young physicians from entering specialties such as internal medicine or from practicing in geographic locations where the burden or risk of caring for patients with HIV disease is perceived to be high (Ness et al., 1989). In some areas, AIDS remains an uncommon phenomenon; in others, it is promient: "Today, a third-year medical student in New York City has more direct experience with [HIV] disease than a practicing internist in virtually any small town in the nation" (Cotton, 1988:520).

Surveys of physicians in training reflect concerns that AIDS will adversely affect training programs by skewing the mix of patients (Imperato et al., 1988). Such concerns tend to overlook the wide spectrum of diseases represented by AIDS and the historical fact that physicians have always been trained by studying the most prevalent disease at the time, such as tuberculosis or syphilis.2 Moreover, physicians in training at sites where AIDS is prevalent tend to overestimate significantly the proportion of patients with AIDS under their care, perhaps because of anxiety or stress associated with HIV disease or the exigencies of caring for patients with such great needs (Cooke and Sande, 1989; Hayward and Shapiro, 1991).

No firm evidence is yet available to determine whether HIV disease is contributing to the continuing decline in popularity of primary care specialties and causing young physicians to shun areas with a high prevalence of AIDS when making career choices. As with topics treated in other chapters of this report, confounding factors make it difficult to sort out the particular impact of HIV disease. Some cities where AIDS is prevalent have also suffered declines in the quality of life that make them less attractive to young professionals. But many urban hospitals with high proportions of AIDS patients are also prestigious teaching centers, and a few of the specialties in which occupational risk has been particularly feared, such as orthopedic surgery, are particularly well paid. Thus, there are incentives that might draw graduate physicians toward AIDS care.

A recent survey of internal medicine and family practice residents in ten geographically representative states showed that 77 percent rated their ambulatory care of AIDS patients an excellent educational experience. Yet 23 percent of the residents stated that, given the choice, they would not take care of any patients with AIDS (Hayward and Shapiro, 1991).


Assessing the impact of AIDS on the supply of nurses is somewhat more problematic, although hospitals, nursing homes, and other institutional health care providers are currently experiencing staffing problems, and the National Commission on AIDS (1990) identified a shortage of nurses as an obstacle to improved care of AIDS patients.

Nurses and their professional associations have not figured prominently

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