family physician, who usually tries some antihistamine preparations for a few weeks. When symptoms continue to recur a consultation with a dermatologist is sought. By the time the patient gets to see a consultant that magic 6-week period has elapsed, and the patient is labelled as having chronic urticaria or angioedema. Because of the presumption that most cases of chronic urticaria are idiopathic a consultant may try a different set of medications to provide symptomatic relief. I believe that if symptoms reappear after a couple of episodes physicians should make an effort to identify and remove the causal agent(s) instead of continuing to prescribe medication. In this way some patients may escape the situation of being labelled unnecessarily. I agree that extensive investigations such as routine biopsy, culture, serologic testing and radiography are usually not very rewarding. However, in my experience allergy skin tests are extremely rewarding, not useless, as Dolovich proclaims. I was surprised to note that he cannot think of a single case of chronic urticaria or angioedema in which investigation of the cause had been useful. I have observed that in more than half of such cases a cause can be delineated through testing with a wide variety of food and environmental allergens. The difference in our experience may be due to the different battery of allergens that we use when investigating such cases. On the basis of my personal observations I would urge all physicians to put allergy at the top of the differential diagnosis when dealing with urticaria and angioedema. Food and environmental allergens as a cause of these conditions should be ruled out before extensive and expensive investigations are undertaken. We may thus be able to provide dramatic relief to the patient when allergy is 1304
CAN MED ASSOC J 1992; 147 (9)
the cause instead of offering a suscitation, trauma care, toxicology, prehospital care, disaster planlabel and a handful of pills. ning and the administration and Jagat N. Singh, MD management of emergency departWinnipeg, Man. ments. The focus of residency training in family medicine is on comfamily medicine munity-based Is emergency medicine care, with usuand hospital-ward a specialty? ally no more than 2 months' experience in an emergency departEv mergency medicine is a ment in the 2-year training prospecialty, and it has been gram. This is an excellent baseline recognized by numerous for further training in emergency medical jurisdictions throughout medicine; however, in itself it is the Western world. not adequate or appropriate for a The Quebec controversy on physician intending to devote a the status of emergency medicine large part of his or her practice to discussed in "Is emergency medi- emergency medicine. The days of cine a specialty? Quebec MDs dis- learning emergency medicine by agree over controversial issue" trial and error while working (Can Med Assoc J 1992; 146: alone in the emergency depart1632-1633, 1635-1636), by ment in the middle of the night Michel Martin, has nothing to do have surely passed. with the specialty nature of the The results of Quebec's faildiscipline and everything to do ure to recognize emergency mediwith medical politics and "turf' cine as a specialty are predictable. protection by the Federation des Emergency specialists are no difmedecins omnipraticiens du Que- ferent than other specialists and bec. generally choose to practise where Emergency medicine is a pri- they are recognized. The CMA mary-care specialty historically Physician Resource Databank on linked to general medical practice, Dec. 31, 1986, indicated that of and its development as an in- all physicians practising emergendependent discipline has often cy medicine predominantly or exbeen opposed by the existing clusively only 17% in Quebec, as family-medicine establishment. compared with 41% in the rest of The reason for this opposition is Canada, had postgraduate certifiunclear. Emergency medicine and cation in emergency medicine family medicine are both broadly from either the Royal College of based and devoted to the care of Physicians and Surgeons of Canapatients of all ages and with all da or the College of Family Phystypes of health problems. Howev- icians of Canada. This discrepaner, other than in breadth of scope cy exists even though, ironically, the focuses of the two disciplines the oldest and one of the largest differ substantially: training programs in emergency medicine in Canada is located in Emergency medicine is a specialty Quebec, at McGill University. based on knowledge and skills in- the diagnosis and management of the Quebec already has specialists in acute and emergent aspects of illness emergency medicine working in and injury affecting patients of all age its hospital emergency departgroups with diverse medical, surgical, ments. Absurdly, this specialization is only recognized outside of and behavioral disorders.' the specialists' home province. Quebec will recognize emerIn addition, emergency-medicine medicine as a specialty. The gency physicians have developed special is not if but when. issue reexpertise in cardiopulmonary LE lr NOVEMBRE 1992
The longer the medical bureaucrats delay, the more medical misadventures will occur in Quebec emergency departments and the louder will be the outcry from coroner's inquests, the public and physicians more concerned with emergency care than with medical politics.
for age and sex has diminished by 25% in the past 15 years. In so far as can be determined this is the greatest decrease in the shortest period in Canadian recorded his-
tory. This decrease in the annual death rate is certainly not due to improved economic conditions or to an improved environment, beGarth Dickinson, MD, FRCPC cause the economy and the enviCairo, Egypt ronment have not improved in the past 15 years. It is due to Reference health care, both curative and pre1. Royal College of Physicians and Sur- ventive. By this standard we have geons of Canada: Report of the Task achieved the most dramatic imForce on Emergency Medicine, 1988, provement in the quality of health RCPSC, Ottawa, 1988: 21 care in our history. Similar approaches can be taken to measure the prevention of permanent disability and of Achieving quality of care disease as well as the enhancement of well-being. W rith regard to the article "Quality of care: Mark A. Baltzan, MD, FRCPC, FACP 1. What is quality and Saskatoon, Sask. how can it be measured?" (Can Med Assoc J 1992; 146: 2153- The article by the Health Services 2158), by the Health Services Re- Research Group is timely and of search Group, Sunnybrook Health great interest, not only to CanScience Centre, I believe that to adians but also to Americans. achieve health care of high quality Health care in the United States is the health care system must meet in a double crisis: it is expensive, its objectives. The degree of suc- and it is not as good as it should cess it has in meeting its objec- be. Cost is easily measurable, but tives is a measure of the degree of quality is more difficult to assess. An evaluation of the quality quality that it provides. From the public's point of of health care would be simple if view the most important service it could be reduced to an analysis the health care professions offer is of the end results: those practithe prevention of premature tioners who had achieved the best death; the second is the preven- clinical outcomes would be astion of permanent disability; the sumed to have provided highthird is the prevention of disease; quality care. However, this would the fourth is the promotion of unfairly leave out of consideration well-being, not simply the elimi- other factors in the process of nation of disease; the fifth is the care. For example, physicians relief of suffering when nothing treating severely ill patients, even else can be done; and the sixth is with superb care and dedication, the transmission of knowledge. may not look as good as those The prevention of premature treating patients at lower risk if death is easily measured. Accord- the end results alone were being ing to the Bureau of Chronic Dis- compared. ease Epidemiology, Laboratory One of the references cited by Centre for Disease Control, Otta- the Health Services Research wa (personal communication, Group concerned the automotive 1992), the death rate standardized industry.' At first glance this in-
NOVEMBER 1, 1992
dustry may not seem to have much in common with the health care system, but both are measured in terms of quality. W. Edwards Deming, a champion of industrial quality, proposed a solution to the problems of quality and productivity in the US automotive industry. Detroit was not ready for him, and he took his theory to Japan. The Japanese accepted Deming and applied his principles, which simultaneously improved the automotive industry and transformed Japan into a world economic giant. Deming's proposed combination of improved quality and productivity had been considered incompatible in the United States. Americans must learn, too, how to improve the delivery of health care. The problem in medicine, however, is that we do not practise enough prevention, and there is no incentive to deliver better, less expensive health care. We know how to do it and what's required. We must show people that they can receive the excellent, affordable health care they deserve. Stefan Seimchyshyn, MD, FRCSC, FACOG Summit, NJ
Reference 1. Deming WE: Out of the Crisis, MITCAES, Cambridge, Mass, 1986: 23-24
The Health Services Research Group has attempted to define quality of medical care and pointed to the increasing importance of quality assurance. Nevertheless, many physicians remain antipathetic to the concept of quality assurance, partly because they view it as politically or economically motivated' and partly because there is an aura of mystique and obscurantism surrounding quality-assurance jargon. Yet for clinicians, striving for quality of care is the essence of the therapeutic enCAN MED ASSOC J 1992; 147 (9)
1305
CAN MED ASSOC J 1992; 147 (9)
the cause instead of offering a suscitation, trauma care, toxicology, prehospital care, disaster planlabel and a handful of pills. ning and the administration and Jagat N. Singh, MD management of emergency departWinnipeg, Man. ments. The focus of residency training in family medicine is on comfamily medicine munity-based Is emergency medicine care, with usuand hospital-ward a specialty? ally no more than 2 months' experience in an emergency departEv mergency medicine is a ment in the 2-year training prospecialty, and it has been gram. This is an excellent baseline recognized by numerous for further training in emergency medical jurisdictions throughout medicine; however, in itself it is the Western world. not adequate or appropriate for a The Quebec controversy on physician intending to devote a the status of emergency medicine large part of his or her practice to discussed in "Is emergency medi- emergency medicine. The days of cine a specialty? Quebec MDs dis- learning emergency medicine by agree over controversial issue" trial and error while working (Can Med Assoc J 1992; 146: alone in the emergency depart1632-1633, 1635-1636), by ment in the middle of the night Michel Martin, has nothing to do have surely passed. with the specialty nature of the The results of Quebec's faildiscipline and everything to do ure to recognize emergency mediwith medical politics and "turf' cine as a specialty are predictable. protection by the Federation des Emergency specialists are no difmedecins omnipraticiens du Que- ferent than other specialists and bec. generally choose to practise where Emergency medicine is a pri- they are recognized. The CMA mary-care specialty historically Physician Resource Databank on linked to general medical practice, Dec. 31, 1986, indicated that of and its development as an in- all physicians practising emergendependent discipline has often cy medicine predominantly or exbeen opposed by the existing clusively only 17% in Quebec, as family-medicine establishment. compared with 41% in the rest of The reason for this opposition is Canada, had postgraduate certifiunclear. Emergency medicine and cation in emergency medicine family medicine are both broadly from either the Royal College of based and devoted to the care of Physicians and Surgeons of Canapatients of all ages and with all da or the College of Family Phystypes of health problems. Howev- icians of Canada. This discrepaner, other than in breadth of scope cy exists even though, ironically, the focuses of the two disciplines the oldest and one of the largest differ substantially: training programs in emergency medicine in Canada is located in Emergency medicine is a specialty Quebec, at McGill University. based on knowledge and skills in- the diagnosis and management of the Quebec already has specialists in acute and emergent aspects of illness emergency medicine working in and injury affecting patients of all age its hospital emergency departgroups with diverse medical, surgical, ments. Absurdly, this specialization is only recognized outside of and behavioral disorders.' the specialists' home province. Quebec will recognize emerIn addition, emergency-medicine medicine as a specialty. The gency physicians have developed special is not if but when. issue reexpertise in cardiopulmonary LE lr NOVEMBRE 1992
The longer the medical bureaucrats delay, the more medical misadventures will occur in Quebec emergency departments and the louder will be the outcry from coroner's inquests, the public and physicians more concerned with emergency care than with medical politics.
for age and sex has diminished by 25% in the past 15 years. In so far as can be determined this is the greatest decrease in the shortest period in Canadian recorded his-
tory. This decrease in the annual death rate is certainly not due to improved economic conditions or to an improved environment, beGarth Dickinson, MD, FRCPC cause the economy and the enviCairo, Egypt ronment have not improved in the past 15 years. It is due to Reference health care, both curative and pre1. Royal College of Physicians and Sur- ventive. By this standard we have geons of Canada: Report of the Task achieved the most dramatic imForce on Emergency Medicine, 1988, provement in the quality of health RCPSC, Ottawa, 1988: 21 care in our history. Similar approaches can be taken to measure the prevention of permanent disability and of Achieving quality of care disease as well as the enhancement of well-being. W rith regard to the article "Quality of care: Mark A. Baltzan, MD, FRCPC, FACP 1. What is quality and Saskatoon, Sask. how can it be measured?" (Can Med Assoc J 1992; 146: 2153- The article by the Health Services 2158), by the Health Services Re- Research Group is timely and of search Group, Sunnybrook Health great interest, not only to CanScience Centre, I believe that to adians but also to Americans. achieve health care of high quality Health care in the United States is the health care system must meet in a double crisis: it is expensive, its objectives. The degree of suc- and it is not as good as it should cess it has in meeting its objec- be. Cost is easily measurable, but tives is a measure of the degree of quality is more difficult to assess. An evaluation of the quality quality that it provides. From the public's point of of health care would be simple if view the most important service it could be reduced to an analysis the health care professions offer is of the end results: those practithe prevention of premature tioners who had achieved the best death; the second is the preven- clinical outcomes would be astion of permanent disability; the sumed to have provided highthird is the prevention of disease; quality care. However, this would the fourth is the promotion of unfairly leave out of consideration well-being, not simply the elimi- other factors in the process of nation of disease; the fifth is the care. For example, physicians relief of suffering when nothing treating severely ill patients, even else can be done; and the sixth is with superb care and dedication, the transmission of knowledge. may not look as good as those The prevention of premature treating patients at lower risk if death is easily measured. Accord- the end results alone were being ing to the Bureau of Chronic Dis- compared. ease Epidemiology, Laboratory One of the references cited by Centre for Disease Control, Otta- the Health Services Research wa (personal communication, Group concerned the automotive 1992), the death rate standardized industry.' At first glance this in-
NOVEMBER 1, 1992
dustry may not seem to have much in common with the health care system, but both are measured in terms of quality. W. Edwards Deming, a champion of industrial quality, proposed a solution to the problems of quality and productivity in the US automotive industry. Detroit was not ready for him, and he took his theory to Japan. The Japanese accepted Deming and applied his principles, which simultaneously improved the automotive industry and transformed Japan into a world economic giant. Deming's proposed combination of improved quality and productivity had been considered incompatible in the United States. Americans must learn, too, how to improve the delivery of health care. The problem in medicine, however, is that we do not practise enough prevention, and there is no incentive to deliver better, less expensive health care. We know how to do it and what's required. We must show people that they can receive the excellent, affordable health care they deserve. Stefan Seimchyshyn, MD, FRCSC, FACOG Summit, NJ
Reference 1. Deming WE: Out of the Crisis, MITCAES, Cambridge, Mass, 1986: 23-24
The Health Services Research Group has attempted to define quality of medical care and pointed to the increasing importance of quality assurance. Nevertheless, many physicians remain antipathetic to the concept of quality assurance, partly because they view it as politically or economically motivated' and partly because there is an aura of mystique and obscurantism surrounding quality-assurance jargon. Yet for clinicians, striving for quality of care is the essence of the therapeutic enCAN MED ASSOC J 1992; 147 (9)
1305
