News and analysis · Nouvelles et analyses

CMAJ 1999;161:13-15

• Bringing health care to the homeless
• Coming soon to a store near you?
• OMA, CMA trailblazer retires
• Make technology work for you
• MDs needed to cope with "extreme brutality" in Sudan
• Pulse: Where have all the nurses gone?
• Breast cancer treatment and older women

If the mountain won't come to Mohammed, then Mohammed will go to the mountain.

That's the underlying philosophy of a new program that brings general and mental health care to 5 Toronto hostels for the homeless and a detox centre. The Shared Care ­ Hostel Outreach Program is an initiative of the Centre for Addiction and Mental Health, the Queen Street Mental Health Centre and the Toronto Hospital.

Dr. Clive Chamberlain, vice-president of mental health programs at the Queen Street centre, says the program is vital because of the growing number of homeless people using hostels. Many of them have serious mental health and addiction problems, and are in poor physical health.

Most hostel workers do not have the skills to cope with these problems. At the same time, most hostel users don't have up-to-date health cards and can't apply for one without an address. As a result of this catch-22, they are shut out of mainstream health services. But even if they had access to the system, many homeless people are reluctant users because of previous experiences.

Chamberlain says these obstacles can be overcome by providing a user-friendly system within the hostels and at the detox centre. Each of the 6 sites has a nurse, an outreach worker, a part-time family physician and a consulting psychiatrist. Physicians are paid a salary, getting around the need for clients to have a health card to receive services.

The outreach worker strikes up a conversation with clients, identifying those who want or are obviously in need of health care. The nurse attends to immediate problems and is the link between client and family physician. The family physician consults with the psychiatrist on diagnoses and the prescribing of appropriate psychoactive medications, or arranges an appointment with a psychiatrist.

"Having a visiting psychiatrist is highly desirable," says Dr. Robert Frankford, the family physician at the Seaton House men's residence. "It makes me feel better about how I practise, that I'm not working in total isolation. It's nice to be able to consult, get advice on prescribing practices, get help with psychosocial problems."

For many patients, says Chamberlain, receiving health care can be the first step toward getting back on their feet. Once stabilized on appropriate drugs for physical or mental health problems, good case management can lead to suitable housing and steer those who are willing into alcohol, drug or risk-reduction programs, and eventually provide help with finding employment. "These people especially require tailor-made solutions," says Chamberlain. "Off-the-rack solutions just won't work."

People who stereotype the homeless as people with inherent character weaknesses shouldn't be too smug, he added. "This program is important because any one of us is just a fine line [away] from the same fate through a piece of bad luck — losing a job or family and social supports, or bad health. We've seen doctors, lawyers, priests and nurses end up on the street for a variety of reasons. This can happen to anyone." — © Olya Lechky, Toronto

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Dr. Carole Guzmán, a trailblazer for women physicians who has a passionate interest in the evolution of Canada's health care system, retired in May after spending more than 6 years as the CMA's associate secretary general.

She served the organization for 20 years, beginning as a committee member in 1979 and becoming a board alternate in 1984 and a board member in 1988. She was president of the Ontario Medical Association in 1989, and 2 years later assumed the CMA presidency. Guzmán was the second woman to head both these organizations. She was also president of the Federation of Medical Women of Canada from 1981 to 1983.

Guzmán, who graduated from the University of Toronto in 1958, is an internist specializing in pulmonary disease. She did research and practised rehabilitation medicine at Ottawa's National Defence Medical Centre for 22 years. She also developed a care model for patients with chest disease that is still used today. In 1992 she quit her practice to assume the CMA post, but she continued to teach at the University of Ottawa.

Guzmán became involved in organized medicine because she felt the profession was being "assaulted" by politicians, economists and others. She vowed to help improve the environment so that "physicians could do what they were trained to do." She adds that "the profession has a role in helping society make decisions."

In retirement, she plans to pursue her hobbies and volunteer work and spend more time with her family; her husband, Tony, is a neurologist, and her first grandchild was born in June. She still plans to do limited consulting in health policy and professional issues. — Barbara Sibbald, CMAJ

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The new Alberta Doctor's Guide to Office Automation offers physicians practical advice on using computers to enhance patient care. The 28-page booklet, produced by the Alberta Medical Association, provides an overview of software, the Internet and email, electronic patient records, levels of automation, implementation and cost.

AMA President Rowland Nichol says office automation has become "an invaluable part of ensuring consistent, ongoing quality patient care." Possible applications include monitoring for drug interactions and patient recalls, supporting clinical care, conducting literature searches and making charts more legible and comprehensive. The guide is free to the AMA's 5700 members; others may purchase it for $10 (plus shipping, handling and tax) by calling 780 482-2626 or by contacting ama_mail@amda.ab.ca.

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The African Medical Association of Scandinavia (AMAS) is making a special appeal for aid for the western and eastern parts of Sudan. Some 2 million people are affected by the "bloody and protracted conflict in Sudan," states the association, which is seeking voluntary health care workers, medicine, medical equipment and cash contributions. "There is compelling evidence of attempts to ethnically cleanse the Nuba peoples from this region. . . . These people are totally helpless in the face of extreme brutality."

AMAS is particularly concerned about the "total lack of state institutions" in Sudan. In the Nuba Mountains, for example, there are 2 German "housemen [not fully qualified] doctors" working in "extremely primitive conditions." They are providing care for about 500 000 civilians widely dispersed over 7 counties. There is no vaccination program and no sanitation or clean-water projects.

AMAS is planning a 5-part project that includes improved sanitation, creation of a piped water supply, a comprehensive vaccination program, nutrition education and primary and emergency health care. Specific initiatives will include sending 1 doctor to each of the 2 regions, training volunteers to provide vaccination, clean water and sanitation, training traditional midwives in family planning and providing food.

AMAS was established in 1991 and has 109 members, 29 of African descent. It hopes to act as soon as possible. "It is after all a matter of life for tens of thousands of people," the organization said in a letter to CMA President Allon Reddoch.

AMAS is a registered charity. For information contact AMAS, PO Box 511, S-581 06 Linkoping, Sweden; dr.a.kangoum@ebox.tninet.sefax.

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Recent data from the Canadian Institute for Health Information (CIHI) indicate that the total number of registered nurses employed in Canada dropped by 3.4% between 1993 and 1998, falling from 235 630 in 1993 to 227 651 in 1998 (Table 1). Because of a growing population, this represents an 8.3% decrease in the number of nurses per 100 000 Canadians.

Although half the provinces showed gains in the overall number of nurses employed between 1993 and 1998, only Newfoundland showed an increase in the number of nurses employed relative to population. Ontario experienced the largest decline, with a 12.4% decrease per 100 000 people. In that province, there were 5518 fewer nurses in 1998 than in 1993.

CIHI also found that the nursing population in Canada is aging, with 25.5% of nurses being 50 years or older in 1998; 5 years earlier, the comparable figure was 20.7%. At the other end of the scale, the proportion of nurses under 30 decreased from 14.2% of the total in 1993 to 10% in 1998.

There has also been a significant change in the profile of employment opportunities for registered nurses. An increase in the availability of casual part-time positions has increased the proportion of those working part time from 39% in 1993 to almost half — 48% — by 1998. The proportion of nurses working in the fields of community health and home care also grew, from 9.2% in 1993 to 11.5% in 1998. The proportion working in hospitals had fallen to 62.4% in 1998, down from 67.3% in 1993.

This column was written by Lynda Buske, Chief, Physician Resources Information Planning, CMA. Readers may send potential research topics to Patrick Sullivan (sullip@cma.ca; 613 731-8610 or 800 663-7336, x2126; fax 613 565-2382).

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Fifty percent of breast cancer cases now involve women older than 65, but are these women victims of ageism when it comes to research, diagnosis and treatment of the disease? This was one of many issues explored at a recent Vancouver conference on breast cancer treatment involving older women.

Sixty-five-year-old women can expect to live another 18 years and 75-year-old women another 12 years, said Dr. Sharon Allan, head of medical oncology at the BC Cancer Agency in Victoria. But treatment for breast cancer within this age group can be controversial because most clinical studies have not included older women. Treatment decisions have to be made in the context of other illnesses and the women's social situation. Ageism — the feeling that these women are not worth treating because of their age — should be avoided as a rationalization for withholding treatment, Allan said.

Studies show that older women undergo screening mammography less often than younger women and are less likely to have breast-preservation surgery. However, cancer detection from mammography is more common in 65-to-75-year-old women than in younger women. Dr. Noelle Davis, head of surgical oncology at the Vancouver Hospital and Health Sciences Centre, said these women should have mammograms biannually, and after they reach age 75 if they are healthy.

Davis said one study showed a 40% reduction in breast cancer in older women who took tamoxifen prophylactically. Tamoxifen is "very well tolerated in older women," Davis concluded.

Although older women are less likely to receive appropriate therapy for breast cancer, most cope well with radiotherapy and surgery. Davis said a lot of myths surround the use of radiotherapy for this age group; for instance, women with osteoporosis can receive radiotherapy if the body is positioned carefully, although the use of chemotherapy remains controversial because there are no good data.

For frail, elderly patients, Davis said limited surgery, such as lumpectomy, can be done under local anesthetic, and should be followed by radiotherapy. The future, she concluded, "presents a great opportunity for better screening and prevention efforts" in older women. — © Heather Kent, Vancouver

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© 1999 Canadian Medical Association (unless otherwise indicated)