One-stop care at breast centre another sign of patients' increasing influence
Charlotte Gray
CMAJ 1997;157:1419-20
[ en bref ]
Charlotte Gray is a CMAJ contributing editor.
© 1997 Charlotte Gray
In brief
The Ottawa Regional Women's Breast Health Centre is an example of a new wave of Canadian clinics that are trying to offer improved quality of care for women with breast abnormalities. The new centres are a response to patients' requests for changes in the way care is provided.
En bref
Le Centre régional de la santé du sein à Ottawa, est un exemple d'une nouvelle vague de cliniques canadiennes qui essaient d'offrir des soins de meilleure qualité aux femmes atteintes d'anomalies du sein. Les nouveaux centres répondent aux demandes des patientes qui souhaitent qu'on modifie la façon de leur prodiguer les soins.
Talk to women with breast cancer and a common complaint about fragmented care often emerges. If a woman finds a lump in her breast, she often finds herself shuttled between her family physician, a mammography clinic, a surgeon and a cancer centre. She may spend hours on the phone trying to make appointments in offices scattered across town, and end up fearing that her life is slipping away in the delays between tests and interviews. If she has to undergo surgery, she often feels she is left in limbo immediately afterwards, wondering when the next stage of therapy can begin. "The stress can be appalling," says nurse Cathy de Grasse. "We got that message loud and clear. Various breast cancer survivor groups told us that we must do something about it."
The "something" is the new Ottawa Regional Women's Breast Health Centre, which officially opened with some fanfare last month. The new centre, which is unique in Ontario, is being showcased as a comprehensive-care model for women with breast abnormalities. It is on the leading edge of current management trends, since it is organized around multidisciplinary care teams and contains built-in lessons about healthy lifestyles. De Grasse, who has years of experience in oncology and serves as the centre's coordinator of clinical services, has already fielded calls from reporters and health care providers from Canada and the US.
There have been several other Canadian attempts to improve the quality of breast-related care. Although mortality rates for breast cancer have begun to decline, incidence rates are rising steadily. Eleven percent of Canadian women can expect to develop breast cancer during their lifetime and 4% of them will die from the disease.
Those facts mean that a growing number of frightened women are demanding better care. Modern hospitals, acutely aware that they must respond better to patient needs if they are to survive, are developing some interesting responses.
Two years ago, Toronto's Mount Sinai Hospital opened the Marvelle Koffler Breast Centre, which offers women a comprehensive cancer service from diagnosis through all stages of treatment, plus psychosocial counselling and information on nutrition. This year, North Vancouver's Lions Gate Hospital is poised to become the first Canadian hospital to offer the latest in positron emission tomography for monitoring breast tumours. Next year, the Ontario Cancer Institute/Princess Margaret Hospital Breast Centre will open in Toronto, giving that city 2 centres that offer the full spectrum of care, from screening and radiation treatment to genetic counselling for women and families at risk.
In Ottawa, the challenge was that the city's hospitals were in turmoil when the idea for a centre was first raised in 1993. Ottawa has 2 adult teaching hospitals and provincial restructuring had made it clear that 1 of them might close, so it wasn't an auspicious time to suggest a new program. But the group that was pressing for change was undeterred. Led by the Civic Hospital, the steering committee also included representatives from the University of Ottawa and other hospitals and organizations. The Civic was the logical site for the centre, since space was available in a building next to the Ottawa Regional Cancer Centre. The proposal that emerged would bring all elements of diagnosis, treatment choices, planning and support under 1 roof.
Thanks to private-sector donations, an empty floor at the Civic was refurbished. De Grasse, who oversaw the decor, tried to create a nonclinical atmosphere. Landscape photographs line the waiting area, and there are round tables in the consulting rooms instead of the desks that can create barriers.
Mirrors are everywhere. Some will help women who are being taught breast self-examination, says de Grasse, while others are for those who have been crying and "will want to check their appearance once they have regained control." This attention to detail reflects the centre's patient-centred approach.
Most of the centre's users will be referred from family physicians or the province's breast-screening program, but women can refer themselves. As soon as a potential patient has contacted the centre, a nurse will call to prepare her for the first appointment. Dr. Douglas Mirsky, the surgeon who serves as program coordinator for medical services, says the calls help reduce anxiety. "We also know that improved communication enhances post-treatment recovery."
When they arrive, women are escorted from the waiting area into a consulting room by a nurse, who takes her history. The ratio of nurses to surgeons is 2:1, compared to a ratio of 1:1 in most oncology departments. This allows nurses to spend more time with each patient. De Grasse says the emphasis placed on this nursepatient relationship meant she started gets calls asking for advice after women learned she was working on the Breast Health Centre project. "I found myself helping them formulate the questions to ask their surgeons, in order to get the pieces of information they needed to make decisions," says de Grasse. Now, the centre's nurses are trained to perform this advisory role.
Most women with breast abnormalities do not have cancer, since 80% of lumps are nonmalignant. The Ottawa centre's appeal is that it has brought together the techniques that allow rapid diagnosis: mammography, ultrasonography and the 2 core-biopsy techniques. "This is the hub of our centre," explains Mirsky.
All tests can be done on the spot, often during the same appointment, and surgeons can walk down the corridor to discuss results with the radiologist and x-ray technicians. "It's a team thing," says Mirsky, who notes that the 4 surgeons who provide care deal almost exclusively with breast surgery, and the care won't be diluted by the use of "casual breast surgeons. We don't want to be a breast factory, churning out mediocre imaging and care for patients with breast disease."
The Ottawa centre doesn't provide the surgery, since that is done at the neighbouring Regional Cancer Centre. This means the centre is not as comprehensive as the ones at Mount Sinai Hospital or the Ontario Cancer Institute/Princess Margaret Hospital. "The continuum of care doesn't have to be under 1 roof," says de Grasse. The Ottawa centre does welcome women to discuss concerns at any stage of treatment, and a social worker is on staff to deal with family or personal issues.
"Nothing can prepare you for the shock and devastation of receiving the diagnosis," explains Carol Harkness, a cancer survivor who sat on the centre's steering committee. "Fear can paralyse you, confuse you, demoralize you and rob you of your usual good judgement and coping abilities."
Harkness, a nurse at the University of Ottawa Heart Institute, says information "became for me the enemy of that fear. It allowed me to participate actively, make informed decisions and develop strategies to cope with whatever lay ahead."
Neither Mirsky nor de Grasse could estimate how many women will seek the centre's help. In the Ottawa-Carleton region about 1000 women are diagnosed with breast cancer every year, and a further 4000 are found to have some form of breast abnormality. The centre saw its first patients in early September, but the launch is happening in stages so its approach can be fine-tuned. In 1998 it will be open 5 days a week, but de Grasse knows that "our numbers could explode -- the potential demand is far larger than we could cope with."
Both she and Mirsky are emphatic that they do not want to generate too large a patient flow. "The whole point is to reduce the wait between the initial mammogram and treatment from an average of 9 weeks to 7 to 10 days -- and the next day if the lump is obviously malignant," says Mirsky. "Ottawa may discover it needs a second breast health centre in the near future."
De Grasse anticipates that the centre may have to hold clinics on evenings and weekends to accommodate working women.
This centre appears to have met 2 goals: it offers a well-designed response to patient needs and a realignment of resources that reflects current thinking about health care delivery. Given that it all came together during a year of turmoil for hospitals, when many health care providers chose to hunker down in the face of massive change, the centre is indeed an important, and surprising, achievement.
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