A significant proportion of internal medicine residents rated their HIV ambulatory training as inadequate and did not feel competent to provide HIV outpatient care. Thirty-four percent of junior and senior residents reported a deficiency in their outpatient HIV training, four times greater than the number reporting a deficiency in general outpatient training and seven times greater than those reporting a deficiency in inpatient HIV training. These findings emerge despite strong agreement by residents that HIV care represents an excellent educational opportunity and a high expectation that they will provide care for HIV patients in the future.
Resident self-reported performance frequently did not meet established guidelines in areas of HIV risk factor assessment, testing and counseling, and initial management. The changing epidemiology of HIV has resulted in young people, men who have sex with men (MSM), and minority women bearing a disproportionate disease burden,17,18
yet residents do not regularly perform risk assessment for sexual transmission. Most residents do not report testing patients perceived to be low risk for HIV. This failure to test low-risk patients is especially notable in light of the latest CDC guidelines that recommend expanding testing to all Americans1
and it appears to persist as suggested by a 2007 study of internal medicine resident trainees in New York City that found the continued use of risk-based testing rather than the CDC-recommended routine-based testing.19
In our study while most residents performed pretest counseling, fewer reported discussing HIV prevention or partner notification, both key strategies in reducing transmission.20
Two factors impacted attitudes about HIV care as well as performance: degree of outpatient exposure and perceived adequacy of training. Most exposure to HIV care still occurs in the inpatient setting and HIV care experience in the outpatient setting is limited. Yet our study suggests that resident exposure to ambulatory HIV patients is important to self-assessed competency and performance in key areas of risk assessment, counseling, and initial management of HIV. Performance in these areas was not affected by level of inpatient exposure even though inpatient exposure was much greater. While it was beyond the scope of this survey to assess the type of training received, education efforts in these areas appeared to be effective as residents who perceived their training to be sufficient also reported higher levels of performance of basic competencies in HIV care.
Our results reinforce and expand upon the deficiency in HIV training reported in the 2001 Clinical Practice Reports of Graduating Residents.14
Compared to a prior detailed study on HIV training reported in 1991, our study found that the value of HIV educational experience remains highly rated, but resident reported competency in this area has not appreciably improved.12
Our study has certain limitations. First, the data are self-reported and are therefore subject to recollection bias and may not reflect true practices. However, the survey was anonymous and residents did report varying levels of performance among different aspects of risk factor assessment. Furthermore, studies have shown that physicians' self-assessment skills tend to overestimate their actual skill level; therefore, the deficiencies are likely larger than detected. Second, responder bias may select for those who are more invested in HIV care or who were more dissatisfied with training in general; however, comparison with other parts of their training did not yield high rates of dissatisfaction. Third, our survey only sampled four residency programs, and we do not have survey data from some key areas which train large numbers of residents and have high HIV prevalence, such as California. However, the four programs sampled were large programs located in different geographic regions representing areas with both high and low HIV prevalence rates. Finally, the demographic characteristics of the residents surveyed did not differ significantly from internal medicine residents nationwide. All four of the survey sites had separate outpatient HIV practices, so residents at these sites may therefore have had less ambulatory exposure to HIV infected patients than residents at sites without such specialty clinics.
Finally, 25 years into the HIV pandemic, substantial numbers of residents rate their training in HIV outpatient care as inadequate. Residency training in HIV care continues to occur predominantly in the inpatient setting; however, as the current CDC recommendations are implemented, the need for outpatient HIV testing and care will increase. Our results suggest that increased exposure to HIV patients in an outpatient setting as well as incorporating HIV risk factor assessment, testing and counseling, and initial management training into internal medicine residency curricula are needed to improve ambulatory care of HIV-infected patients and those at risk for HIV. Successfully increasing exposure to outpatient HIV care and developing internal medicine residency curricula that address training in these areas will be essential to the success of the CDC's initiative to expand HIV testing, increase access to care, and reduce transmission.