••Spring 2005/Vol. 9, No. 3

Book Reviews

New York: WebMD; 2004. ISBN 0-9703902-8-9. 2 vols, 2859 pages; $219.00

ACP Medicine | to pdf >> David C Dale and Daniel D Federman, editors Review by Vincent J Felitti, MD

For the past half-century, the teaching of internal medicine in America has been dominated by two widely recognized textbooks: Cecil Textbook of Medicine,¹ and Harrison's Principles of Internal Medicine.² Serious competition has just arrived upon the scene with the two-volume set, ACP Medicine.³ Not only is this outgrowth of the former Scientific American Medicine a heavyweight competitor in its own right, it has the special advantage of being an official publication of the American College of Physicians (ACP). Moreover, the ACP promises that it will reissue the bound set every 18 months to keep it current. Alternative formats exist and are to be updated more frequently.

All three of these major texts are well bound and well printed; they are equally well designed. Each devotes several opening chapters to subjects related to the practice of medicine, such as ethics, geriatrics, and preventive medicine. The editors and authors of all three texts are equally prestigious. ACP Medicine is unique in having a section on bioterrorism and in its variety of formats and free add-ons. By comparison, Harrison has a significant segment dedicated to underlying principles of disease, much in the manner of the old MacBride's Signs and Symptoms⁴ that had chapters on the pathophysiology and interpretation of cough, fever, pain, etc. Cecil has the most comprehensive section on preventive medicine.

The clear purpose of these internal medicine texts is to provide current and helpful information on bio-medicine and disease. To that end, I reviewed in ACP Medicine a few subjects with which I am comfortably experienced, comparing them to presentations in Cecil and Harrison.

• Obesity is discussed more or less equally in the three texts. What minor attention is paid to etiology focuses on the inevitably essential intermediary mechanisms, not on the adverse life experiences we found so commonly causal in our Weight Program at Kaiser Permanente (KP) San Diego, where we have treated, successfully and unsuccessfully, more than 26,000 adult obese patients. No implication is drawn from the fact that every anorexigenic agent ever used (except fenfluramine) has had antidepressant activity.

The dramatic relation between and obesity of various forms of sexual abuse and major household dysfunction is not even hinted at. Indeed, none of the three texts even indexes the subject of incest. Only Cecil and Harrison index Rape and Sexual Abuse; these lead to paragraphs that are tellingly brief, never mentioning the long-term medical consequences of these surprisingly common phenomena in middle-class populations. In other words, a purely biomedical model is in use; nothing close to a biopsychosocial approach is associated with trying to understand obesity.

• Hereditary hemochromatosis is interestingly and concisely presented in ACP Medicine, which supplies a helpful table of additional causes of iron overload. Surprisingly, no mention is made of the significant dissociation between phenotype and genotype in this fairly common homozygous mutation but much less common clinical disease. Genetic analysis is considered in ACP Medicine the gold standard for diagnosis,^3:p1072 thus blurring the important distinction in genetics between the presence of a laboratory marker and the existence of clinical disease or the probability of its ultimate appearance over time. Lastly, no mention is made of using quantitative phlebotomy to replace liver biopsy as the simplest technique for determining iron load. Cecil, though published four years earlier than ACP Medicine, more clearly makes the distinction between genotype and clinical disease. I found the Cecil presentation more helpful clinically than that in ACP. Harrison helpfully explains potentially confusing genetic terminology (eg, haplotypes and penetrance) on the indexed pages for hemochromatosis, thereby integrating it seamlessly. These two topics are not indexed in ACP or Cecil.

• Fibromyalgia is briefly described in ACP and is helpfully related to depression and sleep disorder. It is equally briefly described in Cecil. Harrison has a distinctly longer description, but one that is icily biomedical. Its approach is epitomized in the sentence, "Several causative mechanisms have been postulated to explain abnormal pain perception."^{2:p 2055}

In essence, this sampling suggests that George Engel's concept of the need for a biopsychosocial approach to diagnosis and treatment has not made much headway in the quarter century since his widely acclaimed article in Science.⁵ Review of the Psychiatry section in ACP Medicine shows that my conclusion is probably not due to sampling bias. We learn: "Psychological models for the etiology of mood disorders, especially depressive disorders, have also (sic) been proposed."^3:p2544 The focus on depression in ACP is on intermediary mechanisms, not basic causes. Any sense of understanding human beings is absent. Harrison is similar, only shorter. Fifteen of its >2700 pages are devoted to "Mental Disorders." In Cecil, psychiatry has been reduced to a nine-page section of neurology. Although tremendously important for pharmacotherapeutics, these etiologic conceptualizations of depression lack the insight and understanding proposed by Alan Barbour in his superb book, Caring for Patients,⁶ where he helps us see that depression is not a disease but a normal response to abnormal life experiences.

Each of these three internal medicine texts represents the best of current mainstream American medical thinking; some limitations in that thinking are exposed and propagated as well. ACP Medicine is a compendium of diseases, each treated as a solely biomedical entity. Unfortunately, this imposes significant limitations on the internist or family doctor treating patients. Michael Balint expressed this in his comment, "Doctors see patients because of disease. Patients see doctors because of anxiety. Therein lies the problem between the two."⁷ One hopes that the editors of this important text will repair this weakness in future editions. A lesser problem to solve would be to print the full index for the set at the end of each of the two volumes.

While it is easy to find fault with anything this big, it is even more important to acknowledge that the editors have taken on a monumental task in bringing together the knowledge of the various contributing authors; this is a huge intellectual endeavor. We are in their debt, even while wishing for more. ACP Medicine is sufficiently good to want it to become even better.

Finally, ACP Medicine has some advanced features worthy of note because they may be the harbinger of future approaches in medical texts. A monthly e-newsletter and a useful PDA download for diagnosis and treatment are available free from the publisher at www.acpmedicine.com/dxrxpromo1.htm. ACP Medicine is available in several formats:

• A two-volume hardbound set of books with three months of free online access ($219)
• A multi-CD-ROM version that is updated quarterly ($329)
• Two loose-leaf volumes updated monthly, with one year of online access ($349)
• An online full-text service allowing digital searches ($179)

ACP Medicine has joined Harrison and Cecil as the major American texts in internal medicine. Many physicians will see ACP Medicine as having the best start on meeting the future needs of clinicians seeing adult patients as we move into a digital era.

References

1. Goldman L, Ausiello D, editors. Cecil textbook of medicine. 22nd ed. Philadelphia: WB Saunders; 2004.
2. Kasper DL, Braunwald E, Fauci A, Hauser S, Longo D, Jameson JL, editors. Harrison's principles of internal medicine. 16th ed. New York: McGraw-Hill Medical Publishing Division; 2005.
3. Dale DC, Federman DD, editors. ACP medicine. New York: WebMD; 2004.
4. Blacklow RS, editor. MacBrydes's signs and symptoms: applied pathologic physiology and clinical interpretation. 6th ed. Philadelphia: Lippincott; 1983.
5. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977 Apr 8;196(4286):129-36.
6. Barbour AB. Caring for patients: a critique of the medical model. Stanford (CA): Stanford University Press; 1995. p 199.
7. Balint M. The doctor, his patient, and the illness. Revised ed. New York: International Universities Press; 1972. [As quoted in: Perm J 2003 Winter;7(1):54].

Vincent J Felitti, MD, has been with the Southern California Permanente Medical Group since its opening in San Diego in the late 1960s. E-mail: vjfmdsdca@mac.com

 

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