Carlson’s recent essay in JAMA, “You Did Not Teach Me What You Thought You Did”, reminded me of all the times my words and actions had unintended consequences.

I had been seeing Tricia for about a year.  She had been referred to me for ITP, Immune Thrombocytopenia, (a low platelet count) back in the mid-1990’s.  In the history I elicited that she was sexually active and had unprotected sex with several partners over the last few years. Her platelets were low but not dangerously so.  I recommended no immediate treatment but rather that we should do some workup.  That included an HIV test.

I did not expect it to be positive and she certainly did not either.  The shock, anger, and terror were palpable in that room.  Ultimately though, we all came to terms with the news. I had over a hundred patients with HIV/AIDS that I provided primary care for and I add Tricia to my panel.  Many new medications for HIV had become available and HAART (Highly Active Antiretroviral Therapy) with 3 drugs resulted in many patients having their viral loads fall to undetectable levels. Later it became clear that with this kind of treatment, the life-expectancy became close to normal.

Tricia was an ideal patient; she always came to her clinic appointments and always took her medications.  She looked great, she felt great and she glowed. Each visit I reviewed the labs and medications and praised her for how hard she worked at being well.  I celebrated her success at keeping the virus undetectable. One day at the end of such a visit as I put my hand to the door, she stopped me and said “Where’s my advice?”.  I did not know what she was talking about.  She filled me in that apparently, at the end of every visit I usually suggested some general healthy living practice; like getting a vaccination, healthy eating or exercise.  What would be her assignment this time?   I told her I didn’t realize I was doing this and asked, “Why is it so important?”

Tricia said “It means that you expect me to live a long and healthy life…. to not die from HIV…. It means that things are getting back to normal!”

I thought for a moment and admonished her to “Always wear your seatbelt”!

Carlson, M. A. (2019). You Did Not Teach Me What You Thought You Did. JAMA, 322(16), 1555-1556.

photography by Dr. Jeanie Youngwerth

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