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Oxford Textbook of Clinical Pharmacology and Drug Therapy

Article  in  Journal of the Royal Society of Medicine · January 1993

DOI: 10.1258/jrsm.95.9.472 · Source: PubMed Central

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 JOURNAL OF THE ROYAL
Book of the month
The Resourceful
Patient
The most obvious changes in medicine over the past half-
century have been in technology and treatments: new
drugs and surgical and laboratory techniques have
transformed the way we practise medicine. Yet the
heart of medical practice remains, as it has been for
thousands of years, the relationship between the physician
and the person ‘who is or who believes himself to be
ill’. But this too has changed. In the 1950s, many
medical practitioners believed their professional secrets
were none of the public’s business. Medications were
labelled cryptically ‘The Mixture’ or ‘The Tablets’, and
the dispensing of coloured water as a tonic or the
injection of sterile water placebos was acceptable
practice. Patients were advised to follow ‘doctor’s
orders’, and a close interest in the details of their
conditions was considered unhealthy. Even 25 years ago,
to tell a patient he or she had a fatal illness was thought
dangerously radical by some, and hospital records were
marked ‘Confidential—not to be handled by the patient’.
Nowadays I am bothered when patients are unable to tell
me what tablets they are taking; how could they give an
adequate history to an unknown doctor in an emergency?
Patients who say ‘I take the little white ones—I don’t
know what they are for doctor’, who would once have
been considered well behaved, are now irritating. Like
most of my colleagues I tell my patients as much as I can
about their condition (subject to the limitations of my
knowledge, the medical evidence, their understanding of
their bodies and the time available, which taken together
often means not much).
As Muir Gray points out in The Resourceful Patient1, this
change is part of a wider social evolution as a consumerist
egalitarian society replaces a hierarchical bureaucratic one.
Professions lose power, the ‘lower orders’ are more
sceptical about authority figures, postmodernism and New
Age thinkers question medicine’s scientific foundations, and
in the past few years a new force has appeared, whose
impact we are only just beginning to suspect—the Internet.
Just as computers have made possible ‘evidence-based
medicine’ by allowing rapid and systematic access to
research evidence, so the Internet makes medical
information previously only found in medical libraries or
expensive books potentially available to all who wish to
access it. Electronic patient-held medical records will be
the norm within a few years. Muir Gray believes these
factors will create the ‘resourceful patient’, a person as
SOCIETY OF MEDICINE Volume 95 September 2002
well informed as the doctor about treatment and
BOOKS
prognoses.
How will this affect the doctor–patient relationship?
In many instances probably not a lot. Books on car
maintenance have been in the public library all my life
but I have never chosen to read them; I rely on the
competence and diligence of my garage. Many people
will I suspect, for good or ill, take the same view of
their bodies. For some patients, however, access to this
information will change the doctor–patient relationship
considerably—as it were from that between primary-
school teacher and pupil to that between PhD student
and supervisor. The doctor will not be a purveyor of
information but a sounding-board for ideas, testing the
logic and pointing out issues that the primary
researcher—the patient—has overlooked. Muir Gray
paints a rather positive vision of this Enlightenment
relationship, but there are potential difficulties. Not all
the information available to patients is sound; there are
lots of people with financial interests only too eager to
persuade patients to buy or get their doctors to prescribe
drugs of dubious benefit. There are some very strange
ideas around about the body and how it works which
give rise to what a colleague refers to as ‘lunatic
medicine’. Part of the new role of doctors will be to
help people sort out this tangle of truth, half-truth and
falsehood. This will require new skills and a new attitude
from many doctors.
Communicating risk, probability and uncertainty is not
something we are good at, and we will need to learn it
well and quickly. Most of us pick up what we know
about explaining illness by example or trial and error.
Communication skills stand in dire need of a sound
evidence base. As Muir Gray points out, we will need
much better and more rapid access to reliable information
than in the past, which will require new ways of
working.
Whilst the rational model of the adult patient and her
physician supervisor is attractive, not all doctor–patient
encounters are so rational. Muir Gray points out that
doctors act also as healer, witchdoctor, drug and St Peter—
approving access to illness. This does not apply only to the
ignorant or foolish: we all need parent–child as well as
adult–adult relationships at times. I vividly remember a
senior academic sociologist and patient of mine coming in
with ’flu and saying with striking insight ‘I need permission
to adopt the sick role’.
As with many innovations, these changes threaten to
advantage the rich and educated at the expense of the
poor and ignorant, who remain marginalized. This is not
because the latter group are necessarily stupid or
uninterested in what is going on with their bodies: having
worked with culturally and socially varied populations I 469
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
can vouch that this is not the case. But not all will have
ready access to the Internet and the time or skills to use it
to their advantage. Encounters with resourceful patients
take time, and this may well be at the expense of the less
resourceful. Muir Gray has written a thought-provoking
but in some ways unsatisfying book. It surveys the area
and raises many important questions, but does not
organise the issues or suggest more than fragmentary
answers. It is not clear how he thinks the problems raised
here (and many others) should be addressed. It is a
Pain Management—a Practical Guide for
Clinicians
6th edition. Editor: R S Weiner
1168 pp. Price £191 ISBN 0-84930926-3
Boca Raton: CRC Press, 2002
Recently I was asked to see a patient with a very difficult
pain problem related to reflex sympathetic dystrophy (now
known as complex regional pain syndrome). I reached for
Pain Management: A Practical Guide for Physicians to find out
what to do. The relevant chapter is detailed, evidence-based
and well referenced. Although I cannot claim to have cured
the patient of her pain as a consequence, the text (which is
written by members of the American Academy of Pain
Management) gave me all the up-to-date information that I
needed.
I have since delved into other sections of the book that
are of particular interest to me. Our unit is one of several
involved in a clinical trial of the use of cannabis for the
control of cancer-related pain. I was therefore keen to read
the chapter on the role of cannabis and cannabinoids in pain
management. In his introduction, the author proposes to
examine the use of cannabinoids ‘historically, scientifically
and anecdotally in relation to a variety of pain syndromes’.
He obviously believes strongly in the benefits of these
compounds, but as yet there are few hard clinical data to
support their use as analgesics. Most of the evidence is in
the form of case studies or anecdotal reports—hence the
strong emphasis on history and anecdote.
The management of neuropathic pain is complex and is
often frustrating to patient and physician alike. The chapter
on neuropathic pain and its management is excellent. It
gives an unbiased, evidence-based, well-referenced over-
view of the current situation. It is obviously written by
someone who has much clinical experience in the area and
not by a laboratory-based academic reporting on what
470 should happen on the basis of rat-tail flicks. The author
Volume 95 September 2002
beginning not an end; the issues it raises will be with us
for a long time hence.
Peter D Toon
Department of Primary Care and Population Sciences, University College
London, UK
E-mail: petertoon@aol.com
REFERENCE
1 Gray JAM. The Resourceful patient. Oxford: eRositta Press, 2002 [154 pp;
ISBN 1-904202-00-4 (p/b); £14.50]
stresses that it is important to have realistic expectations
when treating patients with chronic nerve damage.
Complete pain relief is unlikely. Improving function,
providing a degree of comfort and treating associated
problems are more appropriate goals. ‘The difficulty in
treating this pain probably stems from our relatively poor
understanding of the mechanisms and the limited efficacy of
currently available analgesics’. Non-pharmacological meth-
ods may be as effective as pharmacological approaches.
Patient support is paramount. There is relatively little on
the use of NMDA antagonists in this chapter. This is
appropriate. Despite animal studies suggesting similarities
between opioid intolerance and neuropathic pain, there is
little to support their use clinically and considerable
concern about side-effects.
Within the chapter on drug misuse and detoxification
there is an interesting section on iatrogenic dependence. As
more and more opioids are becoming licensed for use in
benign pain, the author points to an unfortunate paradox.
Whereas patients with chronic non-malignant pain are
increasingly being prescribed opioids and other depen-
dence-producing medications, pain in the terminally ill is
still commonly under-treated. A frequent cry by authors in
this book is for more emphasis and teaching on proper pain
management techniques as opposed to treatment of all pain
as acute pain. This chapter lacks a section on how to treat
pain in drug abusers, a difficult and not uncommon
dilemma, especially in oncology. The multitude of nerve
blocks that have been used in the management of common
pain syndromes are all very well described. I would have
welcomed more diagrams to support the text; also, there is
no discussion as to the efficacy of each technique in relation
to standard analgesia.
This book has a very wide scope, embracing such
techniques as Koryo hand therapy, Tai Chi Chuan, magnetic
stimulation and Qigong. The emphasis throughout is on
pain management rather than drug treatment, which is
laudable. There are lengthy discussions on how to set up
 JOURNAL OF THE ROYAL
and support a pain clinic and the necessity for multi-
professional input. As one of the authors points out, ‘the
best pharmacotherapeutic approach to pain management is
no drug therapy at all’. This might explain why the section
on drug management is so short. With the recent explosion
of new and alternative opioids onto the market, a somewhat
deeper discussion of opioid pharmacology might have been
warranted.
In summary, Weiner’s text is state-of-the-art on all
aspects of pain and its multidisciplinary management. It
rises to the fact that pain (especially chronic benign pain) is
‘the most common medical complaint of civilised man’.
Unusually for a tome this large, it makes for quite a good
read. It even tells you how to fix a headache.
Janet Hardy
Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK
Dr Foster: Good Hospital Guide
xvii+510 pp Price £14.99 ISBN 0-09-188377-6 (p/b)
London: Vermillion, 2002
If a physician had been asked in 1992 to predict how
healthcare in the UK would change in the following decade
his or her thoughts would have most likely turned to the
impact of new pharmaceuticals and medical technology.
Some might have identified the potential of advances in
genetics. Few, I suspect, would have predicted the
enormous change in the public scrutiny applied to the
practice of healthcare.
Of course healthcare is not unique in this respect. The
whole country has been subjected to a vast natural
experiment in which successive governments have sought
to measure everything that moves or, as often in the case of
railways, does not move. We are bombarded with data on
the performance of schools, public utilities, and police
forces, though not yet of government ministers.
Information-gathering on this scale has few precedents,
except possibly for the activities of the State Statistical
Committee in the Soviet Union, and it is noteworthy that
our European neighbours have not gone down this road.
The challenges identified by Soviet state planners are
surprisingly relevant to our present situation in which
patients are ‘lost’ from waiting lists, children of borderline
ability are prevented from taking exams, and the scheduled
journey times of trains are extended to avoid the risk that
they will ever be ‘late’. They too identified concerns about
falsification of data and a focus on achieving official targets
by any means, regardless of whether they actually did any
good.
For these reasons I approached the Good Hospital Guide
with some reservations. If I want basic information on
SOCIETY OF MEDICINE Volume 95 September 2002
choosing a hospital I can look at the published star
ratings, telling me something about waiting times and
similar measures (conveniently ignoring the fact that
they will be out of date by the time they are
published). If I have sufficient time on my hands I can
read some of the growing number of reports from the
Commission for Health Improvement. Yet neither is
particularly helpful for a prospective patient. Does Dr
Foster do any better?
On balance the answer is yes, but what I found most
helpful was the text, rather than the tables. The first 70
pages are used to explain the patient pathway through the
healthcare system. In the next 150 pages it examines
different aspects of hospital care, such as heart disease,
cancer care and care of older people. Each is illustrated by
brief case studies telling the stories of ordinary people. The
content is accurate and accessible. Unlike some politicians,
it recognises that the UK already has extensive private
healthcare provision, providing a useful guide to what it
offers and how to access it.
It is, however, the information on individual hospitals
that fills most of the book. Each contains a brief narrative
description and a table of performance data. I immediately
looked for the account of my local hospital. The description
was upbeat and certainly did not capture my personal
experiences of being in a surgical ward without a
functioning bath or shower, or in a emergency department
cubicle with congealed blood on the walls. Turning to the
data for further enlightenment, I admired Dr Foster’s ability
to obtain the information that is presented, when I find this
so difficult as a researcher, but was puzzled as to what it
meant. Some hospitals have more doctors and nurses per
bed than others. Of course they do; with the vastly
expanded range of treatment modalities, such as ambulatory
surgery, rehabilitation and high and low dependency units,
each involving objects we call beds, but with very different
uses, this is what one would expect. The estimation of
mortality is similarly problematic. Although the authors
have been as rigorous as they could in adjusting for co-
morbidity, our own analyses indicated that secondary
diagnosis coding in England was so variable as to be
meaningless.
I do feel that this book will help patients (and, I suspect,
many health professionals) to find a way through an
increasingly complex healthcare system. It may also
stimulate some hospitals to reassess what they offer in
those areas where they are judged, such as provision of
24-hour CT scanning. However, I doubt if it will fix the
shower in my local hospital.
Martin McKee
London School of Hygiene and Tropical Medicine,
London WC1E 7HT, UK 471
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
Oxford Textbook of Clinical Pharmacology
and Drug Therapy
D G Grahame-Smith, J K Aronson
656 pp Price £60 (h/b); £29.50 (p/b) ISBN 0-19-850944-8;
0-19-263234-5. Oxford: Oxford University Press, 2002
In the medical press there has been much debate about the
lack of clinical pharmacology and therapeutics teaching in
medical schools—with a suggestion that this might be a
factor in the excessive number of prescribing errors in
hospitals. With the 3rd edition of their textbook, Grahame-
Smith and Aronson aim to provide medical students and
junior doctors with a very practical guide to good
prescribing. The text comes in four sections, the first of
which deals with pharmacokinetics and pharmacodynamics.
The principles are well explained, with good examples.
Subsequent chapters in this section offer advice on how to
take a good drug history, what factors to consider when a
patient responds poorly to treatment, and special
precautions for prescribing in the young, the old, the
pregnant and the patient with renal failure. One of the best
chapters explains the process of drug discovery from
laboratory to clinic. It discusses the roles of the Committee
on Safety of Medicines and NICE, and what is required of a
drug for licensing purposes. Then follows a chapter on how
to look at the design of clinical studies on new drugs. These
two chapters deal with an area that tends to be neglected at
medical school, yet has to be understood by anyone who
wishes to evaluate a new agent on the market. My only
criticism of this whole section is that it lacks an account of
the role of the clinical pharmacologist in both laboratory
and hospital medicine. What sort of patients should be
referred to a clinical pharmacologist?
The second section, entitled ‘Practical prescribing’,
begins with the thought-processes one should go through
before deciding which drugs to prescribe for a patient; and
readers are then told exactly how to write a prescription for
a hospital patient or in general practice. The third section
adopts a systems-based format to discuss the pharmaco-
logical treatments of common medical and surgical
conditions. Although these recommendations are well
explained and easy to read, I would have welcomed more
information on the quality of the evidence. For example, a
treatment with an excellent evidence base could have been
given two stars, a treatment with moderate evidence one
star and a treatment with no evidence no star. The last
group tend to survive because of ‘tradition’. In long-case
exams and on ward rounds we are often asked ‘how good is
the evidence’—for thrombolysis, for example. These parts
of the text might usefully have been referenced. I was
disappointed by the chapter on immunological therapies. It
472 provides a basic explanation of the four types of
Volume 95 September 2002
hypersensitivity reaction but no account of the inflammatory
mediators involved—essential information for an under-
standing of immunomodulatory anti-inflammatory agents
and the cytokine-antibody therapies now being used in
rheumatoid arthritis and Crohn’s disease. The last section is
a pharmacopoeia—in effect, short notes on all the
commonly prescribed drugs. This will be useful for fast
information and last-minute revision before exams.
The first two sections of this textbook will be of
particular value to junior doctors who wish to sharpen their
prescribing skills; they cover practical matters that are little
discussed in other texts. The information in the third and
fourth sections can be found in any good book on
pharmacology, but the presentation focuses much more
on practical issues for clinicians. Any clinical medical
student or junior doctor will find this work enjoyable and
useful.
Daniel M Sado
Royal Bournemouth Hospital, Bournemouth BH7 7DW, UK
Conflict and Catastrophe Medicine:
A Practical Guide
Editors: J Ryan, P F Mahoney, I Greaves, G Bowyer
409 pp Price £35 ISBN 1-85233-348-0 (p/b)
London: Springer-Verlag, 2002
In 1918 the British Prime Minister, David Lloyd George,
believed that with the signing of the armistice between the
allied powers and Germany ‘came to an end all wars’.
Sadly, mankind seems to have an inexhaustible appetite for
conflict. UNICEF has characterized the past fifty years as
an ‘age of neglect’—a time when governments sacrificed
the basic needs of women and children to build military
arsenals and finance projects that did little to help the
poorest. Between 25 and 40 wars were active at any one
time in the 1980s and 1990s, almost all ‘internal’ and
principally targeting civilians and their ways of life.
While established democracies move towards globalization
in trade, defence, communication and the espousing of
‘human rights’, many unstable and economically poor
states move towards disintegration and further internal
conflict. In what has been described as double jeopardy,
population growth and increasing urbanization in the
developing world mean that more and more people are
exposed to conflict in the areas most at risk for natural
disasters. These trends have been met by a burgeoning in
the global humanitarian industry. By 1997, there were
260 international governmental organizations and more
than 5400 non-governmental organizations on the world
stage, with spending on emergencies running at over
 JOURNAL OF THE ROYAL
US$7 billion per year by the mid-1990s. Massive
expansion in the capability of global newsgathering means
that the victims of conflict and natural disasters can be
viewed halfway around the world in ‘almost real-time’.
Often there is a generous public reaction, but in the
recent past too much of the assistance from donor
countries has been misdirected. A hasty response can
make matters worse: it is better to wait until the needs
have been assessed. Assistance must take into account
local conditions and complement the internal efforts.
Conflict and Catastrophe Medicine: A Practical Guide takes a
welcome step towards collating essential knowledge, both
theoretical and practical, for healthcare workers contem-
plating such humanitarian work. The chief editor James
Ryan, who heads the Leonard Cheshire Centre of Conflict
Recovery based at the Royal Free and University College
Medical School, has assembled 43 contributors, mostly
from the UK, who deliver a strong thread of personal
experience throughout the text. Their collective aim is to
provide an entry-level text for medical, nursing and
paramedical staff working in hostile environments.
The first of six sections discusses the risks faced by
humanitarian volunteers and how they can stay safe. It
introduces the concept of ‘the failed state’ and explores the
nature of conflict in some detail. Natural and man-made
disasters and the problems of refugees and internally displaced
people are discussed. Experts on remote medicine offer
valuable advice about providing medical care in austere
circumstances. The final part of this section discusses the
issues around the decision to commit to a humanitarian
intervention and introduces the various ‘players’.
The second section details the process of working in
international humanitarian aid. In addition to hints on how to
combine aid work with career progression back home, it
provides specific instructions and check-lists on practical topics
such as personal medical preparation, insurance, passports
and other documents, clothing and equipment. It advises on
safety and cultural issues while working abroad, and a
particularly strong chapter, relevant to the aid worker, is the
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SOCIETY OF MEDICINE Volume 95 September 2002
one on the psychological aspects of humanitarian aid,
reminding us that vulnerability is not confined to the ‘victims’.
Section three contains information on prehospital
planning and on relevant aspects of aviation medicine.
Communications technology gets close attention: though
the rapidly growing capabilities are revolutionizing
humanitarian missions, wrongly used equipment can be a
confusing and expensive liability. The last part of this
section deals with acute medical troubles such as infectious
diseases, surgical illness, trauma, bites and stings, and dental
emergencies as well as pain relief and anaesthetic options in
an environment outside the usual ‘zone of comfort’. It is
recognized that women and children in conflict or refugee
settings face special difficulties in gaining access to health
services, in obtaining food and commodities, and in
securing protection from sexual violence; two chapters
focus on these and other issues.
The fourth section introduces the concept of conflict
recovery, describing phases of transition from first response
to long-term recovery, with examples from the Falkland
Islands, Kosovo and Azerbaijan. Particularly enjoyable is the
section entitled ‘hard knocks and hard lessons’, with stories
that should help well-meaning workers avoid difficulties in
the future. The penultimate section includes a guide to
publications, Internet sites and specialist suppliers; and in
the short final section the editors offer a code of behaviour
for humanitarian workers.
Professor Ryan helped to establish the RSM’s Conflict
and Catastrophe Forum, which aims ‘to create an
international forum for humanitarian aid workers of all
skills and specialities, to facilitate teaching, training and
education in the humanitarian field and to raise the
awareness and profile of humanitarian aid and medicine’.
The Practical Guide is a valuable resource for all those
contemplating involvement in this arena.
Douglas M Bowley
Department of Surgery, University of the Witwatersrand,
7 York Road, Parktown 2193, Johannesburg,
Republic of South Africa
473