NEW YORK -- Dr. Frances E. Robles was working in the emergency room of Bronx Lebanon Hospital recently when a taxi driver ran in, shouting that a woman was giving birth in his cab.
Dr. Robles raced outside and saw that the baby's head was about to emerge. The doctor, her hands firmly at her sides, waited an agonizing few moments until someone brought protective gloves in case the laboring woman had acquired immune deficiency syndrome.
"I thought, 'This baby could suffocate; this baby could die,' " she said. "But my health comes first. It's either you or me, and I'm going to look out for me."
Dr. Robles has reason to be afraid.
Four years ago, she accidentally stuck herself in the finger with a needle she had used to draw blood from a patient with AIDS, and although she has tested negative for the disease, she panics every time she feels tired or has a sore throat.
But even for health care workers who have not had so close a call, fear of violence and diseases such as AIDS, tuberculosis and hepatitis is changing the way they practice medicine, sometimes to the potential detriment of their patients: A doctor risks the health of a baby because she has no gloves; another checks on a tuberculosis patient less often than patients with other diseases; a third shies from seeing patients when there is no security guard present, for fear of physical harm.
"It is human nature for people to fear for their own health," said Dr. Robert M. Wachter, a professor of medicine at the University of California at San Francisco, who is studying the effect of AIDS and tuberculosis on doctors' behavior.
"In any contact with patients, one is always going to have to weigh the risk to themselves over the care they are going to provide for that patient," he said, noting that such choices are made most often by inner-city doctors. "I worry that people are not providing the medical care they would like to be providing."
Dr. Robles is unusual in her candor. This is a situation many do not want to talk about openly.
In poor areas, where these problems are worst, hospital administrators concede that they often have a difficult time attracting doctors, and studies published in several medical journals show that AIDS in particular scares many away. But administrators are reluctant to make the connection.
"There are a lot of reasons" for the difficulty in attracting staff, said an administrator of one New York City hospital who lTC requested anonymity, "namely, the lower salaries and the high cost of living in New York."
"Fear is part of it," he said. "But you won't get me saying on the record that doctors are afraid of their patients."
Doctors, in turn, are reluctant to admit publicly that they are afraid or that their concern for their own safety is causing them to hesitate, even slightly, on the job.
"I'm not proud of this," said a pediatrician who works at a clinic run by the New York City Health Department. Several months ago she was accidentally stuck with a needle while trying to give an injection to a squirming child who she suspects has AIDS.
Now she avoids giving injections to squirming children, and has considered delaying their vaccinations for a month in the hope that another doctor will be on call that day.
One doctor, who asked that his name and the name of his hospital not be used, worries that he and his colleagues do not examine tuberculosis patients as often as they should, for fear of catching the disease.
On a recent morning, he said, there were three patients in the hospital with a strain of TB that is resistant to several common drugs.
"Today we didn't go in their rooms," he said. "It's inconvenient to don gown, mask and gloves. It's not necessary to examine every patient every day, but I hate to think we're staying away when we should go inside."
Historically, medicine has been a dangerous profession, and until this century, doctors regularly died of the plagues they were called upon to treat. Even today, many doctors believe the current dangers are an acceptable occupational hazard.
"Doctors have a responsibility to treat patients, and they fulfill that responsibility," said Dr. Lonnie R. Bristow, an internist in the San Francisco area and a trustee of the American Medical Association. "Anyone who chooses the profession of medicine because it's safe and clean has made the wrong decision."
Dr. Alan A. Bloom, head of gastroenterology at Bronx Lebanon, believes that the fear is greatest among younger doctors who are more likely to hesitate before caring for a patient with AIDS, TB or hepatitis.
Earlier that day, he said, he had been called by a younger radiologist who had just treated a patient with active, drug-resistant TB and "who said she didn't want any contact with this guy ever again."