first known HIV positive surgeon to be allowed to operate. But would others be as well treated as he was?

The risk of the virus going from the surgeon’s body into the patient’s is said to be very, very small. However, the case of American orthopedic surgeon Dr. Scoles comes to mind. He was thrown out by his hospital because, as an HIV positive surgeon, even though the risk of his transmitting the virus to patients was very low, he was still a “significant risk”. Allegedly, there was a significant chance of his blood coming in contact with the patient’s.
Scoles lost his career, though he won a court case against the corporation owning the concerned hospital.
It is interesting to note that while he was discriminated against on the grounds of the principle that “the only acceptable answer is: no risk”, the hospital concerned had a significantly high death rate when cancer patients were admitted into their intensive care units. So did the hospital inform its patients before admitting them that they were twice as likely to die of pneumonia than in some other center? You bet not!
Scoles’ defendants asked: “With this in mind, who faces the greater risk: [..the hospital’s] cancer patients, or those seeking orthopedic surgery from an HIV-positive surgeon with an unblemished record?”

As a patient, you expect your surgeon to possess certain skills and standards. However, as a human being, is he a risk-taking type? Does he do drugs? Does he get drunk sometimes? Does he abuse people when agitated?

Would every patient be entitled to such personal information about their surgeon, because in specific cases it may be life-saving? Where does a surgeon’s right to privacy end and the patient’s right to know begin?

I have known of ‘great’, macho surgeons being absolute drunkards outside and inside hospitals. They have operated while being piss-drunk, or sniffed anesthetic gases before and after surgery, and no one really knows how many they have killed.
Therefore, these questions do have a valid, rational basis, though they may have sounded far-fetched at the outset.

My opinion is that an HIV positive surgeon, while maintaining his own confidentiality, should shift to mainly consultation, or do minimally invasive procedures, where there is minimal risk of his coming in direct contact with his patient’s blood. He should also keep a back-up surgeon in case something goes wrong and an invasive, open procedure is needed.

In recent years, the issue of HIV positive surgeons is being tackled in a pragmatic way. Various UK Government Health bodies have opined that “…it is no longer necessary to notify every patient who has undergone an exposure prone procedure by an infected HCW because of the low risk of transmission and the anxiety caused to patients and the wider public.”

I started off by talking about a young surgeon, back in 1992, giving a talk on ‘AIDS and the Surgeon’. He ended his talk by advising the audience to wear double gloves to protect themselves against accidental inoculation with HIV-tainted blood. His Professor then took the mike for expert remarks. The Professor said, “…He has given us new issues to deal with. However, one thing I must tell you: as a surgeon, you must do everything you can to prevent getting AIDS from patients. And the best way to do that is….USE A CONDOM!”

*General disclaimer: this blog and its owner have been certified as HIV negative*
*For a fascinating account of the Scoles case, read this article.*

39 responses to “THE HIV-POSITIVE SURGEON AND YOU

  1. Interesting post rambo-doc. As someone who has gone under the knife, I hadn’t even thought of asking this question of my surgeon, and this wasn’t when AIDS was not known. 🙂
    I’ll have to think about it a bit before I can comment more.

  2. It’s a dilematic situation. But the surgeon should accessed by himself how likely he will put risk on the patients. Since this activity invloves open surgery and considering the accidental situation that might happen I suppose the HIV infected surgeon should not perform operation… aha?

    Ady,
    That is the question…current recommendations are contrary, but very convenient for the system!

  3. Doc, I know nothing about biomedical ethics, so thanks for giving me my daily nugget of knowledge. I don’t agree with that hospital’s decision to sack Scoles, and I don’t think there is anywhere you can draw the line here, but in an ideal world all HIV-positive surgeons would just wear double gloves. Then again, in an ideal world nobody would make any mistakes and patients would always trust their surgeons and we would have ice cream that’s healthy for you.

    Yes, and there would be no AIDS….

  4. Rambodoc:

    Good, serious post.

    However my first thought, at 530am, as I soak up news is this “aur bhi gham hain zamaane mein surgeon ke siwa..”.

    See:

    Risk assessment is something that developed countries’ societies are increasingly muddled about. It does not help that people want to know too much and do not have the capacity to assess the information and take a decision which is on the balance right for them. And then there are malpractice lawsuits.

    I wanted to say more but I have to empty bins, make tea and go running. So may be more during the day.

    Thanks for providing a point to reflect on during the run.

  5. Quick second comment:

    Talking of rights, does the doctor have a right to refuse to operate on an HIV-positive patient?

    Shefaly,
    I think every doctor has the right to choose his patient, just like the well established right of every patient to choose his doctor. However, the moment one refuses an HIV +ve patient, a horde of world media will swoop on the guy, screaming ‘discrimination’, and the guy would possibly lose his license. If, however, a doctor has commenced treatment, he does not have the right to refuse further treatment (upon learning of the patient’s HIV status), unless the patient is also willing to be treated by someone else.

  6. nicely put
    u scare me by ur routine disclosures of medical neglegance
    the fact is that there is such a dearth of good surgeons that hiv positive status might not be a big negative factor , though ur idea about him shifting to consulting is good

    and lastly 🙂

    Thanks, Prax!

  7. I was just going to suggest that such a surgeon should simply switch to consultation or something that does not involve actual surgery but you already covered that point.

    Marc,
    I have, but a surgeon doing only consults is going to starve very soon! But, then, that is HIS problem, not the patients’!

  8. This is a very thought provoking post. Mostly doctors are worried about catching HIV through their patients but few people think of the reverse. In fact once I had a long conversation with my dentist about the precautions he took to prevent getting HIV from patients…
    I was wondering whether HIV positive surgeons can do surgery without demonstrating on live patients? Perhaps they can take theory classes. Personally I would not like to be operated upon by an HIV positive surgeon.

    Nita,
    That is assuming that doctor will be eligible for a teaching post. A big assumption.
    So, are you going to ask your surgeon if he is HIV +ve or not?
    🙂

  9. An unusual issue. And discussed well.
    There is still a lot of misinformation and distrust, even among the so-called educated sector, about AIDS and HIV. Given that, it is probably best to NOT disclose the surgeon’s HIV status to the patient, especially since the risk is anyway, small. Even the CCU or ICU or whatever it is called, carries with it a small, but definite risk of cross-contamination. My comatose uncle died of pneumonia that he caught at the ICU and not the Parkinson he was ailing with. Such risks are not disclaimed. So, why should the surgeon’s HIV?

    Lakshmi,
    What about the right of the patient to be informed? What about his or her choice that is not being considered??

  10. Curious – In what way would HIV get transmitted from the surgeon to the patient or vice versa? At any point, do you guys (surgeons) operate with naked hands that have cuts? Is other assisting staff also vulnerable?

    And was that expert professor trying to be funny, or was he plain dumb 😀

    Priyank,
    Gloves get punctured during surgery. Surgeons get needle stick injuries, and so there is potential for his tainted blood entering the patient’s body. The advice to wear double gloves is to reduce the possibility of a needle puncturing his skin.
    That professor was a wickedly witty man!

  11. Hmmm – intuitively, all things being equal, I would prefer not to have an HIV positive surgeon. Potential for cuts, knicks and transfer of blood, especially for open type surgeries.

    That being said, the surgeon should also have career opportunities, whether in teaching, research, sales, or other non-invasive medical areas, etc.

    If he/she wants to perform operations, it should be with full disclosure to the patients. However, liability-averse USA probably would frown on this practice.

    This issue is really pretty complex – what is his viral load? Is he compliant with the antiretroviral rx regimen? Also, given full disclosure and the unlikely event of unwillingly infecting a patient (low probability but high consequence event) — you also have the option of post-exposure prophylaxis.
    On and on.
    I fear nosocomial harm more than many. At every teeth cleaning (which is invasive!), I grill the hygienist, and inspect equipment and ask about sterilisation. They are used to it now 🙂

    Good points, Jackie!
    However, the crux is ‘disclosure or no disclosure’. On moral grounds, the key issue is the right of the patient to informed consent.

  12. Doc, re-read your post and links, and please allow me a coupla more thoughts before they evaporate…

    Health care workers suffer more in danger of being infected/harmed by our patients than the reverse, at least in some specialties. (Personal examples: teeny primary care offices with hacking coughing, pooping kids; manic patients needing ‘takedowns’ for their safety…. a newspaper editor patient once accidentally knocking the wind out of me while gesturing wildly with his hands; older kids flailing at you during immunisations, infectious disease investigation and field work……etc etc.

    A beloved infectious disease doc I once worked with had a splatter type incident with an AIDS pt. He took the post exposure treatment protocol, and HIV tests for quite a while. In that line of work, who knows what else his patients exposed him to?

    What of our lab technicians – who draw blood all day- accidents happen. We had a contract with a local Emergency Dept. for post exposure tx. The techs were extremely stressed as they waited for serial testing of blood borne pathogens. Note: patients have the right to refuse HIV, HepC, etc testing too, so the wait must have been excruciating.

    That is the flip side. The other side is our patients. If we adhere to the ‘do no harm’ credo, we must mitigate any potential harm we do to our patients. HCW’s know our work is like a battlefield at times, but our goal is still to help our patients. That does not include HIV infected surgeons operating. Sorry. It’s not a huge threat, but adds another potential complication for our (already) ill patients.

    You can’t compare an HIV infected surgeon to one who huffs gases or drinks alcohol on the job. The latter examples are blatantly illegal. HIV infection issue is ethical, but not really legal, I don’t think.

    Why surgery? Trained physicians can certainly go into less invasive work. Our patients must come first, regardless. HIV transmission is a very small risk, but a risk nonetheless that we can control. Full disclosure is the ethical thing to do, especially for a surgeon.

    There are still sporadic reports of blood and organ banks, too, inadvertently transmitting HepC, HIV, malaria, BSE?….

    Anyhow, the positives outweigh all the risks we HCW’s face, but we also must address potential risks, if they are known. It’s the right thing to do. Especially for direct care situations. Ah, I miss ye, but glad I’m no longer in the trenches. Have paid my dues!

    Thanks again for a thought provoking topic.

  13. The only way out seems to be when a preventive vaccine against HIV is made available, I know research is going on but sooner the better. Beauty salons would be another source of HIV infection. The surgeon is well informed about the preventive methods and is thus capable of handling the risk. The people working at even the best of salons are ignorant about the risks.
    I won’t offend the surgeon by questioning him about his HIV status. Along with the surgeon a whole lot of staff is invovled in the surgery and is practically not possible to question everybody. If the surgeon is capable of doing a good job of the surgery I will trust him with the medical ethics because the person who is saving my life would not take it knowingly. If I am unlucky it is like meeting with an accident.

  14. Ram,

    Well, it is up to the public (patients) and medical organizations (docs) to decide whether to let the doc go on operating or whether they wish to be operated by such surgeon.

    The patient has the right to know that the surgeon is HIV positive and be informed about the (very minimal) risk involved.

    Cheers,

    Moshe

  15. I ve been on the operating able once. Not sure if my doc was HIV or not, but I wonder if anything would have changed if he was and I knew it. Come to think of it, that low risk, if materialized, would put you on a trip to point of no return. Anxious, yes I would be, but would also be comforted by the fact that he disclosed this info instead of keeping me in the dark. In the end, probably yes, yes I would have gone under his knife I think.

  16. @ Prerna:

    “The only way out seems to be when a preventive vaccine against HIV is made available, I know research is going on but sooner the better.”

    The nature of HIV is such that this will probably not come to pass in your or my lifetime. First there is the ever-mutating nature of the virus. Secondly there are many strains and it is difficult to ‘choose’ which one should have a vaccine. Then there is a whole range of global trade issues and intellectual property issues involved, which means private investors e.g. pharma firms do not want to invest in vaccines. Vaccines themselves are a can of worms in design, transportation, delivery and compliance terms. Much of HIV positivity and AIDS resulting from it is in poor countries – where in marketing terms, there is a ‘need’ but in the absence of purchasing power, no ‘market’. Nobody wants to develop something when the payer mechanism is not clear.

    What is required instead is that human beings understand better the concept of ‘risk assessment’. Getting out of bed is the most risky thing we do. And that they understand their own ‘risk propensity’ before they start jumping on someone else’s throat.

    If you read one of my earlier remarks, I asked if the doctor had any right to stop treating/ operating on an HIV-positive patient, and apparently it is not his privilege. What price fairness?

    Jackie writes about risks run by healthcare workers every day. One could argue they develop immunity (I spent 3 weeks visiting a family member, who was admitted with meningococcal septicemia into the Infectious Diseases ward; I was given a prophylactic and I was fine; Indeed I would go further and stay those who work there have especially compassionate hearts and they were very considerate, given the risks of their job).

    If healthcare workers became as risk-averse as the general population, we would be dying in such numbers – sometimes of entirely preventable ‘lifestyle’ diseases, perhaps deservingly so – that the surgeon’s HIV status may be the last thing on our minds. Perhaps for the better…

  17. I don’t think I can ever actually ask anyone whether they are HIV positive, and certainly not the doc! If a doc chooses not to disclose this information then it’s unethical of him/her but there is no way a patient can find out.
    My father in law got hep B through an operation inspite of wearing gloves. he used to deliver babies in africa. Patients can get infected too, the risk may be small but it exists, particulary if the doc is careless.

  18. Nita:

    Ironically the first person who brought HIV to Europe was a Belgian doctor who used to work in Africa with local people…

    Which brings us squarely to the question I asked earlier – can a doctor turn down an HIV positive patient and Rambodoc explained he cannot.

    Disclosure/ non-disclosure is one thing; but the personal morality, risk propensity and judgement are quite something else.

  19. All,
    The risk of doctors, nurses, and related others getting bad bugs from patients is much higher than the reverse. That is why I say that if you have to get AIDS you better get it the right way! 🙂
    Shefaly,
    As far as HIV therapeutic research is concerned, there is a real problem created by the lack of adequate patent protection policies in most poor, developing or poor countries. If a company spends billions on developing a new drug or vaccine, it almost certainly will not enjoy the right to sell it in those countries at the price it wants. On top of that, me-too generic preparations will undermine its interests. Governments in these countries will surely raise populist cries and demand that the drugs be ‘freed’ from patents on ‘humanitarian’ grounds. We have already seen the ill effects of this in many countries. Thailand comes to mind.

  20. Rambodoc: Thanks.

    The biggest problem is in the petri-dish, so to speak, the rest is by the way (and reminds me of Radha, her dance and enough oil… 🙂

    And of course, it is the poor countries that the Doha Round aims to protect and amongst their meagre successes is compulsory licensing, so the national regimes of IP regulation do not even need to be factored in.

    A great book on the history and sociology of HIV/ AIDS by the way, which I am sure you have read, is And The Band Played on, by Randy Shilts. Vaccines and all are of course recent things but this is an intriguing account of how diseases go or do not go mainstream enough to warrant attention.

    Thanks.

  21. Thought provoking post and very interesting too. The comments are as engaging.

    At the cost of a surgeon’s privacy, I think a patient ought to know the truth IF that patient inquires if her/his surgeon is HIV positive. Whether or not a patient would want to proceed with surgery after knowing the surgeon is HIV positive, is up to the patient.

    Thanks to your post, if I were to have surgery now, I’d want to ask the surgeon if he/she is HIV positive. I would want to know anyway. How I would react after the surgeon’s disclosure of being positive is not something I can describe at this moment but am pretty comforted with the fact that the risk of the virus going from the surgeon’s body into the patient’s is “very, very small.”

    As to “disclosure of a positive HIV status would … a major chance of starving to death” I feel things can’t be so bad for an educated and intelligent person – even a surgeon. As said by you, and explained by Jackie, he has other career opportunities “whether in teaching, research, sales, or other non-invasive medical areas, etc.” or in the worst case, consider an alternative profession and if the surgeon “wants to perform operations, it should be with full disclosure to the patients.”

  22. Celine,
    I like what you are saying here, and wholeheartedly agree!

  23. rambodoc, in another post not so long ago, you mentioned the necessity of moral clarity when it comes to issues of life-and-death. Doesn’t your statement re: “populist cries and demand that the drugs be ‘freed’ from patents on ‘humanitarian’ grounds” runs counter to that very same moral clarity then? 🙂

    I think in both cases (DDT & AIDS drugs), the main issue is return on investments in the form of profits, but not stated in so many words. 🙂

  24. rambodoc, in another post not so long ago, you mentioned the necessity of moral clarity when it comes to issues of life-and-death. Doesn’t your statement re: “populist cries and demand that the drugs be ‘freed’ from patents on ‘humanitarian’ grounds” run counter to that very same moral clarity then? 🙂

    Somewhat simplistic, but I think in both cases (DDT & AIDS drugs), the main issue is return on investments in the form of profits, but not stated in so many words. 🙂

  25. Amit,
    No one is obliged or duty-bound to save anyone else. That is the moral clarity here. All human action has to be willful and voluntary. It is the productive human mind that creates these products. And you will always find these in the profit seeking companies.

  26. Great post. It made me think. I have no answer. In Canada there is a massive shortage of doctors. In the case of HIV-positive surgeons, could they not be streamed into general practice where surgery and contamination are less of a worry?

    On disclosure: My father was a police officer. He responded to calls several times at the home of an orthopedic surgeon. The man enjoyed getting drunk and beating his wife. The surgeon was called when my father was taken to the hospital after injuring his back on duty. He refused to let the man touch him. I wonder if other patients would have done the same if they knew about his home life?

    Steve,
    Thanks for sharing your thoughts.

  27. I guess im in the middle. Im currently in school for nursing and we take some of the same risk taking care of the public due to the nature of our career. My feelings are what about the other non curable disease doctor’s or nurses could have and can be transmitted thur sexual contact as well as blood(herpes,syphlis) need I say more.
    Shawntale

  28. surgical resident

    i was searching online for any info on the surgeon and HIV and stumbled onto this and found it quite interesting and my only comment refers to the fact that many practitioners do not get tested regularly or routinely and the same way we apply universal precautions because you can never tell which patient has HIV the reverse applies….there is a high chance that the surgeon you are seeing does not know his/her current status…..so as the patient the only universal precaution you can really take is to pray before every procedure!

  29. surgical resident

    and plus ….being in the OR so often ….when a blip or blunder occurs it is almost always to the detriment of the surgeon ….his/her assisstant ( most often) and occasionally the scrub nurse….the patient rarely if ever i have seen!

  30. i am doing a project on this and the topic is very interesting! the comments are interesting to read and i think that hiv positive surgeons SHOULD be allowed to operate if the proper precautions are taken such as: double gloves, tell the patient, etc.

    as many people have said, the risk of transmitting hiv from the doctor to patient is very small.

    so thats my viewpoint but im sure that others have different ones!

  31. I am sorry I did not reply to the last few comments.
    I don’t know how you guys found this post, but Brother Google must have played a role, I am sure.
    Student, yes, I found the comments very interesting, too. Thanks for visiting!

  32. hi again,
    rambodoc, thanks for this post. i found it helpful for my project and will cite it in my bibliography 🙂

    i hope that people will start being more open to letting HIV positive surgeons operate on them

    if i had an operation i would want to know whether or not the surgeon was HIV positive but would still let he or she operate on me if the proper precautions were taken

    thanks again! 😀

    ~student

  33. 🙂 😀 😉 ;D

    sorry im bored!

  34. Natilee Beowulf Ashlen Parker

    I think it is an opinion whether HIV positive surgeons should be allowed to operate. This website has helped me with the paper that I’m writing, but I believe surgeons go through so many years of training that they should be careful enough not to cut themselves while operating. The only logical way I can think of that would have HIV-infected doctors pass on the desease is that they would be having sex with their patient. If they are surgoens in the first place, being through so many years of medical school should have prepared them and taught them that HIV is extremely dangerous in the first place, so unless they had HIV before they went into medical school, then there shouldn’t be any reason for these professionals to have HIV. IN studies that I have conducted, I see that it is very low of a chance for a surgeon to be allowed to operate with the desease. Unless I am mistaken, HIV infected surgeons either preform more easier surgeries, or they are layed from their job. I believe surgeons tested positive for HIV should at least tell their patients, because there is some risk of transmission, but it isn’t a very high risk. Therefore, I believe that HIV-infected surgoens should be allowed to operate, but should have to at least tell their patients for them to decide to go on with the procedure.

  35. trhurtutru6yutj watwee

  36. i don’t think they should be allowed to operate, i don’t want to die because of them.

  37. benjii u suchs assholeee u have noo brian stuip

  38. In light of the fact that there are no tests to diagnose HIV Infection , i think its pretty unfair this doctor was even given that diagnosis.
    Hiv tests are non-specific antibody tests , which mean they are not specific for HIV.
    ABBOTT Industries package inserts for those tests categorically state , “At present , there is no recognised standard for establishing the presence or absence to antibodies to either HIV-1 or HIV-2 in human blood”.
    Doctors use reactive antibody tests to “pressume” infection. They confirm one non-specific test with another , then another. Unfortunately , just because three liars are all telling the same lie does not mean they are telling the truth. In the absence of facts its only pressumed they are.

    This doctor doesnt have a virus that knocks out the immune system thereby aquiring IDS.

    And the HIV drugs ? , those very drugs are responsible for giving asymptomatic individuals Aids defining illneses . Since when did you here of even a cancer patient being prescribed chemoantibiotics and DNA chain terminating drugs for life. And as for prescribing them for a so called immune dissorder , what better way to trash ones immune system ?!

    If they came up with a vaccine , that would mean everyone could be vaccinated , and then everyone would test positive on their antibody tests.

    Every single test kit has manufacturers literature within that package insert for that test kit which states the tests are not validated to diagnose infection with HIV.

    I hope this doctor gets this information instead of following the belief system that has become a religeon. Those who question well learn well.

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