Hepatitis C Virus–Infected Resident: End of Residency, End of Career?

Abstract

Robert M. Sade, MD Every surgeon faces the possibility of becoming infected by a bloodborne pathogen during the course of an operation. Cardiothoracic surgeons are among those with the highest risk because of the confined, deep spaces in which we operate. The possibility of cross-infection between surgeon and patient has been recognized since the existence of bloodborne viruses has been known, but came into high relief in the early days of the human immunosuppressive virus epidemic of the 1980s. Hepatitis C virus (HCV) is the most common such infection, affecting 2.7–3.9 million Americans (about 1–1.5% of the U.S. population). [1] The number of cardiothoracic operations carried out annually is well over 300,000, suggesting that cardiothoracic surgeons face roughly 3,000 potential exposures every year. The number of surgeons who become infected is unknown, is probably low, but definitely occurs.[2] The CDC has no guidelines for surgeons who become infected with HCV, but recommends standard precautions for all health care personnel—this would seem especially important in the operating room where the risk of transmission is particularly high. Once infected, a surgeon can transmit the virus to a patient during surgery, but this risk is apparently very low.[3] The consequences of infection with a bloodborne pathogen are most notably worrisome when the infected surgeon is a resident in training, because the stigma of such an infection may affect the chances of the resident finding a position when his training is completed. We present a case of an infected resident and a difficulty faced by his residency director: he must write a letter of recommendation (LOR) to accompany the residents job applications. The Case of the Unlucky Resident and the Perplexed Director A resident becomes infected with HCV, probably from an incidental sharp injury during a routine cardiac surgery operation. He is later found to have high HVC RNA titers and cannot participate in the training program for a year while treated with interferon. His titers fall over the course of the year to a level that the infectious diseases consultants declare to be compatible with the resident resuming his place on the CT surgery team, including in the operating room. The well-liked and respected resident completes his residency successfully and the CT faculty believes he is clinically well-prepared and technically competent to start working independently in either private practice or an academic setting. He still has a low HCV titer, and is deemed by the infectious diseases consultants to be able to operate safely, posing minimal risk to his patients. His residency director is writing a LOR for job applications. The director believes that anyone who learns that the applicant is HCV positive is unlikely to hire him, perhaps to the point that he cannot get a job at all as a CT surgeon. He also believes that the information about the resident’s HCV status is relevant to his job application, so perhaps should be disclosed in the letter he is writing. Should the director disclose the resident’s HCV status?