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How Doctors Think Book BOOK REVIEWS The ACP Evidence-Based Guide to Medicine (NCCAM),4 “Complemen- been published in peer-reviewed jour- Complementary & Alternative tary and alternative medicine [CAM] nals. In fact, that is exactly what I do to Medicine is a group of diverse medical and develop relevant information for my [healthcare] systems, practices, and lectures to osteopathic medical students. Edited by Bradly P. Jacobs, MD, MPH, and products that are not generally consid- However, for the busy osteopathic Katherine Gundling, MD. 452 pp, $69.95. ered part of conventional medicine.” physician, such extensive routine exam- ISBN: 978-1-934465-04-2. Philadelphia, Pa: These CAM systems include acupunc- ination of published clinical data is usu- ACP Press; 2009. ture, Ayurvedic medicine, chiropractic, ally not practical. Fortunately, assis- homeopathy, naturopathic medicine, tance for this important task can now be ecades ago, undergraduate stu- traditional Chinese herbal medicine, obtained from The ACP [American Col- Ddents majoring in pharmacy were and various manual procedures. lege of Physicians] Evidence-Based Guide to required to take a 1-year course in phar- Researchers have suggested that the Complementary & Alternative Medicine— macognosy, a scientific branch of expanding use of CAM, often in the an excellent text that provides exten- learning devoted to studying plants that absence of efficacy studies, may be sive facts on the efficacy of not only have pharmacologic activity. Included in related to the high cost of conventional herbal products and other dietary sup- this requirement was a weekly 4-hour medical care,5 the ineffectiveness of that plements, but also many of the CAM laboratory component in which students care for patients with some chronic con- systems noted above. This book is an examined such plants both grossly and ditions and life-threatening illnesses,6 outstanding source to guide physicians in microscopic detail. I was one of those or the wellness movement—aiming, as through such evaluations. undergraduate students. However, after it does, to improve and enhance health The ACP Evidence-Based Guide to I moved into my graduate program to through “natural” means.1 Complementary & Alternative Medicine is specialize in pharmacology, I paid little However, are herbal products toxic? edited by Bradly P. Jacobs, MD, MPH, attention to pharmacognosy. Do they interact with medicines pre- and Katherine Gundling, MD. Dr Jacobs Over the years, undergraduate scribed by physicians? In regard to dietary is founder and director of the Institute exposure to pharmacognosy was trun- supplements, some of these products are for Healthy Aging at Cavallo Point in cated to one semester, and ultimately actually nothing more than placebos, Sausalito, Calif. Dr Gundling is asso- the subject became an elective as those while others do exhibit clinical activity. ciate clinical professor of allergy and in control of curricula deemed this dis- Certain kinds of dietary supplements are immunology in the Department of cipline to be anachronistic. As I con- more likely to produce toxicity or inter- Medicine at the University of California- tinued my career in medical research, actions that can affect the activity of pre- San Francisco. More than 20 contribu- some of my classmates went on to scription medications. The fact that dietary tors, including the editors, authored become osteopathic physicians. None supplements are sold on an over-the- chapters in the book. of us paid much attention in our respec- counter basis makes the problem of A total of 15 chapters are divided tive careers to the almost defunct disci- detecting such interactions more difficult into two sections. Part I, “Fundamentals pline of pharmacognosy. than it is for prescription medications. of Complementary and Alternative During the past 15 years, however, How can we know which supple- Medicine,” consists of a chapter on many adults in the United States and ments are clinically useful and which are CAM definitions and patterns of use and other countries have increased their use merely acting as placebos? How can we a chapter on the framework for of dietary supplements, including readily evaluate their potential toxic addressing CAM in clinical encounters. herbal products.1,2 Many of us in the effects, which range from minor events to Part II, “Evaluation of Complementary healthcare professions now clearly rec- life-threatening interactions with routinely and Alternative Medicine Systems and ognize that many patients presenting prescribed drugs? Such evaluations are Therapies,” is divided into 12 chapters on for office-based treatment or surgery difficult because the US Food and Drug CAM as it relates to specific medical con- are using such items on a daily basis.3 Administration does not require pre- ditions. These conditions—in the order Thus, I have now come full circle, market clinical trials for dietary supple- presented in the book—are allergic dis- because today I give a required pre- ments or “herbal remedies.” orders, asthma, cancer, general medicine, sentation on herbal products to second- Clinicians might evaluate the effi- gastrointestinal health, coronary heart year osteopathic medical students. cacy and safety of dietary supplements disease, human immunodeficiency virus, As defined by the National Center by routinely reviewing evidence-based, men’s health, women’s health, muscu- for Complementary and Alternative postmarket clinical studies that have loskeletal disorders, obesity and over- 400 • JAOA • Vol 109 • No 8 • August 2009 Book Reviews BOOK REVIEWS weight, and depression. The final chapter in the one-sentence section on “osteo- camstats/2007/camsurvey_fs1.htm. Accessed July 23, 2009. in the book is devoted to drug-supple- pathic and chiropractic manipulation” 2. Kelly JP, Kaufman DW, Kelley K, Rosenberg L, Anderson TE, Mitchell AA. Recent trends in use of herbal and other ment interactions. that there is “insufficient evidence to natural products. Arch Intern Med. 2005;165:281-286. The book’s introduction explains support or refute the use of spinal http://archinte.ama-assn.org/cgi/content/full/165/3/281. Accessed July 23, 2009. medical research terminology, such as manipulation as an effective treatment 3. Marinac JS, Buchinger CL, Godfrey LA, Wooten JM, “effect size” and “magnitude of the for dysmenorrhea.” Sun C, Willsie SK. Herbal products and dietary supple- ments: a survey of use, attitudes, and knowledge among effect.” This material may be chal- I recognize that osteopathic physi- older adults. J Am Osteopath Assoc. 2007;107:12-23. lenging for readers with minimal cians do not view osteopathic manipu- http://www.jaoa.org/cgi/content/full/107/1/13. Accessed research backgrounds. However, two lative treatment as a type of CAM. Nev- June 24, 2009. 4. What is complementary and alternative medicine? 4 tables at the end of the introduction ertheless, according to the NCCAM, National Center for Complementary and Alternative serve as guides for how data from effi- types of CAM used in “manipulative Medicine Web site. http://nccam.nih.gov/health cacy and safety evaluations are pre- and body-based practices” include /whatiscam/. Accessed June 24, 2009. 5. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins sented throughout the book. Thus, “osteopathic manipulation” along with DR, Delbanco TL. Unconventional medicine in the United understanding this material does not “chiropractic manipulation,” “massage States. Prevalence, costs, and patterns of use. N Engl J Med. 1993;328:246-252. http://content.nejm.org/cgi /con- require extensive knowledge of statis- therapy,” “Tui Na,” “rolfing,” and sev- tent/abstract/328/4/246. Accessed July 22, 2009. tical methodology. eral other kinds of interventions. And 6. Elder NC, Gillcrist A, Minz R. Use of alternative health The “summary evidence” tables in yet, in reviewing The ACP Evidence-Based care by family practice patients. Arch Fam Med. 1997;6:181-184. http://archfami.ama-assn.org/cgi/content each chapter contain dosing informa- Guide to Complementary & Alternative /abstract/6/2/181. Accessed July 22, 2009. tion, when appropriate and available, as Medicine, I found only a couple refer- well as effectiveness grades ranging ences (dysmenorrhea, hot flashes) to the The 5-Minute Osteopathic from A (high level of effectiveness) to use of “osteopathic manipulation” as Manipulative Medicine Consult D (very low level of effectiveness). Clin- CAM in the treatment of patients. ical recommendations and special com- The book ends with two appen- By Millicent King Channell, DO, MA, and ments are also provided. I found these dices. One appendix contains descrip- David C. Mason, DO. 314 pp, $52.95. ISBN- tables extremely helpful for obtaining a tions and reviews of safety and efficacy 10: 0-7817-7953-7, ISBN-13: 978-0-7817-7953- quick understanding of important clin- of the following “systems of practice”: 1. Baltimore, Md: Wolters Kluwer/Lippin- ical pharmacologic data and other med- Ayurvedic medicine, homeopathy, cott Williams & Wilkins; 2009. ical information about CAM. spinal manipulation, chiropractic, natur- Several examples serve to indicate opathic medicine, and acupuncture and steopathic manipulative medicine the clinical value of this text. In oriental medicine. The other appendix Otruly cannot be practiced by fol- chapter 6, “General Medicine,” the is a glossary of CAM terms. lowing a “cookbook approach,” and authors summarize results from a In conclusion, I view The ACP the authors of The 5-Minute Osteopathic recent
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