In the past ten years, the medical staff credentialing process has become a veritable antitrust minefield. The number of antitrust lawsuits brought by physicians and other health practitioners who have been denied medical staff appointment, reappointment, or whose clinical privileges have been terminated, restricted or otherwise diminished has escalated dramatically. Battles have been, and continue to be, waged in medical staff credentialing committees, hospital board rooms and, ultimately, in the courts over appointment and reappointment procedures, the criteria applied, and the procedures for hearings and appeals. Although aggrieved physicians also sue on other legal theories, antitrust lawsuits are particularly complex, expensive and time-consuming to defend and pose the risk of considerable monetary loss if a defendant is held liable. In addition, antitrust lawsuits may have deleterious public relations effects, impairing a hospital's reputation in the community and its credibility in its business dealings.

Disease classification systems and surveillance definitions are ordinarily tools for medical professionals, not matters for political debate and patient advocacy. It is hard to imagine a protest march complaining about the classification system for colon cancer. But when it comes to AIDS, nothing is ordinary.

The Centers for Disease Control's (CDC) case definition of AIDS is used by public health officials, researchers, clinicians, hospital administrators, disability specialists, insurance administrators, health economists, legislators, social workers, policy makers, and the media. It has influenced the way the HIV epidemic is perceived, managed, and funded.

It is not surprising, then, that the CDC definition of AIDS and its proposed revision is currently the subject of intense scrutiny. The case definition has transcended epidemiology to become a symbol for the inadequacies of the U.S. government's response to the HIV epidemic, and a particular symbol for the failure to address the needs of HIV-infected women.

On February 21-22, 1991, the Centers for Disease Control convened an Open Meeting on the Risk for Transmission of Bloodborne Pathogens to Patients During Invasive procedures in Atlanta, Georgia. Over 80 organizations testified at that meeting.

Almost without fail, every organization testified against the use of mandatory HIV testing to screen out HIV-infected surgeons and dentists from practice. Various groups and individuals, however, advocated that HIV-infected professionals should voluntarily restrict themselves from selected procedures and/or should voluntarily disclose their HIV status to their patients.

Larry Gostin, the Executive Director of the American Society of Law and Medicine, argued that HIV-infected health care workers should voluntarily self-defer from selected invasive procedures. I believe that the approach of voluntary self-deferral has legal and practical flaws and is not the appropriate public policy for the CDC to adopt.

In his compelling poem, “Talking to the Family,” physician poet John Stone describes the presentation of unbearable news, the death of a mother, to the awaiting family holding the now-motherless infant. First the physician puts on his white coat and reveals the death to the family. Then he takes off the coat, drives home, and replaces a light bulb in the hall. In seven short sentences the reader is drawn into a barren description of tragedy that seems cold and methodical. In line eight, the center of the poem, a single-line stanza thuds heavily, mimicking the message he bears: “I will tell them.”

The Centers for Disease Control published its long awaited guidelines for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients on July 12, 1991. The guidelines recommend voluntary HIV and HBV testing of all health care workers performing exposure-prone invasive procedures. Special safeguards are applicable to any worker who is infected with HIV or the most virulent form of hepatitis B—i.e., hepatitis B e antigen positive (HBeAg). HIV or HBsAg-positive health care workers should not carry out exposure-prone invasive procedures unless an expert panel has approved and provided individualized guidance, and the patient is informed about the HCW's serological status.

Characteristics of exposureprone procedures include digital palpitation of a needle tip in a body cavity or the simultaneous presence of the worker's fingers and a sharp instrument in a poorly visualized or confined anatomic site.