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An ER Doc Discusses PEP, Emergency Medicine and Universal Health Care

August 20, 2014

Bill Honigman, M.D.

Bill Honigman, M.D.

"Part of what I do is being resourceful," says Bill Honigman, M.D. That's an understatement.

Dr. Bill, as he is known by patients, colleagues and the single-payer advocacy community, is an emergency room (ER) doctor in Anaheim, California. He's a co-coordinator of the "Healthcare as a Human Right" Issue Organizing Team of Progressive Democrats of America, a member of probably every California single-payer health care organization, a mentor to young members of CaHPSA (California Health Professional Student Alliance), a relentless political activist (in general, but always for universal health care), and a husband and father.

Dr. Bill sat down with me in the Oak Tree Inn in Monrovia, California, before joining the Drive for Universal Healthcare (DUH, which is the organization that I founded and direct) at the Arcadia Unitarian Universalist church's screening of The Healthcare Movie and moderating the panel discussion afterwards. He graciously accompanied the tour through La Jolla, Costa Mesa, Irvine, Claremont, Arcadia and Los Angeles.


PEP in the ER

PEP (post-exposure prophylaxis) was the first topic of the day.

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As an ER doctor, Dr. Bill noted that most of the people he has encountered seeking PEP are likely to be hospital personnel who had an accidental exposure and outside populations like EMTs, police and other first responders -- all of whom have been trained in the use of PEP and know they have 72 hours after the exposure to start the meds. And, of course, there are the people with random exposures, either sexual or non-sexual, who seek PEP from the ER.

"You have to be prepared to deal with that and all of its implications. In my practice environment, I have access to infectious disease specialists at all hours," he says of the resources available to him. "I see almost no [HIV patients] without calling them -- it's about the advisement of whether or not a patient wants to be on post-exposure drugs or not and what their level of risk with the exposure is. When the potential consequences are a life-long struggle, people tend to opt for it, whether their exposure was trivial or not."

In addition to PEP cases, Dr. Bill has also seen other kinds of emergencies related to HIV. "In terms of HIV treatment in general, the kind of emergencies I see are when people fall through the cracks, whatever the reason -- I have to have awareness of what resources are available for them."

In addition to financial barriers to care and treatment, people may end up in the ER because they'd never been tested and don't know they have HIV until they get sick. IV drug users and undocumented residents may put off seeing a doctor for fear of arrest or deportation. Fear, ignorance and stigma are also common obstacles that lead to ER visits.

Dr. Bill is not the only physician who has stories to tell of patients showing up with AIDS, the advanced stage of HIV infection, simply because they had no access to the health care that would have prevented their HIV from developing into AIDS. Though patient and provider advocacy have resulted in HIV-positive people having programs and assistance that those with other diseases don't have, the current climate in Washington, D.C., and some states threatens to erode health care access -- leaving people living with HIV, along with others, without the care and treatment they need.

Dr. Bill says this relates to the political activism he does.

"I want to be sure those anti-HIV drugs are available to people and affordable and that not only resonates in the universal health care movement, but also in terms of things like the Trans-Pacific Partnership -- if we have to go back to not having good generics available because the drug companies have managed to get their patents back, that would be a disaster, not only for HIV, but for malaria and TB [tuberculosis] and other things that are treated around the world."


Choosing the ER

Never without his sense of humor, Dr. Bill jokes that he chose emergency medicine because he "wanted to know just enough to be dangerous." Contrary to that assessment, though, it seems that ER doctors must have a wider knowledge base than a specialist simply because they have to be able to handle a variety of situations or at least know with whom to consult.

"Ah, yes," he laughed, "the illusion of competency." He then admitted that emergency medicine requires a wide range of knowledge, put to use in an environment of incredible stress.

"It's not the life and death stuff that everyone thinks of -- the trauma you see on TV -- but the fact that a screaming child with an earache in the middle of the night is stressful, for the parent, the child, everyone. I often say pain is contagious and our job is to find a way to ameliorate that pain."

Dr. Bill's not an adrenaline junkie, either, as some ER docs are. "No, in fact, the more heightened anxiety and panic around a case, the less I enjoy it. I guess there are people out there who do, but to me, it wears on me even more. I like to have time to sit down and talk to people! No practice environment is perfect, though, and when there is a more serious situation, you kind of switch on your more directed approach to problem-solving."

The nature of ER medicine has changed greatly in the 30 years he's been practicing. "I blame Reagan and Bush, both Bushes," he asserts, explaining that policies set in place under their administrations run counter to what he learned early on about ER management.

Originally, the conventional wisdom was that the best policy was to staff the ER for the "peak volume," making sure that there would be enough medical providers to handle any emergency.

"What you find now is that they're not staffing for peaks, they're not even staffing for averages. They're staffing for 'troughs' [the lowest volume] so that if anyone's sitting around doing nothing, they get rid of them," he says. "So what happens if you're only staffed for a minimum volume night and you have a busy, or hugely busy, night? You don't have the staff for it. So these long waits that are common in emergency rooms are largely due to these 'business decisions' that have just made it horrible."

He says the worst aspect of the problem is when he and his colleagues are rushing around, worried that they won't have enough time to get all the information they need.

"[We're] just trying not to kill anybody or make a mistake -- give somebody the wrong meds or IVs or, worse yet, miss a diagnosis altogether because we were just too busy to recognize something, a clue or a key or a sign of some kind. It's a real problem in today's American health care system -- it's uniquely American and it's uniquely awful."


Health Care and HIV

"The struggle for recognition of HIV as a treatable illness and as a public health scourge is really an excellent example of how communities need to rally to certain challenges and also to recognize that we're all members of the community," he explained, when asked how the HIV community is and could be affected by the health care system.

"We know in the health care movement that we can do things as a community that we can't do by ourselves. Thanks to the activism of folks in the HIV treatment community coming together and overcoming biases -- an amazing transition of consciousness, I think -- that happened and it highlights how important it is that we have universal health care. And that means all the people get all the care they need, whether that means HIV treatment or open-heart surgery or liver transplants or whatever it means."

Today, many say that apathy and cynicism have infected the silent majority. Dr. Bill even maintains that it's become stigmatizing to be involved in politics. And people living with HIV know stigma. They know how it limits and defeats and harms. But they also know the empowerment that comes from confronting and overcoming it, and perhaps now is the time to see that stigma, unlike health care, is already universal -- it can limit, defeat and harm anyone, so uniting with others who live with chronic disease strengthens everyone.

Dr. Bill finds hope in younger people. "They care about each other more," he said. "They're going to do better ... with health care, with climate change, with human rights, everything."

We can only hope. But one thing is certain. For as long as he is able, Dr. Bill Honigman will be resourceful, involved and outspoken.

Sue Saltmarsh has worked in the HIV/AIDS field for over 20 years, the first 10 as an herbalist and energy therapist at Project Vida, the last six as a writer and copy editor for Positively Aware magazine. She is now a freelance writer and editor and is also able to devote more time to her passion as founder and director of the Drive for Universal Healthcare (DUH).


Copyright © 2014 Remedy Health Media, LLC. All rights reserved.



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