Intimate Questions: Retooling the Health Hazard Survey
"Oral sex? Anal sex? Fetishes?" These are questions on the patient intake form at AlphaBetterCare, an LGBT-friendly primary care practice owned and operated by Howard Grossman, MD.
"If you don't ask people, they're not going to tell you. If you make assumptions about people's sex lives, you miss things," Grossman says. "People put themselves at risk when they get involved with things they haven't been educated about."
With decades of HIV-focused internal medicine experience, Grossman set out to build a practice targeting lesbian, gay, bisexual, and transgender patients. These patients, he said, have often avoided doctors, many times because they worried about negative or judgmental attitudes of clinicians.
With that focus he opened offices in midtown Manhattan as well as Millburn, N.J.
But Grossman didn't start out treating patients in two of the most affluent neighborhoods in the U.S. He trained at a public hospital in Brooklyn during the early 1980s in the early days of the HIV epidemic. That whetted his appetite for working with underserved populations. Along the way he has taken a right-to-die case to the Supreme Court, and served a term running the American Academy of HIV Medicine.
Now, he's focused on open communication in primary care. "When you get into these intimate details with people and they know they can talk to you about anything, then they're much more likely to be honest about all the rest of the stuff," he says. "I talk the same way about weight."
Though these questions might seem uncomfortable, Grossman says talking about people's sex lives can be a jumping-off point. "Then they're telling you about their work lives, how busy they are, how they don't have time for sex, we're talking about their relationships, their use of drugs and alcohol. It actually opens the door to lots of other conversations."
"You Can't Lie to Save Your Life"
During his undergraduate studies at Haverford College in Pennsylvania, Grossman, a poli-sci major, set his sights on law school. But the summer before his senior year, while working in his family business's warehouse, the family intervened.
"'We've decided you can't be a lawyer,'" Grossman recalls one uncle saying. "'We've dealt with lawyers our whole lives in the trucking business and you can't lie to save your life. You really need to be a doctor.'" Grossman smiles, remembering his uncle turning to his father, and saying point-blank: "If you don't send him, we will."
This dramatic shift left Grossman struggling to balance medical school prerequisites on top of his senior load. With a pending "D" in organic chemistry, Haverford booted him from the pre-med track. "That was depressing," he says.
But after graduation, Grossman persevered through Columbia University's post-baccalaureate prerequisite program. He then worked nights as a technician at Albert Einstein Hospital. And in 1979, he entered Downstate College of Medicine, now the State University of New York at Brooklyn.
After a geriatric elective in San Francisco, Grossman began to shape his career. "I loved the team approach that geriatrics pioneered. It was the early '80s, and I wanted to do something that was relevant to the gay community, and it seemed to me that there were a lot of people getting older."
On the same trip, during a pulmonary elective at Moffitt, he encountered his first patient with HIV. "He had a reaction to Bactrim and had a bright red rash. When I first walked into the room, he said, 'Look at me -- I look like Suzy Shrimp.'"
A couple of weeks later, walking across Castro and Market with friends, someone yelled "Dr. Grossman!" It was him. "That was the first time anyone ever called me Dr. Grossman."
Training in the Midst of a Pandemic
In 1983, few programs existed for geriatric primary care, so Grossman arranged the next closest thing: a combined residency in internal medicine and psychiatry at the hospital right across the street from Downstate.
The first week of residency, the hospital ran out of Tylenol. And then, out of alcohol pads. "It was terrifying," he says of Kings County Hospital, a public institution in the middle of a high-crime, impoverished Brooklyn neighborhood that served a patient population heavy with drug users and Haitian immigrants.
Grossman landed in the heart of an epidemic, beginning the internal medicine portion of his residency at a time when 5% of the world's documented HIV cases were in Kings County. "We were seeing so many people in those days. Right at the beginning, we had no idea what we were seeing."
It may have been hell at King's County, but Grossman says it taught him how to make things work, and to take challenges head on. "You couldn't wait around for somebody to do something. There was very little grandiosity about being a doctor."
Treating poverty-stricken patients in a scarcely-resourced environment, Grossman says, taught him what sort of physician he wanted to be. "It was a wake-up call about keeping a better attitude in medicine and about how to treat people with decency -- learning by negative example."
But it also put the brakes on the second portion of his residency. "Kings County was such a horrible place. I was so burnt out. There was no way I was going to do the psychiatry part." At any rate, Grossman said he was ready to take on HIV patients full time.
No Hospital Wanted to Be Known as an HIV Center
After residency, Grossman worked in the HIV unit at Saint Claire's Hospital, a Catholic facility built in the 1930s in Hell's Kitchen, which housed one of the first dedicated AIDS units in the U.S. "It seemed like the place to be at the time," he says.
After about a year, Grossman joined a private practice with one of the first internists in New York City who focused on treating patients with HIV. He also worked part time at Community Health Project, which was later turned into Callen-Lorde, a gay- and lesbian-friendly free clinic.
In 1990, Grossman opened up his own practice in Greenwich Village, but he struggled to obtain hospital privileges. "Every place I applied, they wouldn't even talk to me," he says.
The hospitals wouldn't even ask him for his credentials. "I could have been a MacArthur scholar for all they knew. No hospital in New York wanted to be known as an HIV center. I couldn't get privileges anywhere in town."
The Perpetual Activist
In 1997, Grossman was one of three physician plaintiffs in Vacco v. Quill, a case heard by the Supreme Court. Three terminal patients asked their doctors to write them prescriptions to end their own lives. Since that's illegal, they sued the Attorney General of New York, Dennis C. Vacco, seeking the right to assist their patients in suicide.
"We won in New York state," Grossman points to a framed front page of the New York Times from the day the court overturned the ban. "But then it was appealed in the Supreme Court," where it was overturned, he says. "They said there was no right to assisted suicide."
In 2004, Grossman went to Washington, D.C., to run the American Academy of HIV Medicine. After 2 years there, he spent 10 months traveling in Nepal, Eastern Europe, Russia, and Siberia teaching about HIV.
Returning to U.S., he practiced with a friend in San Francisco for 6 months before heading to Boston to work for a year at Fenway Community Health -- a large LGBT-focused clinic. And now that the stigma surrounding HIV has eased, Grossman says he's shifted his activism toward LGBT health. "That's what prompted me to move into New Jersey."
AlphaBetterCare
After 3 years in midtown, Grossman realized he had a lot of patients coming in from New Jersey. So he approached a hospital within Atlantic Health Systems in New Jersey, and they offered to help him get a second office up and running.
Their flagship, Overlook Hospital in Summit, is a 750-bed tertiary referral center, and they want to become a center of excellence on LGBT care, Grossman says, "which is really exciting."
Access to care for members is the LGBT community has been poor, historically, according to Mitchell R. Lunn, MD, of the LGBT Medical Education Research Group at UCSF. "They go to a doc who isn't prepared to treat them, who's discriminatory, offensive, so they never go back to the doctor again."
"The patient-provider relationship is very unique. You tell all our intimate secrets, then take off all your clothes, and let them touch you," Lunn says. "Patients traveling to Grossman isn't surprising to me at all."
Open and Honest in the Exam Room
"It's part of your job as a physician to take care of your patients holistically and that includes sexual health. It's important from a behavioral standpoint to know what organ is going where. [It's] risk assessment," Lunn says.
In a study of men living in New York City, researchers discovered that 91% identified as straight, but 9% of that group said they'd had sex with men in the past year.
Getting a thorough sexual history isn't just about risk assessment, it can keep docs from offending patients. "Most of the lesbian women I know avoid medical care," Grossman says. "Every time they go to the doctor, people try to shove birth control down their throats, and that gets really offensive after a while."
And this offense keeps patients from seeking medical treatment for other conditions, too.
"There's a huge epidemic of obesity in the lesbian community." And for those women, he says, as with many people with weight problems, they just stay away from doctors.
Things are just as tough for gay men. Even docs who think they're culturally sensitive, Grossman said, will immediately test them for HIV and STDs. "We [gay men] get pathologized as being carriers of sexual disease. Doctors think they're being sensitive to our needs, but in fact they're not treating us as whole people."
In an LGBT health survey, 8% of LGB patients, and 27% of transgender patients, said they'd been denied care because of their sexual orientation or identity. Furthermore, several responders reported healthcare professionals had blamed them for their health status, been physically rough or abusive, and/or used harsh or abusive language.
Reaching Out to the Transgender Community
"There's a ton more work to do in all of LGBT health," Lunn says "But especially the T."
Grossman agrees, "transgender patients have a whole separate need in areas that aren't being addressed."
A national survey on transgender discrimination found that 50% of transgender or gender nonconforming patients said they had to teach providers about transgender care, and 28% said they'd postponed medical care due to discrimination.
AlphaBetterCare has been actively reaching out to members of the transgender community. "They haven't had medical care, some of them, in 15 to 20 years, since they transitioned, because they're afraid to go to the doctor," he says. "They didn't know where to go."
Overall, he suggests doctors focus on the individual patient, and step away from trying to put people in silos. "Good LGBT primary care is going to spill over to being good primary care for everybody."
The Future
Even though AlphaBetterCare is relatively new -- 5 years in NYC and 1 year in New Jersey -- Grossman said the practice is expanding rapidly at both sites. They have roughly 1,200 to 1,500 patients, and add three to four new ones per day.
In the future, Grossman says, he'd consider experimenting with other types of clinical practice structures. "There's all kinds of models."
Although, he notes one exception: "We have a system of insurance, so I believe doctors should take it. Doctors who are opting out are doing a disservice," Grossman says. "If you don't like it, we should be changing it, not just pretending it doesn't exist. All they're doing is skimming off the healthiest, richest patients."
If Grossman won the lottery, he says he'd dig into social policy. "That's a passion for me." But also, "My fantasy would be to train the next generation of doctors to do what I do, and to be better doctors. And to make sure LGBT people and people with HIV have access to high-quality care."
Despite grappling with serious, frustrating community health disparities for decades, Grossman remains centered. "If I'm going to be angry all the time, I might as well find something else to do. We've known for a long, long time that the system is badly broken and nobody seems to want to fix it."
"It's getting worse. So, the whole idea that I've always thought is to just stay on top of it as much as possible, and survive," Grossman says as he knocks on the door before entering an exam room decorated with a wall of signed, framed Broadway Bares posters donning muscular near-naked stars.