As chief of service at El Rio Special Immunology Associates (SIA) in Tucson, Dr. Carmichael oversees the care of 1,500 HIV-infected patients and personally attends to 300. He also travels the state to provide care for patients and give clinical support for physicians dealing with HIV in farflung rural areas.
In his spare time, Dr. Carmichael is an avid rock climber and insists the hobby is as safe as any other outdoor activity. "It's just being scared that keeps people from trying it," he says.
He applies the same belief to HIV. "Fear is the enemy. Fear makes you passive, it makes you stupid, and fear will kill you faster than HIV," Dr. Carmichael tells his patients. He provides them with education and reassurance, telling them, "You are not going to die; there are effective treatments."
This from a man who, seeing his physician father working long hours, vowed early on to avoid medicine. But while obtaining a graduate degree in exercise physiology, he began to realize he wanted to do more, and entered medical school at the University of Miami in the 1980s.
His focus on HIV crystallized there. "I remember it clearly. It was a noon lecture about Gay-Related Immune Deficiency. You can see how early it was. They were still referring to it as 'Gay-Related.'" But at hard-hit Miami hospitals, many HIV/AIDS patients were surfacing who weren't gay. "We knew then it was a disease of the people," says Dr. Carmichael, and for him there was no other choice.
His dedication took a toll, especially in the early years, when the work was largely about caring for dying people. For emotional release, he began writing stories about his experiences. "Lila Falling" recalls a young woman he couldn't save, and connects rock climbing and HIV treatment. He relates that he has "seen the scars on the hands of a friend" who had broken the fall of a climbing companion by hanging on desperately to the belaying rope. "The rope burned deep," Dr. Carmichael writes, "but it saved his partner's life. ... Where do the scars of the falls not held appear? I search my hands, my face my heart. I dream of Lila, falling."
Today, with improved medications lowering mortality rates, Dr. Carmichael doesn't have that same kind of dreams as much. But he still worries about other "falls," like society's indifference to HIV's spread, and the lack of tools to help patients deal with the emotional and social implications of living long-term with HIV. Still, he says, "I can't imagine what else I'd do."
How long have you been practicing?
I have been a physician since 1986. My work with HIV began in medical school before graduation.
Can you describe how your work has changed since you started?
There was a time where our work was largely about caring for dying people. Since 1996, however, it is more about helping people living with HIV live meaningful and healthy lives. Doctors who are getting into HIV treatment today have a different perspective. When I started, there were times when no matter how much you wanted to, there was simply nothing you could do. There was a terrible feeling of impotence and frustration. Newer doctors are being spared some of that.
What's the best thing about your job?
I am very fortunate in that, unlike many physicians, my patients know I am on their side and working for them.
What's the worst thing about your job?
Having the tools to keep people with HIV alive, but not having the tools to help them find a way to construct lives worth living.
What have been your greatest successes in your work?
Getting out of bed and coming to work each day.
Each patient who dies alone and uncared for represents a failure ... not the dying part but the alone and uncared-for part. It's what we work against. What troubles me most is those patients who decide to end their lives.
What is the biggest challenge you face as a clinician?
Fighting with the health care system for what our patients need.
What do you think is the biggest problem people with HIV face today?
The biggest problem people with HIV face today is that we live in a society that continually devalues human worth. HIV and the response to it is just another part of that.
For the most part, what do you think is the biggest risk factor for HIV?
Lack of imagination, lack of a sense of self-value.
Do you think that prevention efforts are sufficient?
Not really. I don't think there is a societal will to stop HIV and the epidemic.
What single change would you like to see in HIV care?
Universal health coverage for all.
What education or counsel do you provide for newly diagnosed patients?
This, of course, is a very emotional moment for patients. They think, "My life is over. I'm going to die tomorrow." I think it's very important at this early juncture to establish an empathetic relationship. So, the first thing I do is explain they are not going to die. There are effective treatments. I let them know what's ahead, that there's hope, and that I'm willing and able to work with them to not only keep them alive but living a worthwhile life.
In many ways, treating the HIV is the easy part. It's helping patients deal with the emotional and social implications that can be difficult. They have job and relationship concerns, and self-esteem issues. Those all have to be addressed for treatment to be effective.
Sex is a big issue. At first, patients say, "I'm never going to have sex again." And I say, "Well, that's probably not so." But I remind them that they are responsible for their and others' safety.
What do you provide patients who are about to begin treatment?
In the early days of AIDS, the prevailing thought was hit early and hit hard. Now, with the newer drugs, it's more a case of establishing the best regimen we can come up with. A big part of that is working the drugs around the patient's schedule, to make it easier for them to take their meds based on their work hours, for instance. Some drugs are once daily, others have to be taken more than once or have other considerations. So, it's all about getting them to take their drugs. One thing I tell patients is "Either take your drugs or don't take them, but don't take them half-assed." I tell them if they get to the point they are taking their meds only half the time or irregularly to call me because that's even worse than no drugs at all. It's a sure set-up for resistance.
If you were infected with HIV today, at what T-cell count would you begin treatment?
Likely about 300.
What treatment regimen would you choose if you had to begin treatment today?
Likely a boosted PI and two of the newer nukes.
What's the key to a great healthcare provider/patient relationship?
Empathy, imagination and honesty. It's like ballroom dancing. You have to have to build trust with your partner, know when to lead, when to follow; know the steps and establish a rhythm.
How do you feel about patients who take a proactive role in their own treatment?
I demand that my patients take a proactive role in the management of their lives. Hate it when they don't. But many of my patients are very smart. I had a patient come in and ask about a drug. I was like: Oh, my God, I never heard of that. That very night I went to a seminar and they were discussing that very drug. I find that those who seek treatment are intelligent and not poor. Those that don't are on the flip side of that coin.
Who was your all-time favorite patient and why?
I have lost nearly 700 patients and have another 300 living today. There are no favorites. They all are. My story says more on this subject.
What is the most important thing you have learned from your patients?
That I am going to die.
How do you maintain a positive outlook and avoid burning out?
I don't know, I may be burned-out already. But I get up each day and come to work.
If you weren't a clinician what would you be?
Don't know. I can't imagine what else I would do.
What was your first reaction when told about this award?
Honored and humbled. There are so many who deserve recognition.
Who do you dedicate this award to?
My father, who taught me how to be a doctor.
Where did you grow up?
What did you want to be when you were a kid?
A herpetologist. Believe it or not, the part of Miami I grew up in was at that time almost rural. We had a donkey, dogs, ducks and geese. But I dug snakes. Doesn't every kid? I had about eight or 10 of them at one time.
What kind of work did your father do?
Dad was a family physician. Actually, he started the first family medicine residency program in the U.S. at the University of Miami in the '60s.
When did you decide on medical school?
As a child, seeing how hard my dad worked and the long hours, I said I would never be a doctor. I didn't do pre-med or biology in college. I was a Phys. Ed. major. But while I was working on my Ph.D. in exercise physiology, I began to realize that I really wanted more. It wasn't an epiphany or anything like that. As a kid, I often accompanied my dad on housecalls. When I was older, I even helped him in the lab. I guess it all kind of caught up with me, like it was in my blood.
What made you decide to go into HIV care?
No other choice existed: It had to be done and nobody wanted to do it. I more or less got drafted. I was in medical school at the University of Miami and I attended a lecture. I remember it so clearly. It was a noon lecture about "Gay-Related Immune Deficiency." You can see how early it was. They were still referring to it as "Gay-Related." But Miami had been hit hard by what really was HIV/AIDS and we were already seeing many Haitian immigrants, for example, who weren't gay, yet were infected. We knew then it was a disease of the people.
Who were the most influential people in your life, both professionally and personally?
My patients and my family.
What do you do in your spare time?
Rock climbing. A lot people look at me like I'm crazy when I say that. They think it's so dangerous, which is the spin Hollywood puts on it. But truly, today, with modern equipment, it's much safer than most sports. Of course, you've got to know your limitations. But it's the fear that keeps most people from trying it.
Can you tell us a little about your family?
I have a wife, two sons and a dog or two.
Where do you live?
If you had anyplace to live besides where you live now, where would you live?
Laughing Bird Cay, Belize.
What's the best vacation you ever had?
Going to Africa with my wife after she finished medical school and climbing Mount Kenya and Mount Kilamanjaro.
What's the biggest adventure you ever had?
What's currently on your bedside table for reading?
The Little Prince and A Fortunate Man: The Story of a Country Doctor by John Berger.
What music do you like to listen to?
Springsteen, U-2, Los Lobos, Ani de Franco, Joni Mitchell, Sade.