When Laura Cheever, M.D., started working as an HIV doctor in San Francisco in 1990, she thought that most of her newly diagnosed patients would likely die of AIDS-related complications. Today, Cheever feels elated to be able to tell her patients that they can expect a near-normal lifespan thanks to advancements in antiretroviral therapy.
But that is not to say that working as an HIV provider is a stress-free job.
"Burnout does happen over time," said Cheever, associate administrator of the HIV/AIDS Bureau, Health Resources and Services Administration (HRSA), in Rockville, Maryland. "Providers need to really take care of themselves, take time out and connect with others," she said.
"The biggest frustration today is the challenge of seeing patients with complex problems," said Kevin Fiscella, M.D., M.P.H., professor at the University of Rochester. Today, physicians also face growing administrative challenges that can lead to burnout, Fiscella said.
It is important "to have relationships with providers doing similar work, to share experiences and acknowledge the stress the work can bring," said Peter Meacher, M.D., chief medical officer at Callen-Lorde Community Health Center, in New York City.
As an HIV provider, self-care means working with a strong team, staying on top of current research and making time for exercise and work/life balance, experts agreed.
Working with a team is an important part of self-care, said Meacher. "When a provider has a challenging situation and is looking after a patient or patients who are in a lot of distress, I think it is enormously helpful to look laterally for support," Meacher said.
Some patients may be suffering from substance abuse and other problems. The best way to help challenging patients is to act not as an individual provider, but as a team of people, Meacher said.
Cheever shares her high-need patients with a team of experts, including a nurse, pharmacist and case manager. Team-based care makes it less likely that a provider will "hit a wall" with a particularly demanding patient, Cheever said.
"Very few people are working in HIV by accident," said Cheever. HIV clinics can feel like home because providers there have a common purpose, she continued. Team-based care is also important for clinicians who work in private practice, said Meacher.
According to Fiscella, a team-based approach can be applied not only as a way to cope with challenging patients, but also as a way to ease administrative burdens.
"We've all seen that, as we are asked to do more and more with less and less time, one starts to feel ... an erosion in a feeling of competence," Fiscella said. For example, physicians are increasingly asked to seek prior authorization forms for medications, and the existence of an electronic medical record allows physicians to log in at home instead of leaving work at the office, he continued.
A motivated and competent administrative staff and clinical team can support each other to manage an ever-growing administrative burden and avoid burnout, he added.
Staying on Top of Research
With HIV guidelines that change every year, it can be difficult to stay on top of all new HIV research. The constantly shifting guidelines can be especially demanding for primary care providers who only treat a very small number of HIV patients.
Providers who want to brush up on HIV expertise can pick from a wide variety of continuing medical education programs and other available resources.
"I think a good starting point to consider is the American Academy of HIV Medicine (AAHIVM)," said Meacher. AAHIVM offers a certification program for clinicians hoping to broaden their HIV expertise. Clinical providers who complete the program, which includes an open book exam taken every two years, will be certified "HIV Specialists."
The AAHIVM certification is a "validating process," and it is "reassuring to feel you have that qualification," Meacher said.
Another resource is the AIDS Education and Training Center (AETC) Program, under the umbrella of the Ryan White HIV/AIDS Program. AETC is a national network of HIV experts, and the program helps distill HIV information in to bite-sized chunks, said Cheever.
An additional Ryan White Act-funded resource is the TARGET Center, which is a source of technical assistance and training for clinicians.
Yet another resource, the Clinical Consultation Center, is almost like a clinician hotline for confusing or complex cases.
For example, Cheever reached out to the Consultation Center after getting back some "very strange" syphilis tests results for one of her patients. Experts at the Consultation Center offered her advice on how to handle that patient's case.
Ultimately, "one of the best resources we have is the HIV guidelines posted on the AIDSinfo website," Cheever said. This website also posts any new research that supports or changes the most up-to-date thinking reflected in the treatment guidelines, she said.