The Ethic of Excess
I'm not sure whether I should switch doctors. The physician I have been seeing is nice, but she doesn't seem aggressive enough. When I ask her about vitamins, immune boosters, herbs, and experimental HIV treatments, she tells me that my T-cell count is great and that my viral load is undetectable, so we "shouldn't rock the boat." The people in my support group tell me I am being naïve—that this doctor doesn't seem to know much about the latest treatments. Am I doing myself a disservice by leaving well enough alone?

We live in a culture in which the prevailing mantra is that "more" is generally accepted to be "better"—more money, more fame, more power, more muscles, more drugs. One of my favorite pieces of erudite rest room graffiti is "The thing that separates man from animals is man's desire to take drugs." Men with perfectly sculpted bodies are forever hitting me up for anabolic steroids, growth hormone, and advice on vitamin supplements in an endless quest to get even bigger. And now with the domestic AIDS epidemic having settled down to become more "chronic and manageable" than ever before (for those lucky enough to have medical insurance), many healthy patients are looking for more novel and sometimes unconventional ways to treat their disease. In short, more drugs.

I classify my private patients into three general groups: the Happy, the Restless, and the Frantic. The Happy are about 50% of my patients and generally are content to take their medications and not think too much about HIV between office visits. As long as their T-cell count and viral load are cooperating, they ask relatively few questions and tend to depend on me for updating them about new medical developments. Often these are bright people who have busy lives, and HIV has simply become a maintenance issue.

The Restless (about 40% of my patients) are socially and medically aware and have seen the ups and downs of the HIV treatment saga. Often these patients are over 30, have a peer group that has been profoundly affected by the disease, and have a keen sense of our checkered history in the development of AIDS treatments. They generally ask lots of questions, read voraciously, and tend to be skeptical regarding the continuing relevance and safety of their medications. These patients are interested in experimental medicines but look before they leap when any new therapy is introduced.

The Frantic are about 10% of my clientele and expend far more energy worrying than their lab numbers would logically support. They seek to gain control of their HIV disease by action. Rarely content with their medicines, their vitamins, their doctors, or their own health, these poor souls mistake their anxiety and irrational behavior for healthy vigilance. They believe (to paraphrase ACT UP) "Complacency equals Death" and that disaster will befall them if they are not "doing something."

The irony is that the Frantic are at the highest risk for medical complications of excessive treatment. Unfortunately, they are the darlings of the loosely credentialed, loosely regulated, cure-promising industry that thrives on bilking scared people out of their limited resources. They are the patients who were surreptitiously swallowing Saint-John's-wort with their Crixivan and unknowingly causing their protease inhibitors to drop to dangerously subtherapeutic levels. They were taking megadoses of vitamin C and having terrible diarrhea, injecting huge weekly doses of vitamin B complex and developing neuropathy, or injecting ridiculously expensive growth hormone to combat lipoatrophy only to watch their faces shrivel further and their muscles ache.

The ethic of excess does not translate when it comes to health and medicine. Your well-meaning friends may care very much about you, but they may also be projecting their own anxieties onto you. "Aggressive" treatment should encompass balance and intellect, not just more pharmaceuticals. If your doctor says you are doing fine and your own instincts and your viral load support that contention, then you can believe it. Uncertainty, anxiety, and impulsiveness can often spell medical disaster if one does not take a step back and carefully consider the full implications of any particular intervention.

Cohan is an attending physician and vice president with Pacific Oaks Medical Group (www.pacificoaks.com), one of the nation's largest medical practices devoted to HIV and AIDS treatment, located in Beverly Hills, Calif. He serves on the board of AIDS Project Los Angeles and has expertise in nutrition, anabolics, and exercise.