Should We Screen Patients With Viral Symptoms for HIV Disease?

To the Editors,

There is another very practical issue involved in considering HIV screening in all patients with viral syndrome symptoms: physician time. How busy are physicians? We interrupt the patient giving the chief complaint and HPI after on average 17 seconds. We spend 5 minutes or less of face time with the patient at the average visit. Now what will happen if we add HIV testing to the frequent (and often pleasingly quick) viral illness visit? Doctor, "It's a viral head cold. And, by the way, let's do an HIV test." A few patients would say "ok", and most patients have no idea what tests their doctor has ordered when they trudge compliantly off to the phlebotomist. But many will reply, "You're gonna test me for HIV?!?" So I estimate that the average discussion will double the visit time.

Of course, the above example is paternalistic. Doctors ideally should give informed consent regarding any test, especially one of such importance and impact as HIV. In fact, in NY State, informed consent and signature of doctor and patient is required, which lengthens the process even further.

I am dedicated to patient centered care. I am not paternalistic. However, I am very practical. I cannot double the length of many of my office visits, slow my patient flow, increase my documentation on the important matter of HIV testing consent, and still get home to my family at the current disappointingly late hour I do. Yeah, that consideration is doctor-centered care, and I feel guilty for considering anything but the needs and health of my patients. But working something less than an 11 or 12 hour day every day is seriously important to me and to most everyone else practicing in the real world. If I lengthen my day even further, this family doctor won't see his family and won't have a family.

I suggest adding physician decreased productivity (or longer grumpier work hours) into the decision analysis. As the accompanying editorial said, there are lots of variables not considered in any decision analysis, and this practical consideration is just such an item.

Yours Truly, -- Joshua Steinberg MD, Family Physician, Syracuse, NY

Competing interests:   None declared