IM Program Directors Report Residents Unprepared for HIV Care Management: Findings from a 2008 Survey of IM Program Directors

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1 IM Program Directors Report Residents Unprepared for HIV Care Management: Findings from a 2008 Survey of IM Program Directors 42% of IM program directors felt it was important to train residents to be PCPs for HIV-infected patients Only 19% of IM program directors felt their graduates had these skills Reasons for the disparity: belief that patients prefer to be seen and receive better care in ID/HIV clinics than in general medicine clinics Adams, et al. Training Internal Medicine Residents in OutpatientHIV Care: A Survey of Program Directors. J Gen Intern Med 25(9):

2 AAHIVM Survey: 2008 Survey of Provider and Student Members (N>400) ~1/3 in the last quarter of their careers, with plans to retire within 10 years Majority concerned about impending shortage of HIV providers >90% have seen an increase in patient load in the last 2 years Among students: Willingness to work in underserved/urban areas >85% said that loan repayment program would influence their decision to pursue a career in HIV medicine Averting a Crisis in HIV Care: AJoint Statement of the American Academy of HIV Medicine (AAHIVM) and the HIV Medicine Association (HIVMA) On the HIV Medical Workforce. June 2009.

3 HIVMA and Forum for Collaborative Research 2008 Survey of Ryan White Part C-Funded HIV Programs 70% of 363 clinics responded ~70% reported difficulty recruiting HIV providers, attributed to: Lack of qualified providers Low reimbursement rates Mean increase in patient load of 29% over 3-year period Averting a Crisis in HIV Care: AJoint Statement of the American Academy of HIV Medicine (AAHIVM) and the HIV Medicine Association (HIVMA) On the HIV Medical Workforce. June 2009.

4 HIVMA Survey of Internal Medicine Program Residents May 2004: HIVMA survey of first-year internal medicine residents in the 10 states with highest HIV prevalence (CA, FL, GA IL, MA, MD, NJ, NY, PA, TX) 15-question survey sent to program directors of 66 programs to distribute to first-year residents, 62% participation Average debt level among 729 residents was $108,209

5 Career Plans after Residency 4% 6% 20% Fellowship Training Internal Medicine Academia or research Other 70%

6 HIV Medicine: Medical Resident Interest and Preparation Are you interested in working in HIV medicine or research? If YES, how would prefer to prepare for a career in the HIV field? 21% 21% 40% 39% 79% Yes No Uncertain 2-3 yr fellowship 1 year of focused HIV training

7 Has your medical residency prepared you to practice HIV medicine? Unsure 26% Yes 23% Yes No Unsure No 51%

8 Antiretroviral Knowledge Among Physicians Caring for Hospitalized HIV-Infected Patients Electronic survey of 10 clinical scenarios based on ARV prescribing errors observed at 2 teaching hospitals. 157/343 (46%) completed at least 1 question. Mean percentage of correct responses: 33%: residents 37%: attending physicians 93%: ID or HIV specialist physicians Errors included dose, frequency, renal dosing, drug interactions, or missing agents High scores associated with ID/HIV specialty, number of outpatients seen per month, and reported comfort level in managing HIVinfected patients (p<0.001) Arshad S, et al. Survey of physician knowledge regarding antiretroviral medications in hospitalized HIVinfected patients. J Intl AIDS Society 2009;12

9 HIV Care: Then and Now Then Almost all HIV-infected patients were hospitalized at some point Inpatients represented a crosssection of the epidemic Inpatient HIV care was intellectually stimulating Outpatient HIV care was depressing and hopeless Reimbursement was often high due to hospitalization and home care HIV medicine was a cause and a passion Now A small proportion of HIV infected patients are hospitalized Inpatients are often difficult with complex psychosocial problems..who are often hospitalized for non- HIV-related conditions Advancements in the field affect outpatient care, which trainees don t see Reimbursement is low HIV medicine is now viewed as just one of many low-paying career choices

10 Established Physicians Decreasing access to HIV experts and medical education in community/private settings Internal and external restrictions on drug company educational/promotional activities Declining CME funding by the pharmaceutical industry More institutional restrictions and bureaucratic requirements for preceptorships and on-site training Declining reimbursement: HIV care no longer seen as a viable career choice in the private sector Uncertainty about the future of HIV care in academic and community-based settings (e.g. the future of Ryan White after healthcare reform) Fewer opportunities for supplementing income The success of the HIV Care is for Experts message Perception of HIV medicine: a problem of the past, too complex, just drugs and numbers, no longer a cause

11 Recommendations for Building the HIV Workforce Pipeline Develop opportunities for medical students to pursue clinical fellowships in HIV medicine. Doris Duke Charitable Foundation s Clinical Research Fellowship Expand outpatient training opportunities in HIV medicine for IM and family medicine residents. Link Ryan White-funded clinics to residency programs Offer HIV clinic as an option for residents primary care clinics Support clinical training opportunities and fellowships for primary care clinicians. Increase satellite learning and consultation through teleconferences and web-based programs to increase primary care provider competence and confidence. Averting a Crisis in HIV Care: AJoint Statement of the American Academy of HIV Medicine (AAHIVM) and the HIV Medicine Association (HIVMA) On the HIV Medical Workforce. June 2009.

12 What else do we need? Loan repayment programs for those providing HIV care to underserved populations Increased reimbursement for HIV care, primary care, and other cognitive disciplines Support and reimburse alternative models for expert/primary care collaboration & consultation e.g. distance consultation (telemedicine, phone/ support) CME reform: De-emphasize promotional and single-company sponsored CME programs Encourage funding for independent, multi-company sponsored CME programs