Rhetoric and Poetics

BOOK REVIEWS
into an area of excess fat, lipoma, gynecomastia or breast tissue through a
small or existing wound at surgery. Then, the tube is passed back and forth
through the excess tissue and the excess vacuumed out with approximately
one atmosphere of negative pressure applied to the metal tube by means of
stiff flexible tubing.
The technique is now in the armamentarium of most plastic and reconstructive
surgeons, who have done special study to familiarize themselves
with the procedure and its expected effects and the appropriate precautions. It
is important, however, that physicians using it have backgrounds that provide
a proper foundation for its application-which is not always the case.
Dr Hetter has gathered together an excellent assembly of authors with
historic connection to the technique or explicit experience with it. The book
is exceedingly well illustrated and is filled with cogent advice about how to
protect one's patients from the risks ofthe procedure.
The philosophy, patient selection, anesthesia, techniques and follow-up
care are all explicitly covered. In summary, this is an exhaustive, well-presented
textbook on current applications of lipoplasty.
RICHARD JOBE, MD
Clinical Professor of Surgery
Department of Surgery
Division of Plastic Surgery
Stanford Medical School
Stanford, California
* * *
MATTERS OF LIFE & DEATH: RISKS VS. BENEFITS OF MEDICAL
CARE-Eugene D. Robin, MD, Professor of Medicine, Stanford University
School of Medicine, Stanford, California. Stanford Alumni Association,
Stanford, CA 94305, 1984. 198 pages, $9.95 (paperback).
This is a provocative book, directed to laymen and warning them of
hazards they might encounter as part of medical care. It also will be of
interest to physicians as it is aimed at structural problems in the medical
industry rather than at incompetent physicians. It may cause patients to
question their doctors more closely and to challenge medical recommendations-
especially some diagnostic tests. It will provoke some physicians to
reexamine assumptions they have been making. It is a plea for more science in
medicine. Parts of the book are excellent but, because of serious flaws, I
would not recommend it to the public-the audience at which it is aimed.
The most serious flaw in the book is the author's disdain for preventive
medicine. In several places, he states or implies that the general public should
"avoid doctors and hospitals unless seriously ill." This advice might have
been appropriate 50 years ago, but the great strides in preventive medicine in
recent years make the advice obsolete and potentially harmful. Robin is
especially critical of screening tests which "make patients out of well
people." His main argument is that few such tests have been scientifically
evaluated from the risk-benefit standpoint, and that false positive tests subject
many people to needless worry, diagnostic risks and expense. He is not at all
impressed by the great decline in mortality from cervical cancer since the Pap
test was introduced, or the decline in mortality from heart disease since its
major risk factors have been discovered. He even rejects screening for glaucoma
and hypertension but recommends that people take their own blood
pressure at booths in supermarkets!
One must agree with Robin when he charges overuse of diagnostic tests in
offices and hospitals and deplores risky diagnostic procedures that are sometimes
done in situations where their results cannot possibly provide any
benefit to the patient, but he does not seem to understand the major reason for
this overuse. He attributes it to making the physician feel more comfortable
(from both a diagnostic and legal standpoint) rather than to benefit the patient.
The most important reason for this overuse may instead be attributed to
the idea he is emphasizing-to put more science into medicine. It is the desire
on the part of most physicians to practice scientific medicine rather than to
rely just on history, physical examination and their own judgment. Medical
schools, in an effort to combat the widespread practice ofjust treating symptoms,
have stressed the importance of obtaining objective data and reaching a
firm diagnosis before starting treatment. It is this demand for objective data
and the desire for definitive diagnoses that leads to most of the overuse. This
drive for objective data and definitive diagnoses has been only partly successful:
Robin points out that of all patients admitted to hospitals without a
diagnosis, only about 65% will have a definitive diagnosis at discharge.
Overuse of tests is largely a "disease" which has resulted from treatment of
another problem.
Robin's use of examples is often appropriate, but some bad examples cast
doubt on his complaints. For instance, when he complains that risky diagnostic
procedures were used in patients with cytomegalovirus disease, pericardial
heart disease, Alzheimer's disease and herpes encephalitis without a
possibility of benefit to the patient, he is using hindsight to condemn the
procedures. The diagnoses had not been firmly established when the tests
were done. The tests might have identified medically treatable diseases.
The best chapters are the ones on treatment of the terminally ill and the
aged, on unnecessary surgery and on the doctor as God. He condemns doctors
who keep terminally ill patients alive as long as possible or who refuse to
fully treat some patients because of their own convictions. He argues that the
wishes of the patient or family or both should be paramount in such situations.
Although Robin correctly argues that the God-like relationship between
patient and doctor is more likely to be harmful than beneficial, he fails
to recognize that it is the great disparity in knowledge between the two that
leads to this relationship.
Robin's main prescription for what ails medicine is more and better
controlled clinical trials. He rejects some of the commonly believed medical
tenets on the grounds that they have not been subjected to such studies. He
glosses over the fact that such studies are usually so very expensive that they
must be sponsored by a major drug company or the government, so few are
done. He has no suggestions as to where the money will come from to conduct
all the studies he demands.
There is an intellectual paradox in the book: it discourages patients from
participating in medical experiments unless they are likely to benefit directly,
yet at the same time it demands more and better clinical trials. Many clinical
trials must have the patients randomly assigned to treatment and control
groups. In double-blind trials, neither the doctor nor the patient can know
whether or not there is a chance for benefit to the individual patient. Some
clinical trials require healthy persons as controls. Self-selection by the patients
into one group or another, or refusal by many to participate, may well
introduce biases into a study which will destroy the usable scientific results
demanded by Robin.
VICTOR E. ARCHER, MD
Clinical Professor
University of Utah
Rocky Mountain Center for Occupational
and Environmental Health
Salt Lake City
* * *
MNEMONICS, RHETORIC AND POETICS FOR MEDICS-Volume IIRobert
L. Bloomfield, MD, and Carolyn F. Pedley, MD, Department of Medicine,
Bowman Gray School of Medicine, Wake Forest University, Winston-Salem,
NC. Harbinger Press, PO Box 17201, Winston-Salem, NC 27116, 1984. 165
pages (softbound), no price given.
How does the overworked medical student, the stressed resident or the
pushed practitioner spell RELIEF? Is it possible to cram into one brain the
causes of impotence, the diseases of anterior pituitary hormone hypersecretion
and the factors predisposing to thromboembolism?
Well, practitioners, here's the book you've been waiting for lo these last
two years: MRPMis back. Unlike Rocky II, Jaws II, Friday the 13th-II, this
opus can and should be taken both seriously and in jest.
Bloomfield and Pedley are not a vaudeville team but two delightfully
clever, capable physicians who tickle us with mnemonics and acrostics that
both teach and entertain. In 162 carefully pruned pages, we find out the
secrets for remembering clinical data from the cardiovascular system to
pulmonary; from neurology to hematology. It culminates with readers' contributions
and is further sprinkled with cartoons, fascinating facts (What's a
theriac?) and fine, witty quotes.
I used volume I in teaching and it was an effective, well-accepted, antidote
to the stomach cramps and muscle spasms that so often accompany sick,
miserable puns and poorjokes.
MRPM-I was dandy and if you like crossword puzzles or Trivial Pursuit,
MRPM-Ilwill be how you spell RELIEF.
ELLIOTT B. OPPENHEIM, MD
Bellevue, Washington
502