There are few medical professionals knowledgeable about treating HIV in his rural area, so he must always educate others about HIV and AIDS. He must compensate for a lack of HIV knowledge, and for inadequate access to care. When Bauguess came to Oroville, no one at the Del Norte Clinics, which is the only system of rural health clinics in the Northern Sacramento Valley, was meeting the needs of the local HIV-infected population, and no one in the area was taking new HIV outpatients. Says Michael, "It took vision, dedication, compassion, perseverance, patience and above all placing the needs of others above my own."
Michael's responses to our Leadership Award questionnaire tell much about the man. Words like "respect," "trust," "learning," "compassion," and "empathy" march steadily across the page. Asked how he decides whether a patient is ready for HIV treatment, he does not consider only CD4 counts, nor does he limit himself just to what he thinks. Instead, he says a patient is ready to begin treatment, "When they are ready, after building trust and rapport." He prefers to connect patients with counselor/social worker and R.N. case manager prior to initiating therapy.
It was his mother's temperament and compassion that has inspired Michael, and when Bauguess traveled to India as a young man, he met a medical missionary who revealed the same sensitivities that would later distinguish Michael's own career. Michael went on to earn a B.A. in physiology and a B.A. in ministerial arts. He received his certificate as a physician assistant from the University of California, Davis in 1993. One of his mentors after school, Dr. Mark Lundberg, supported him in his quest to work with HIV patients, and to start Del Norte's HIV program.
Bauguess' inspiration to work in HIV/AIDS came in part from a friend who died in the days before HAART. The friend was gay and a veteran of San Francisco's fast lane. Bauguess is straight, with a religious background. How did he square the two? "You're talking about two separate things," Bauguess says. "Having compassion for people and helping them, so there's no conflict. I'm totally accepting of people as they are. All my patients know where I'm coming from."
How long have you been practicing?
Since March 1994 with Oroville Family Health Center, one of several medical rural health clinics associated with Del Norte Clinics, Inc. This is a clinic system that has been around for 40 years in the Northern Sacramento Valley. It's a group of community-based health and dental centers and it's geared to people who don't have health insurance or Medicaid. It's the clinic of last resort in these areas.
How did the HIV clinic portion of the Del Norte Clinic get started?
It's a long story. I guess it starts when I met the former medical director of Del Norte Clinics, Dr. Herman Gray. He happened to come to my physician assistant graduation ceremony at University of California, Davis. I interviewed several months later and I have been working in Oroville ever since. At the time, there was no HIV component. The only person treating HIV and seeing more than 20 patients was a hematologist in Chico, Calif. A Hispanic outreach worker was hired at the time to do HIV education and outreach to the migrant community which we serve. We started getting some patients with HIV. This allowed me to apply for funding for a mini residency for myself at University of California, San Francisco. It was a five-day program and I learned about HIV and opportunistic infections. It was a slow process. People found that I had interest and slowly people sent patients with HIV my way. Mostly it was palliative and supportive care in the first years. Back then we had a mixture of migrants and gay, white men from San Francisco who had relocated. We had 10 to 11 people the first year. It was thought back then that HIV could be treated by primary care health care workers in a rural community. Now, I would say that this cannot be done, unless you have some specific training and clinical experience in HIV care. It slowly evolved. We worked with the existing staff and over time we educated them. We got the Title III Ryan White grant in September 2002 and since then we have been able to hire additional staff who specialized in HIV care. We now have 170 patients in our HIV clinic and 40 are being looked at by the infectious disease specialist. I look after about 130 HIV-positive patients.
Is there any way your practice has changed since you first started practicing?
Initially, I focused broadly in Family Practice including children and female health primary care; now, more general Internal Medicine, especially HIV/AIDS care.
What's the best thing about your job?
Freedom to build my own practice and support to build the HIV/AIDS program, along with the relationships established with patients. Longevity, including building relationships over time of mutual respect, trust and knowing that I care about them and that I will go to any length to help meet their needs.
What's the worst thing about your job?
The worst thing is increasing regulations with less autonomy. And also limited funding to meet expanding needs. Ryan White funding has been flat although the patient that need care continue to grow.
Is there anything particularly challenging or different about working in AIDS care in a rural place? How have things changed in this community changed over the years?
One of the good things about working in a rural area is that you build relationships with people you see. Many of these people have unstable lives. At the clinic, they know they have support. In fact, it's often the only place they know that someone will be there for them. So we become their extended family. In terms of rural challenges, transportation is one because although there is limited public transportation, many can't afford cars. They may not live near any bus line. So it's really hard for many people to access care. Access to clinical trials is also a challenge as well as referral access if they need specialty care. In addition, there is more stigma in rural areas. I've had patients tell me that. We have many migrant workers in our clinic but a lot of migrants don't access care because they are very mobile. Many don't even get tested. We depend on outreach workers to identify them. We also have 5 to 10% population of HIV-positive Native Americans at our clinic. We try to have people in our clinic that understand these different cultures, whether it is Native Americans or Mexicans or African Americans.
What have been your greatest successes in your work? Greatest failures?
Greatest successes include establishing an HIV program and providing services to persons living with HIV in a mostly rural community where these comprehensive services were lacking; learning from my patients how to live in the midst of adversity.
Greatest failures include not able to motivate positive change in some patients before they died.
What is the biggest challenge you face? Would other physician assistants give a similar answer?
My biggest challenge has been and is working as a physician assistant as the local expert in HIV, although many do respect the work I do even though I am not a M.D. I believe other physician assistants, especially in rural areas, face a similar burden.
What happens if someone is illegally in the United States? Can they get treatment?
We can help people. We can fund their lab work and handle their medical care. There are programs and funding sources for us to help people who are undocumented or have no way to pay.
What do you think is the biggest problem people with HIV face today?
Knowing that there is no cure for this disease, and that, if they let their guard down, the virus is waiting to take control. There has never before been a disease that requires 95-plus adherence for an ongoing durable response.
Can you tell me specifically how methamphetamine has impacted patients already infected?
We have been told that we are one of the largest areas per capita for methamphetamine use in the whole Northern Sacramento Valley. It's become so endemic. It's amazing how far reaching it is. It greatly impacts our patients: their mental health, access to care issues, adherence with antiretrovirals. I would say at one time or another 75% of our clients have used methamphetamine. It's probably grown over the years. The patients that do best are incarcerated because they have to get clean. It's a complicated group to treat. There are drug treatment programs here, but the services are limited. It's a stereotype that it's all gay white men; that's not what we are seeing here exclusively.
For the most part, what do you think is the biggest risk factor for HIV?
The biggest risk factors are complacency and apathy. Specifically for men who have sex with men, but I am seeing a rise in heterosexual transmission.
Do you think that prevention efforts are sufficient? Anything you would change?
From a public health standpoint, we must continue our messages of safer sex and clean needles and target those at highest risk. I agree with the Centers for Disease Control and Prevention's focus on "prevention for positives," targeting those with HIV disease and their high-risk contacts.
What single change would you like to see in HIV care? Why?
The biggest change I would like to see in HIV care is access to primary care/service, especially early in the course of disease, for all those who are infected. Then there will be increased health promotion and disease prevention. This will lessen the burden on a financially strapped health care system.
What do you provide in terms of education or counsel for a patient who is just diagnosed?
HIV 101 including support for their emotional/mental state and education regarding their contacts. It's individually done and is based on their knowledge. We have booklets and a list of resources to give to people at appropriate educational levels. I'm thankful to have a team of social workers and nurse case managers that will listen to and educate them and note what the barriers are to adherence.
What do you provide in terms of education or counsel for a patient who is about to begin treatment?
I explain that it is never an emergency to begin antiretrovirals, but I do discuss the DHHS general guidelines and assess the patient's readiness to begin and adhere to therapy. I work closely with a licensed clinical social worker and a registered nurse HIV case manager to identify and address potential barriers to adherence.
What treatment regimen would you choose if you had to begin treatment today? Explain.
Truvada and Sustiva. Only two pills, and in the near future, one pill at bedtime -- a very potent and generally well tolerated regimen with low pill burden without association with significant lipodystrophy.
What's the key to a great healthcare provider/patient relationship?
Longevity, consistency, compassion/empathy, trust, respect and empowering the patient to make their own informed decisions regarding their health care. It is a partnership, with both persons providing input. Patients do not care what I have to say until they first know I care.
How do you feel about patients who take a proactive role in their own treatment? Do you have many patients who are proactive?
I encourage patients to be proactive and I do have many who are proactive. I offer many patient education materials plus websites to patients. I believe patients tend to support and adhere to what they help to create.
Who was your all-time favorite patient and why?
LS moved from San Francisco to rural Northern California to die in 1994; not only is he living and functioning well with HIV, he has been a part of meaningful times in my life, including my recent wedding.
What is the most important, memorable or useful thing you have learned from your patients?
To really listen to patients. It is more important to understand rather than be understood.
How do you maintain a positive outlook and avoid burning out?
I am learning to share the burden with others who care, plus I am learning to develop and maintain a balanced life away from work, including regular exercise, regular spiritual connection and meaningful contact with others.
If you weren't a clinician what would you be?
A counselor. I love to empathetically listen and guide/motivate positive change.
Who would you dedicate this award to if you could?
To all my patients who entrusted their lives to my care.
Where did you grow up?
All around the United States and England. My dad was in the United States Air Force.
What did you want to be when you were a kid?
What kind of work did your parents do?
My dad was an Air Force pilot; my mom worked in retail and as a loan officer at a credit union.
When did you decide that you'd like to be a physician assistant? What was your major in college? Any other careers before choosing this one?
In 1988. I thought working as a physician assistant would allow me to combine my desire to work in medicine and counseling, especially with the underserved. My major: B.S. in physiology with a psychology emphasis at the University of California, Davis; later, I received a B.A. in ministerial arts. I worked seven years in tissue transplantation before entering physician assistant school.
What made you decide to go into HIV care?
My desire to work with those who were outcast and dying, plus the intellectual stimulation. I had a close friend die of AIDS-related causes in 1993, which impacted me greatly.
Who were the most influential people in your life, both professionally and personally? Why?
My mom -- her unconditional love and godly example. Professionally, a physician in Calcutta, India, who combined medicine with missionary work and worked as a pastor.
What do you do in your spare time?
I love to travel and experience new places and people. I love to eat out with friends. I love to run/exercise, read a good book, see a good movie, spend time with friends and family and edify my life and others spiritually.
Do you have a partner? Kids? Pets?
I recently married for a second time to a wonderful woman who works as a nurse -- we met caring for HIV/AIDS patients together. I have a biological son age 10; my wife has a 14 year-old daughter and an eight year-old daughter who live with us. We currently have a parakeet and an adopted cat. We hope to add a dog this summer.
Where do you live? What kind of community is it?
I live in Chico, Calif., a rapidly developing State University town 90 miles north of Sacramento, population of the surrounding area is approaching 100,000 -- a beautiful place to live, near the mountains and the coast, not too far from San Francisco or Lake Tahoe.
If you had anyplace to live besides where you live now, where would you live?
If I was not married nor had any ties, I would consider relocating to Europe or possibly work, at least part-time, in Africa or India.
What's the best vacation you ever had?
Greece for one month, Athens and the islands, with those who know the language and culture.
What's the biggest adventure you ever had?
Traveling to Calcutta, India for three weeks -- staying with a missionary family, seeing first hand the poverty, disease and dying and volunteering in their clinics.
What's currently on your bedside table for reading? What book would you say has had the most impact on you?
The latest John Grisham book and the Bible -- the Bible, by far, has most greatly impacted my life.
What kind of music do you like to listen to?
I enjoy smooth jazz and flamenco music the most.
Before you were nominated, did you know about The Body or The Body Pro? If so, what were your impressions?
I receive by fax and e-mail HIV/AIDS medical updates -- I greatly enjoy the useful research and clinical information in the understandable format.
Anything else you think it's important that people reading this interview know about you?
I am greatly honored to be nominated and selected for this recognition. I hopefully represent well the other physician assistants and clinicians, along with the other health care workers, who are dedicated, compassionate and equally deserving of recognition. Thank you!