oured by enthusiasm for a venture. The decline in function of many of the patients in the two groups over the study period indicates that we overestimated the potential for improvement in many cases. Certainly, as a result of the study we have become far more selective in deciding which patients might improve. A third issue is the timing of the study. The geriatric day hospital had been operating for a relatively short time. Substantial development has taken place since then. The therapeutic intervention followed the generally accepted pattern of geriatric care: multidisciplinary assessment, sharing of information in a team conference, formulating a management plan and reviewing progress. The intervention may have been less than optimally effective because initial recruitment was slower than expected, and at times there were very few patients assigned to the experimental group. The decision to start the study before the facility was operating at full capacity and had become part of conventional care was made on the grounds of feasibility. A fourth issue is the care received by the control group. The intensity of the geriatric intervention in this group should not be overestimated. After the initial consultation only 41 of the control patients made outpatient visits to one of the study geriatricians, for a total of only 100 such visits. The intervention in the outpatient clinic was far less intensive than that available in the day hospital. The control subjects had only five admissions to the geriatric assessment unit. Although we agree that the care given to the control group would not be considered conventional in all communities, it is in ours. Furthermore, the comparison strikes us as appropriate. If geriatricians are available the options would be to allow them to see patients in conventional settings or to provide them with a 616
CAN MED ASSOC J 1991; 145 (6)
geriatric day hospital. Dr. Beattie would have us compare (if we interpret her apple and orange metaphor correctly) geriatricians with other health care workers. This may be a relevant question if a community is looking to recruit geriatricians versus other health care workers. Our question, which addresses a choice of what facilities to establish if geriatricians are already available, is at least as relevant. A fifth issue concerns the outpatient services. The use of home care services was very similar in the two groups, and the small additional use in the control group likely occurred by chance (p = 0. 14). A sixth issue is the imbalance in the incidence of depression in the treatment and control groups and the early trends in the data. An analysis that took into account the proportion of depressed patients did not alter the results. The small variations in the rate of deterioration between the two groups were likely due to chance. With regard to the language issue raised by Dr. Watson all those tested could understand the questionnaire items, which were in English. It is true that our results may not be generalizable to those who cannot comprehend English. The points raised in the letters are in general well taken. The remarks should, however, be seen in context. Whether the results would have differed had the population been different or the day hospital further along in its evolution is speculative. Moreover, our results do not stand alone; they are consistent with those of other randomized trials of day hospitals. When looked at together such results at the very least place the burden of proof regarding the effectiveness of day hospitals on their advocates. As Watson points out, a trial with a different population attending a different day hospital could yield different re-
sults. We would welcome a further trial to find out. D. Joan Eagle, MSc Associate professor School of Nursing Gordon H. Guyatt, MD Associate professor Departments of Clinical Epidemiology and Biostatistics and of Medicine Christopher Patterson, MD Associate professor and head Division of Geriatric Medicine Irene Turpie, MB Associate professor Department of Medicine McMaster University Hamilton, Ont.
Informed consent to HIV antibody testing I express my support for Dr. James E. Parker's letter of June 1 (Can Med Assoc J 1991; 144: 1388-1389). We, as a medical profession, have been blackmailed by a largely homosexual lobby and are afraid of being labelled homophobic. As a result, we have allowed our time-honoured scientific principles to be warped. We have stopped being scientists and have done things because of what special interest groups have felt to be correct. We need to stick to the scientific method of approaching disease and be prepared to take the heat from whichever group disagrees with us. The lives of our patients and the welfare of society in general are much too important to do otherwise. Willi D. Gutowski, MD 101-9181 Main St. Chilliwack, BC
Dr. Eike-Henner Kluge is still using a specious argument to support the premise that the Supreme Court of Canada has ruled that a physician must obtain informed consent for HIV antibody testing (Can Med Assoc J 1991; 144: 403-
404). In the case of R. v. Dyvment' LE 15 SEPTEMBRE 1991
CAN MED ASSOC J 1991; 145 (6)
geriatric day hospital. Dr. Beattie would have us compare (if we interpret her apple and orange metaphor correctly) geriatricians with other health care workers. This may be a relevant question if a community is looking to recruit geriatricians versus other health care workers. Our question, which addresses a choice of what facilities to establish if geriatricians are already available, is at least as relevant. A fifth issue concerns the outpatient services. The use of home care services was very similar in the two groups, and the small additional use in the control group likely occurred by chance (p = 0. 14). A sixth issue is the imbalance in the incidence of depression in the treatment and control groups and the early trends in the data. An analysis that took into account the proportion of depressed patients did not alter the results. The small variations in the rate of deterioration between the two groups were likely due to chance. With regard to the language issue raised by Dr. Watson all those tested could understand the questionnaire items, which were in English. It is true that our results may not be generalizable to those who cannot comprehend English. The points raised in the letters are in general well taken. The remarks should, however, be seen in context. Whether the results would have differed had the population been different or the day hospital further along in its evolution is speculative. Moreover, our results do not stand alone; they are consistent with those of other randomized trials of day hospitals. When looked at together such results at the very least place the burden of proof regarding the effectiveness of day hospitals on their advocates. As Watson points out, a trial with a different population attending a different day hospital could yield different re-
sults. We would welcome a further trial to find out. D. Joan Eagle, MSc Associate professor School of Nursing Gordon H. Guyatt, MD Associate professor Departments of Clinical Epidemiology and Biostatistics and of Medicine Christopher Patterson, MD Associate professor and head Division of Geriatric Medicine Irene Turpie, MB Associate professor Department of Medicine McMaster University Hamilton, Ont.
Informed consent to HIV antibody testing I express my support for Dr. James E. Parker's letter of June 1 (Can Med Assoc J 1991; 144: 1388-1389). We, as a medical profession, have been blackmailed by a largely homosexual lobby and are afraid of being labelled homophobic. As a result, we have allowed our time-honoured scientific principles to be warped. We have stopped being scientists and have done things because of what special interest groups have felt to be correct. We need to stick to the scientific method of approaching disease and be prepared to take the heat from whichever group disagrees with us. The lives of our patients and the welfare of society in general are much too important to do otherwise. Willi D. Gutowski, MD 101-9181 Main St. Chilliwack, BC
Dr. Eike-Henner Kluge is still using a specious argument to support the premise that the Supreme Court of Canada has ruled that a physician must obtain informed consent for HIV antibody testing (Can Med Assoc J 1991; 144: 403-
404). In the case of R. v. Dyvment' LE 15 SEPTEMBRE 1991
