Canadian ideology. This mixed blessing makes us capable of selfdeprecating detachment, but robs us of the drama and tragedy of destiny. Canadians tend to be more law abiding and deferential, but also more cautious in economic innovation and risk-taking. Low defines the Canadian identity as "a national form of the narcissism of minor difference". He finds Americans much more aggressive than Canadians; for Americans, individualism is of paramount importance and government but a necessary evil. Attitudes of autonomy and individual rights permeate the US health care system and bring it into conflict with the need to cope with social problems. US history has caused Americans to think that abundance, not scarcity, is the normal state of affairs. This has also made them believe that what is possible is therefore necessary, regardless of pressures on resources. This, coupled with what Low calls "the frontier orientation" of US society, leads Americans to view frontiers as challenges to be conquered, not obstacles that must be accewted.
Within the context of this national character, Low discussed the challenges facing academic health centres in the US. In education he identified the problems of large minority populations, and the need for greater numbers of nonmedical health professionals, particularly nurses. Another problem is the trend toward specialization even though there is a growing need for family physicians. Low said curricula must be modified to provide greater emphasis on prevention, gerontology and health promotion. Although US problems concerning research are similar to those faced in Canada, Americans face added constraints: legislated standards of scientific conduct, requirements to maintain drug-free workplaces, and prescribed procedures for dealing with suspected scientific fraud. Low thinks the area of greatest contrast between Canadian and American health science centres is service, mainly because our methods of paying for health care are so different. One result is that US medical school budgets now depend on revenue from practice plans for 30% of their revenue;
nursing and other schools are increasingly pressing for their own practice plans. Health care costs in the US have risen by 12% annually for the past 25 years, outpacing costof-living increases by 150% to 200%. This has caused an overall expenditure of 12% of GNP on health care, with businesses spending an average of 40% of profits buying health insurance. Still, more than 30 million Americans remain uninsured - the costs of uncompensated care provided by hospitals now amounts to more than $8 billion per year. Low concluded that "who we are, how we live and where we live are the principal determinants of health . . . more doctors and more hospitals do not equate with more health". Apart from the plenary sessions, the 500 delegates attended numerous small-group sessions, each with its own agenda. The quality of the presentations, the enthusiastic participation of the delegates, and the general amity among the various groups gave a clear message that medical education in Canada is evolving with vigour and enthusiasm. m
Cocaine users may not fit MDs' stereotype, FPs warned Bill Trent
P hysicians must put aside embarrassment and check for evidence of cocaine abuse in patients presenting with certain common medical problems, a psychiatrist urged more than 300 Canadian and American physicians attending a refresher course for family physicians in Montreal. Bill Trent is a freelance writer living in Lanark, Ont.
And, warned Dr. Juan Negrete, they must be wary of stereotyping patients. The professor of psychiatry at McGill University and director of the Montreal General Hospital's Alcohol and Drug Dependence Service told participants at the 40th annual refresher course sponsored by the Postgraduate Board of Montreal's Royal Victoria Hospital that they must not assume cocaine users are dishevelled young men aged 18 or 20. Those demure, well-dressed
women in their 50s who arrive with assorted, ill-defined conditions may well be drug abusers, he warned. He said most abusers are older than 25. Negrete said cocaine is the glamour drug of the 1990s and is creating major medical problems. Between 1984 and 1987 the Drug Abuse Warning Network in the United States, which comprises 1750 emergency rooms, reported a fivefold increase in the number of patients treated for cocaineCAN MED ASSOC J 1990; 143 ( 11)
1239
related illness. He thinks the situation is similar here. In door-todoor surveys, researchers have found that respondents show little reluctance in admitting cocaine use - in certain age groups as many as 10% of respondents said they had used cocaine in the past year. "Doctors are embarrassed to inquire about substance abuse", Negrete said. "They don't like questioning someone about a subject that carries a stigma. They are afraid, too, that they might find a condition requiring attention and many don't know what to do about it. Some physicians take the view that this is not their problem. It's a social issue, they claim, but often the doctor is the only person who can help." He said physicians readily inquire about patients' tobacco use and coffee consumption, but ask about alcohol less frequently and are reticent when it comes to drugs. He said this is especially true when they stereotype patients - they will ask a middle-aged woman about her tobacco use and perhaps question her about alcohol consumption, but they won't ask about cocaine. Regular cocaine use frequently leads to medical complications and sometimes these result in lifethreatening situations. Negrete discussed the case of a Montreal man in his late 40s who was taken to the Royal Victoria's emergency room after an acute asthma attack. The man had a cardiac arrest but was resuscitated. "Nobody asked him if he had been smoking cocaine", Negrete said, "and the man himself never mentioned it." The fact did come out later. Negrete said cocaine users often end up in a doctor's office or emergency room, but not to seek treatment for their addictions. Some will come because they have experienced cocainerelated arrhythmias and seek medical attention because they 1240
CAN MED ASSOC J 1990; 143 (I 1)
"Doctors are embarrassed to enquire about substance abuse." Dr. Juan Negrete fear they have a cardiac disorder. People who develop chest pains are likely to go scurrying for medical help, said Negrete, especially if the pain is severe, but those with less frightening symptoms may take longer to seek it. He said physicians should check for cocaine-related complications when faced with cases of chronic rhinitis, sinusitis, bronchospasms, wheezing, and even asthma attacks. Cocaine use can have an acute impact on the central nervous system, Negrete explained, and patients brought into the emergency room following a transient ischemic attack, a fissure, or an unexplained brain infarction, or who hemorrhaged when there appeared to be no precondition, should be questioned closely about drug habits. Transient attacks in the brain and spasms in the coronary arteries are both known to occur, particularly in
younger people, after large amounts of cocaine have been consumed in a short period. They may experience chest pain while using the drug or shortly afterwards, and Negrete said this brings them to the doctor's office. However, they do not mention that they have been using cocaine - they simply want assurance that there is nothing wrong with their hearts. "In the event of an intracranial hemorrhagic episode in a young person", Negrete observed, "the possibility of cocaine use must always be questioned, even in patients who have been diagnosed as having aneurysms. Ruptures are more likely to occur [if the patient has used cocaine]." Negrete also warned that cocaine use is a major childbirth issue because the drug interferes with normal pregnancy and affects both mother and baby - 'cocaine babies' may have a lower-thanaverage birth weight and may not grow normally. Many women who use cocaine enter hospital because they have not taken the proper care their pregnancies require, he said. When the warning signs are visible, doctors should inquire specifically about cocaine. "This applies, too, to an asthmatic crisis, particularly in someone who doesn't have asthma. You have to ask if the person has been smoking crack or has been freebasing, because this is not an infrequent complication of it. Sometimes, the patient doesn't put the two things together, although the more frequent the attacks, the more likely they are to see a relationship." Negrete said physicians who doubt the seriousness of the cocaine situation will find ample proof in any medical library. "If you check the files", he said, "you'll find that [the number ofl papers dealing with the medical complications of cocaine has increased more than tenfold between 1985 and 1989.".
Within the context of this national character, Low discussed the challenges facing academic health centres in the US. In education he identified the problems of large minority populations, and the need for greater numbers of nonmedical health professionals, particularly nurses. Another problem is the trend toward specialization even though there is a growing need for family physicians. Low said curricula must be modified to provide greater emphasis on prevention, gerontology and health promotion. Although US problems concerning research are similar to those faced in Canada, Americans face added constraints: legislated standards of scientific conduct, requirements to maintain drug-free workplaces, and prescribed procedures for dealing with suspected scientific fraud. Low thinks the area of greatest contrast between Canadian and American health science centres is service, mainly because our methods of paying for health care are so different. One result is that US medical school budgets now depend on revenue from practice plans for 30% of their revenue;
nursing and other schools are increasingly pressing for their own practice plans. Health care costs in the US have risen by 12% annually for the past 25 years, outpacing costof-living increases by 150% to 200%. This has caused an overall expenditure of 12% of GNP on health care, with businesses spending an average of 40% of profits buying health insurance. Still, more than 30 million Americans remain uninsured - the costs of uncompensated care provided by hospitals now amounts to more than $8 billion per year. Low concluded that "who we are, how we live and where we live are the principal determinants of health . . . more doctors and more hospitals do not equate with more health". Apart from the plenary sessions, the 500 delegates attended numerous small-group sessions, each with its own agenda. The quality of the presentations, the enthusiastic participation of the delegates, and the general amity among the various groups gave a clear message that medical education in Canada is evolving with vigour and enthusiasm. m
Cocaine users may not fit MDs' stereotype, FPs warned Bill Trent
P hysicians must put aside embarrassment and check for evidence of cocaine abuse in patients presenting with certain common medical problems, a psychiatrist urged more than 300 Canadian and American physicians attending a refresher course for family physicians in Montreal. Bill Trent is a freelance writer living in Lanark, Ont.
And, warned Dr. Juan Negrete, they must be wary of stereotyping patients. The professor of psychiatry at McGill University and director of the Montreal General Hospital's Alcohol and Drug Dependence Service told participants at the 40th annual refresher course sponsored by the Postgraduate Board of Montreal's Royal Victoria Hospital that they must not assume cocaine users are dishevelled young men aged 18 or 20. Those demure, well-dressed
women in their 50s who arrive with assorted, ill-defined conditions may well be drug abusers, he warned. He said most abusers are older than 25. Negrete said cocaine is the glamour drug of the 1990s and is creating major medical problems. Between 1984 and 1987 the Drug Abuse Warning Network in the United States, which comprises 1750 emergency rooms, reported a fivefold increase in the number of patients treated for cocaineCAN MED ASSOC J 1990; 143 ( 11)
1239
related illness. He thinks the situation is similar here. In door-todoor surveys, researchers have found that respondents show little reluctance in admitting cocaine use - in certain age groups as many as 10% of respondents said they had used cocaine in the past year. "Doctors are embarrassed to inquire about substance abuse", Negrete said. "They don't like questioning someone about a subject that carries a stigma. They are afraid, too, that they might find a condition requiring attention and many don't know what to do about it. Some physicians take the view that this is not their problem. It's a social issue, they claim, but often the doctor is the only person who can help." He said physicians readily inquire about patients' tobacco use and coffee consumption, but ask about alcohol less frequently and are reticent when it comes to drugs. He said this is especially true when they stereotype patients - they will ask a middle-aged woman about her tobacco use and perhaps question her about alcohol consumption, but they won't ask about cocaine. Regular cocaine use frequently leads to medical complications and sometimes these result in lifethreatening situations. Negrete discussed the case of a Montreal man in his late 40s who was taken to the Royal Victoria's emergency room after an acute asthma attack. The man had a cardiac arrest but was resuscitated. "Nobody asked him if he had been smoking cocaine", Negrete said, "and the man himself never mentioned it." The fact did come out later. Negrete said cocaine users often end up in a doctor's office or emergency room, but not to seek treatment for their addictions. Some will come because they have experienced cocainerelated arrhythmias and seek medical attention because they 1240
CAN MED ASSOC J 1990; 143 (I 1)
"Doctors are embarrassed to enquire about substance abuse." Dr. Juan Negrete fear they have a cardiac disorder. People who develop chest pains are likely to go scurrying for medical help, said Negrete, especially if the pain is severe, but those with less frightening symptoms may take longer to seek it. He said physicians should check for cocaine-related complications when faced with cases of chronic rhinitis, sinusitis, bronchospasms, wheezing, and even asthma attacks. Cocaine use can have an acute impact on the central nervous system, Negrete explained, and patients brought into the emergency room following a transient ischemic attack, a fissure, or an unexplained brain infarction, or who hemorrhaged when there appeared to be no precondition, should be questioned closely about drug habits. Transient attacks in the brain and spasms in the coronary arteries are both known to occur, particularly in
younger people, after large amounts of cocaine have been consumed in a short period. They may experience chest pain while using the drug or shortly afterwards, and Negrete said this brings them to the doctor's office. However, they do not mention that they have been using cocaine - they simply want assurance that there is nothing wrong with their hearts. "In the event of an intracranial hemorrhagic episode in a young person", Negrete observed, "the possibility of cocaine use must always be questioned, even in patients who have been diagnosed as having aneurysms. Ruptures are more likely to occur [if the patient has used cocaine]." Negrete also warned that cocaine use is a major childbirth issue because the drug interferes with normal pregnancy and affects both mother and baby - 'cocaine babies' may have a lower-thanaverage birth weight and may not grow normally. Many women who use cocaine enter hospital because they have not taken the proper care their pregnancies require, he said. When the warning signs are visible, doctors should inquire specifically about cocaine. "This applies, too, to an asthmatic crisis, particularly in someone who doesn't have asthma. You have to ask if the person has been smoking crack or has been freebasing, because this is not an infrequent complication of it. Sometimes, the patient doesn't put the two things together, although the more frequent the attacks, the more likely they are to see a relationship." Negrete said physicians who doubt the seriousness of the cocaine situation will find ample proof in any medical library. "If you check the files", he said, "you'll find that [the number ofl papers dealing with the medical complications of cocaine has increased more than tenfold between 1985 and 1989.".
