#HumansBehindHealthcare: Q&A with Bruce Olmscheid, MD

When the AIDS epidemic swept through the U.S. in the early 1980s, it brought with it widespread backlash against the LGBTQ community. As the disease primarily affected gay men, homosexual males in the U.S. were singled out and largely blamed for the public health crisis. So much so, that the media and politicians began referring to the virus as the “gay plague” or “gay cancer.” With little known known about the virus and how it was transmitted, homophobic and discriminatory attitudes quickly spread across the country, hindering the gay rights movement in its early stages. According to Gallup, more than one in five Americans who reported knowing a gay person at the time, said they had become less comfortable around them since learning about AIDS. Likewise by 1986, over 4 percent of Americans said they or someone they knew had avoided places where a gay person might be in order to avoid contracting AIDS.

More than 40 years later, we now know that HIV and AIDs don’t just impact gay populations. While great advancements have been made in HIV and AIDS prevention and treatment, discrimination and violence against LGBTQ individuals and those living with HIV/AIDS continues to this day, including in healthcare settings. A survey by Lambda Legal, for instance, found that 8% of LGB individuals and almost 20% of HIV-positive individuals reported being denied healthcare because of their sexual orientation or HIV status.

To understand how attitudes towards and care for LGBTQ and HIV patients have changed over the years, we spoke with San Diego District Medical Director and provider, Bruce Olmscheid, MD, who has over 20 years of experience in the study, treatment, and prevention of HIV. Prior to joining One Medical, Olmscheid, who identifies as gay himself, directed the HIV education and training program at St. Vincent's Hospital in New York and spent eight years as the director of Medical Affairs at Gilead Sciences, helping bring the first one-pill-once-a-day HIV regimen to market. He is board-certified in Family Medicine and is recognized as an HIV Specialist by the American Academy of HIV Medicine.

A: I was a kid in a small, rural area in Minnesota. We didn't grow up on a farm but there were farms all around us. It was a small town with about 2,700 people. Growing up, I just knew that I liked the body and I liked science. I liked figuring out how things worked. And then my mom got sick. She was diagnosed with Hodgkin's disease when she was pregnant with my younger brother and ended up dying when I was 12. She went to the doctor all of the time and I would ask my parents questions about everything going on. They would tell me to go run along and play and didn’t really answer the questions for me. So medicine and the hospital especially became this mystery. It was a secret little society and I wanted to get in. I wanted to know what was going on in there and I wanted to understand the language. I just knew from a very young age that I wanted to be a doctor.

A: When I was in medical school at the University of Minnesota there was a big emphasis on training doctors in family medicine and primary care. They were your small town doctors who did everything. They delivered your babies, took care of the kids, and took care of grandparents. They were the old fashioned doctors. I thought that's what I would be too, but just as I was preparing to start medical school, I came out as a gay man. The year that I started medical school, 1983, was the year that AIDS landed on us just like COVID-19 just landed on all of us this year. Throughout the course of medical school, I didn’t lose a lot of friends in Minnesota to AIDS, but it was affecting my community. I stayed in Minnesota for medical school and a Residency in Family Medicine, then met the man who is now my husband, and moved to New York City. I was in a primary care practice there but decided I wanted to take care of patients who had AIDS. I had great mentors and colleagues who helped me learn. It was a time of learning something new all the time. It was hard, but exciting.

A: It felt like a calling. It really did. I have some family members who thought I would've gone into oncology because my mom was sick with cancer so long, but AIDS was this new thing and it was affecting my community. I didn’t get infected. I could have been one of those early patients who got infected but I didn’t, so it felt like I was supposed to be doing this. I was supposed to be taking care of my community. So when I got to New York, I was in a practice and just started taking care of people with AIDS. I learned how to manage patients with medications to prevent opportunistic infections, and to diagnose and treat them when they did occur. We were just beginning to have better medications and the ability to reduce the viral load, which prevented their T-cells from dropping. We were beginning to be able to keep more and more people from getting AIDS. Things really changed for the better when protease inhibitors became available in 1996.

I had been in a private practice in New York City for three years and was very fortunate to be introduced to the director of the AIDS center at St. Vincent's Hospital in Manhattan, one of the epicenters of the epidemic, and he hired me to be on staff in the AIDS center. So for the next few years from 1996 to 2001, all I did was AIDS care. Those were the years that AIDS went from being a death sentence to something that we could treat. It was fascinating, heart wrenching, exciting, and hard.

A: It was rewarding, it was hard, and it felt like I was doing good work. There was such a sense of comradery among all of us who were the caregivers, including the nurses, the social workers, respiratory therapists, home health, research teams. It was team-based care. I never felt like I was alone. It was just always all of us putting our heads together, so it wasn't scary. We all did the best we could. We used to say things like “Oh, this patient finally died. He finally let go.” We would help people pass as comfortably as possible. At the same time, we were struggling and working hard to keep people alive with drugs to treat opportunistic infections. We were doing clinical trials on new drugs to treat the virus itself. There are many similarities to the coronavirus pandemic. We had no idea how long it was going to last. I was learning something every day. We were all learning at the same time. My patients would go out to patient educational groups and they would come back and they would share information with me. They would be teaching me about a new drug because I was in the office taking care of patients. It was hands-on experience that was constantly evolving.

A: Patients got very good care and felt comfortable in our AIDS clinic, but out in the real world and with their families, there certainly was a lot of dicrimination and judgment. I had one patient, for example, who was very young, from Texas and living in Manhattan. When he got sick, his mom quit her job and moved to Manhattan to take care of him. She was with him until he died. His father though, was back in Texas and wouldn’t even talk to him. I don’t even think his father came to his funeral. There were many people I took care of whose families didn’t know why they were sick. We often wouldn’t even tell the families what was really going on because the patient didn’t want their family to know they had AIDS. There was definitely a stigma and that stigma hasn’t gone away. I still see people with HIV who don’t want anyone to know they have it. It was just tremendously hard for a lot of people socially, psychologically, emotionally, and physically. It was a real challenge for them but the community was there. The community took care of each other.

A: Absolutely. Growing up, I knew from a very early age that I was different. I didn't know what the exact terminology was but I knew whatever it was was wrong or bad. I didn't talk about it. But I came out and moved to Minneapolis where things were a little bit more accepting. There was at least a gay community there. There wasn't any community where I grew up in my rural area. It's really hard even to this day to be gay in a rural area. But even in medical school there was still some bullying. At the time, I had a little diamond stud earring and one of the neurologists I was supposed to go on a rotation with wouldn't let me come into his office. It was his private office and he said it would scare his patients. That was in 1988. Rather than fight it at that time I just went to the director and asked to be put somewhere else. I could be out but it was not the same as it is now. It was just different. I was always a bit militant though in that I just never changed pronouns or avoided pronouns when speaking about who I was dating or my personal life. I moved to New York in 1992 and it was so freeing to be there. Today, I’m grateful today to be at One Medical. Everyone is very, very accepting here.

A: Absolutely. There were a lot of people in healthcare early on who were afraid for their own lives and didn’t want to touch people with HIV or treat them. There was a stigma around people with HIV and AIDS at the beginning. We found networks of specialists to work with who we knew would welcome our patients and would care for them as human beings. If we heard back from patients about a bad experience in another healthcare setting, we would not refer there anymore.

A: I think the short answer is yes, it obviously had to. I think there is a whole, separate story to be told about the toll on healthcare providers at the time. Let me answer the question this way —I knew after being at St. Vincent's for only six years that I needed to get out. One day I came home and I was on a call with a patient. My husband said to me, "Bruce, it's time. That's not you. There was no empathy in that phone call." And that's when I left the practice and I went to Gilead, a pharmaceutical company that had a new AIDS drug that I was familiar with from the clinical trials. We didn't know it then but it turned out to be far better than the early drugs on the market that were causing major short-term and long-term side effects. Gilead was going to put this new drug on the market and they asked me to come and help build a medical affairs program. It was a great opportunity for me to leave clinical practice to give my mental health a break while still doing something that was still within HIV medicine. So my husband and I moved across the country to the San Francisco area in California and I worked for Gilead for almost 10 years.

A: First of all, it was a relief. I needed to be out of patient care for a while. We were still on call back then and had to be available around the clock. So I definitely recall that it was a relief. But it was also intellectually stimulating and challenging. It was very rigorous. I got to work with doctors who were treating patients and help them understand how to use the drugs. I helped doctors enroll patients in clinical trials and worked on post-marketing studies. It was very exciting to be right there on the cutting edge. This drug revolutionized the treatment of HIV and is still now the backbone regimen for patients all over the world. We’re now using it for prevention. So it was a big difference to go from deaths in the clinics to being able to actually help patients.

A: After being at Gilead for about 10 years, I don’t think it was actually a mid-life crisis, but I was 50 years old and I was tired. This treadmill just keeps going faster and faster. I decided to step off the treadmill and take a break. I was fortunate to be able to take the time off. During the sabbatical I had to learn how to be a “human being, not a human doing.” As I approached the end of that year, my dad got sick with stomach cancer. I was spending some time with him in Minnesota and he of course knew my whole journey, but still felt that I should be working! He said, "Well, everyone has to work. You have a gift and experience and you need to be using it." Basically, he told me to get my butt back to practice. I literally got back to practice on my 52nd birthday and he died two days later. I made it home to Minnesota just in time to tell him as he was dying, that I was back in practice. I did some work with some friends at a practice in San Francisco and a year later I learned about One Medical.

In my interview with One Medical I was asked if my passion was HIV or primary care. I was hired even though I said my passion was HIV medicine! HIV and primary care go hand in hand. More and more, HIV is in primary care, just like diabetes and high blood pressure are part of primary care. To this day, I continue to do a lot of HIV prevention at One Medical. I just talked to a patient this morning about the drug I worked on at Gilead and was able to alleviate his concerns about it. I’m very proud of the work we did to get here. It just feels like a calling that’s lasted a long time.

A: I think I bond with my LGBT patients very quickly because we're part of the same community. With both my LGBT and non-LGBT patients, I don’t hide who I am. I have a picture of my husband in my office. If a patient is sharing a story and mentions their wife, I talk about my husband. I just am who I am. You tell me who you are. I’m not going to judge you and you aren’t going to judge me. We have very open discussions about drugs, alcohol, stress, and sex. We've always had to talk very specifically about sex so I'm not one of those doctors you're going to come to and it's going to get left out of the conversation. I think my manner is such that I’m just very comfortable with it and I ask questions very nonchalantly that we end up talking about it. I've had many patients say, "I've never had someone I felt like I could talk to about that." I think my approach is just to meet people where they are and accept them for who they are.

A: Absolutely. I'm very passionate about primary care. I think everyone should have a primary care provider, not just LGBT patients. Anyone can take care of LGBTQ patients, but many people want to be seen by someone who is similar to them. A gay man wants a gay doctor and a transgender person wants a transgender doctor. I think we, as doctors, strive to be able to meet everyone’s needs and take good care of them, but patients still seek that common bond. They want someone who really understands. For instance, I delivered over 200 babies when I was in my residency. I don’t do prenatal care anymore and I don’t do a lot of women’s healthcare right now. I can do it, but I don’t think a female patient can bond with me over their babies and children as much as they can with another female doctor who has children. It’s just that human bonding. We celebrate that at One Medical. Primary care is about the unique relationship.

A: I don't even know how to answer that because it just comes so naturally. First of all, I think many of them know that I'm gay myself. They've either been referred by their friends or they've Googled me or looked me up. But I also try to approach questions in a non-judgmental way. I find myself sometimes saying to people, "I'm your advocate here. I need to know these things about you and if there's something that's uncomfortable or you don't want to talk about it or if you want me to take my fingers off the keyboard while we talk about this, I will." I often tell my patients that I don’t have to put everything that we talk about into the chart. Sometimes I just say, “If you need to talk about this, we’ll talk.” Then I turn away from my computer to face them and just talk. It is an honor and a privilege to be a doctor, to be in healthcare, and to have people trust us. It is a responsibility. It is a privilege. My University of Minnesota degree reads, “...the degree of doctor of medicine, with all its privileges and obligations.” There’s responsibility that comes with this. I think my responsibility is to help patients figure out what’s working, what’s not, and what we can change. I’m not here to judge.

A: If you live in a city, you're likely to have access to good LGBTQ care, but there is still a lot of disparity outside of big cities in terms of finding a place where you can go. We’re on top of it at One Medical but it’s different in other places. Where do you go if you're gay? Where do you go if you're lesbian? Where do you go if you're transgender? There are many places where it’s hard to find providers and healthcare specifically for these communities. For example, access to the medication that can be taken to prevent HIV (HIV Pre-Exposure Prophylaxis or PrEP) is not as widely available in the South as it is in other parts of the country. Patients don't know where to go to get PrEP and don't really know that it's available. They don't get consistent messages about its effectiveness. They hear that it's bad or it's dangerous. Many patients don't have any place where they can go to get counseling and treatment.

A: We welcome everyone! We have so many LGBTQ patients and LGBTQ providers and it's a big part of the fabric of who we are. We're very open and accepting. As we grow and expand into other cities around the country we will continue to be a place where everyone is welcome. I talked a lot about HIV and the care we provide for those who identify as gay. I would also like to add that we have providers who specialize in the care of people who identify as trans or non-binary. We recently updated our chart with a place where people can enter their desired pronouns, and we are intentional in respecting our patients’ chosen names. One Medical welcomes everyone. We treat people as people.