BOOK REVIEWS

The ACP Evidence-Based Guide to Medicine (NCCAM),4 “Complemen- been published in peer-reviewed jour- Complementary & Alternative tary and [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, , 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-

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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 Cochrane Database System Review Evidence-Based Guide to Complemen- Manipulative Medicine Consult are in study of 10 randomized clinical trials tary & Alternative Medicine as an excel- agreement. Millicent King Chan- examining the effects of cranberry juice lent database of clinical pharmacologic nell, DO, and David C. Mason, DO— and supplements on urinary tract infec- information, not only on herbal prod- both of the Department of Osteopathic tions. The reviewers concluded that ucts but also on the efficacy of other Manipulative Medicine at the Univer- cranberry juice and related supplements CAM treatments, including acupunc- sity of Medicine and Dentistry of “are associated with a 35% reduction ture, traditional Chinese medicine, and New Jersey-School of Osteopathic in the frequency of urinary tract infec- Ayurvedic medicine. Medicine in Stratford—emphasize this tions when compared to placebo.” fact in the opening lines of the preface. Chapter 10, “Men’s Health,” has study Frederick J. Goldstein, PhD However, to continue the metaphor, Professor of Clinical Pharmacology, information indicating that saw pal- Philadelphia (Pa) College of Osteopathic even the most experienced chef gener- metto causes a “small but definite Medicine; Book Review Section Editor, JAOA— ally relies on recipes as the foundation shrinkage of the prostate gland, which The Journal of the American Osteopathic for his or her art. Similarly, the authors Association, Chicago, Ill means that [saw palmetto] is not just present “recipes” to serve as a founda- treating symptoms but may be used to tion for various osteopathic manipula- both prevent and alleviate BPH [benign References tive treatment (OMT) techniques. These 1. The use of complementary and alternative medicine in prostatic hypertrophy].” In chapter 11, the United States. National Center for Complementary and recipes appear in a handy, easily trans- “Women’s Health,” the author reports Alternative Medicine Web site. http://nccam.nih.gov/news/ portable pocket format, increasing the

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usefulness of this resource for the busy dix 2), and summary charts (appendix 3). For OMT techniques in cases of clinical practice. Also included are recommendations for ankle sprain, the authors present In this book, the authors first set up International Classification of Diseases, options for 2-minute (eg, counterstrain), various clinical diagnoses, suggesting Ninth Revision (ICD-9) codes3 to use when 5-minute (eg, counterstrain, HVLA, a variety of physiologic findings that billing for osteopathic manipulative lymphatic drainage, myofascial release), would be expected in the motor, sym- medicine. and extended (eg, articulatory, coun- pathetic, and parasympathetic systems. Appendix 1 presents OMT tech- terstrain, HVLA) treatment. This listing The book next provides a list of related niques—via written descriptions, pho- makes it clear that counterstrain— somatic dysfunctions common to such tographs, and diagrams—by body sec- which could easily be provided in less patients. Subsequently, the authors sug- tion, including the head, the cervical, than 2 minutes—is not the only manual gest relevant OMT techniques for 2- thoracic, and lumbar sections, the treatment option available. Regardless minute, 5-minute, and extended treat- sacrum, and the upper and lower of whether a radiograph was ordered, ment times. extremities. Techniques addressed in a cast or splint applied, or a prescription While all osteopathic physicians this appendix include auricular for an anti-inflammatory drug given, have training in applying OMT—at least drainage, counterstrain, Galbreath treat- the patient could still benefit from brief during their first 2 years of osteopathic ment, high-velocity, low-ampli- application of OMT and leave the office, medical school—not all DOs have had tude (HVLA), Muncie technique, clinic, or emergency department feeling supervised clinical experience with this muscle energy, and myofascial release. better.4 treatment modality. Given the nature The specialized tests in appen- In the case of ankle sprain, the of clinical encounters for osteopathic dix 2—which is also organized by body authors note that the level of evalua- primary care and specialist physicians, section—include the compression and tion and management coding for an the amount of treatment time available distraction (intervertebral foraminal office visit by an established patient during patient visits for utilizing OMT encroachment) tests and the Valsalva (ie, 99213) could be supplemented with is typically rather limited. The reasons test for the cervical spine; the hip drop a -25 modifier code, indicating that a most often given by osteopathic physi- (sidebending) and straight leg raising separately billable procedure—OMT— cians for not treating patients with OMT tests for the lumbar spine; the ASIS was performed on the same day of ser- are not enough time, lack of experience (anterior superior iliac spine) compres- vice. The authors also include the ICD- with OMT, and poor (or no) financial sion test as well as the seated and 9 code for lower extremity somatic compensation for OMT.1,2 It is possible, standing flexion tests for the pelvis; and dysfunction (ie, 739.6) for use in patient however, to perform OMT in just a few the Apley’s, Phalen’s, and Yergason’s assessment and billing. However, they minutes—with health benefits for the tests as well as the patellar grind and fail to include the primary diagnosis patient and financial compensation for valgus stress tests for the extremities. ICD-9 code for ankle sprain (ie, 845.00), the physician. An easily accessible OMT The summary charts in appendix 3 the prominent placement of which reference, such as this volume, that can address such items as cranial holds, der- (ie, heading) would make completion of be used to jog an osteopathic physician’s matomes, diagnoses, muscle motions, the billing form easier for the osteo- memory would improve the likelihood nerve impingements, and reflexes. pathic physician. of OMT being used in patient care. As an example of the way that the A few additional comments can be The 5-Minute Osteopathic Manipula- authors handle each clinical diagnosis, made about the clinical diagnosis text. tive Medicine Consult has a simple, the section on ankle sprain has a Several of the clinical topics covered by straightforward organization, covering detailed listing of sympathetic findings the authors, including headache and 60 common clinical conditions. Among (eg, “Increased tone-dilated arterioles hypertension, require more than one these conditions are ankle sprain, carpal of the muscles,” T10-L2 myofascial ten- ICD-9 number, depending on the con- tunnel syndrome, depression, fibro- derpoints, tissue texture changes over dition’s etiologic factors and symptoms. myalgia, hypertension, influenza, otitis transverse processes) and motor find- The 5-minute and extended treatment media, pregnancy, restless leg syndrome, ings (eg, L4-S2 common fibular nerve options mentioned by the authors scoliosis, tachycardia, and urinary tract impingement, inversion and eversion include some OMT techniques and infection. After the physiologic findings strain). Regarding other somatic dys- body regions not included among the 2- and related somatic dysfunctions of each functions associated with ankle sprain, minute options. However, almost any condition are described, the authors pre- the reader is directed to look for OMT technique could be performed sent three appendices with step-by-step pes planus (“flat foot”) and certain within the 2-minute timeframe, and instructions for OMT techniques tarsal, metatarsal, tibial, and fibular dys- (appendix 1), specialized tests (appen- functions. (continued on page 464)

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(continued from page 402) area on the inside front cover of the book. Once on the site, however, the three or four OMT techniques could be index at the left side of the Web page By Jerome Groopman, MD. 319 pp, $15.95. completed during a 5-minute treatment was easily searchable. The illustrations, ISBN: 978-0-618-61003-7. New York, NY: session. The choice of techniques would text, and other items loaded quickly Mariner Books; 2008. depend mostly on the skills of the osteo- and were easy to read. Readers should pathic physician and the comfort levels be aware that the online material is not ombining 30 years of dedication to of the patient with the treatment. available in a downloadable format, Cinternal medicine with a reputa- Additional clinical conditions could however. Instead, it must be accessed tion as an accomplished essayist, Jerome have been added to the text without by signing on at the publisher’s Web site Groopman, MD, has produced a fasci- significantly increasing the book’s com- each time one wants to view it. A nating tome exploring the minds and pact size. Some clinical concerns, such downloadable version that could be thinking processes of physicians. How as sensory and symptom relationships, placed on a personal digital assistant, Doctors Think, a New York Times best- could have also been added to the text iPhone, or other electronic device would seller, was first published in 2007 and to further flesh out complicated aspects be a great benefit to the busy osteo- republished in a paperback edition last of certain diagnoses. pathic physician, resident, and student. year with a new afterword. Although the relative brevity of The In summary, The 5-Minute Osteo- Dr Groopman, chief of experimental 5-Minute Osteopathic Manipulative pathic Manipulative Medicine Consult is a medicine at Beth Israel Deaconess Med- Medicine Consult prevents it from being worthwhile book that, when properly ical Center in , Mass, and occu- the final resource on this matter, the used, could increase the clinical appli- pant of the Dina and Raphael Recanati book’s format—with nearly all of the cation of OMT. Expanded use of OMT Chair of Medicine at Harvard Medical material on each clinical condition would benefit patients, osteopathic School, begins How Doctors Think with appearing on facing pages—facilitates physicians, and the osteopathic med- the proverbial introduction. However, quick scanning by the reader. The font ical profession at large. This is not a book instead of the usual perfunctory segue size, however, may be too small for to read and place on the bookshelf. into the main topic, Dr Groopman’s some readers. Most pages have plenty Rather, it belongs in the pocket of the introduction is a 26-page, in-depth expo- of “empty” space in which the text laboratory coat or, at least, on the coun- sition on how the practice of medicine is could have been enlarged for improved tertop in a nearby examination room. in essence a study in communication. readability. Regarding the graphics, the The author intersperses his own diagrams and photographs featured in Dennis J. Dowling, DO observations with interesting details Osteopathic Manipulative Medicine the book’s OMT technique and spe- Associates PC, Syosset, NY regarding the case of a female patient cialized test sections are clear, simple, who was misdiagnosed as having and immediately comprehensible. References anorexia nervosa with bulimia and irri- All things considered, The 5-Minute 1. Spaeth DG, Pheley AM. Evaluation of osteopathic table bowel syndrome. Dr Groopman manipulative treatment training by practicing physicians Osteopathic Manipulative Medicine Con- in Ohio. J Am Osteopath Assoc. 2002;102:145-150. illustrates how faulty physician-patient sult is a good effort and can be recom- http://www.jaoa.org/cgi/reprint/102/3/145. Accessed communication was responsible for the mended to osteopathic residents and June 22, 2009. incorrect diagnosis and how improved 2. Johnson SM, Kurtz ME. Conditions and diagnoses for attending osteopathic physicians. Direc- which osteopathic primary care physicians and specialists communication (ie, open-ended ques- tors of residency training programs and use osteopathic manipulative treatment. J Am Osteopath tions and careful listening) resulted in a Assoc. 2002;102:527-540. http://www.jaoa.org/cgi/reprint osteopathic medical educators who are /102/10/527. Accessed June 22, 2009. correct diagnosis of celiac disease. interested in incorporating OMT into 3. Centers for Medicare and Medicaid Services, National Throughout this fascinating training should make this book required Center for Health Statistics. ICD-9-CM Official Guidelines account, Dr Groopman uses phrases for Coding and Reporting. Washington, DC: reading—or they should consider pur- US Government Printing Office; October 2008. that could well be classified as chasing it for osteopathic residents. http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide0 Groopman aphorisms, including “Think 8.pdf. Accessed June 22, 2009. Unfortunately, the available elec- out of the box,” “Language is still the 4. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manip- tronic version of this book (http://the ulative treatment in the emergency department for bedrock of clinical practice,” and Point.lww.com/channell) may not be patients with acute ankle injuries. J Am Osteopath Assoc. “Freedom of patient speech is necessary 2003;103:417-421. http://www.jaoa.org/cgi/reprint/103 quite as easy to use as the book itself. /9/417. Accessed June 22, 2009. to get clues to diagnosis.” He summa- When the reviewer attempted to access rizes how physicians typically achieve this material online, access required reg- competency and improved patient skills istration with the publisher and then by noting, “Primarily, they [physicians] entering a number from the scratch-off recognize and remember their mistakes

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and misjudgments, and incorporate unstable angina did not show up on man also covers various other areas of those memories into their thinking.” the cardiac enzymes because there concern related to the book’s subject Following the introduction are wasn’t yet injury to the heart muscle, matter. Among these areas are the asso- 10 chapters that further establish and it didn’t show up on the chest ciation among “Marketing, Money, and Dr Groopman’s thesis—offering lessons x-ray because the heart had not yet Medical Decisions” (chapter 9), the begun to fail to pump blood, so there for physicians, as well as advice for influence of aggressive pharmaceutical was no fluid backup into the lungs. patients, on improving communication company representatives, the error of to achieve more effective treatment. Dr Groopman reports that the performing treatments by rote memory Rather than pointing fingers of accusa- physician concluded, “You have to be even when those treatments are not tion or pressing statistical assumptions, prepared in your mind for the atypical effective, and the overreliance on algo- he interviews highly accomplished, and not so quickly reassure yourself, rithms and grids as “shortcuts around competent medical specialists (some of and your patient, that everything is the onerous process of assessing whom use pseudonyms) from across okay.” By presenting this and other each ... complex [case].” the United States. These physicians cases of physician error in a respectful, In the book’s epilogue, Dr Groopman were willing to share with readers sig- collegial manner, Dr Groopman concludes that while writing How Doctors nificant mistakes they had made in strengthens his points about the impor- Think, he realized that in addition to the either diagnoses or treatment and to tance of physicians improving their cog- usual sources of information available to examine and reflect on their thinking— nitive and communication skills. physicians (eg, textbooks, medical jour- or lack of thinking—in those instances. Each of the chapters in How Doctors nals, colleagues), he has “another vital For example, in chapter 2, “Lessons Think contains one or more such partner who helps improve my from the Heart,” Dr Groopman relates intriguing accounts of misdiagnosed or thinking ... my patient or her family the story of a healthy-looking, active incorrectly treated patients. One of the member or friend who seeks to know forest ranger who presented to a physi- other strengths of this book is that these what is in my mind, how I am thinking.” cian with a complaint of chest pain. cases are not written in formal clinical Whether the reader agrees or dis- After physical examination, electrocar- language. Rather, Dr Groopman—who agrees with Dr Groopman’s points, his diogram, chest radiograph, and blood is a staff writer for The New Yorker, a book provides interesting reading and tests all yielded normal results, the frequent contributor to The New cogitation—as well as an excellent physician told the patient, “I’m not wor- Republic, , and The opportunity for introspection for physi- ried at all about your chest pain. You Washington Post, and the author of sev- cians. I recommend this book for all probably overexerted yourself in the eral books—presents the cases in col- physicians, regardless of the type of field and strained some muscle.” The orful, conversational language. His text medicine they practice. next evening, however, a colleague often includes discussions with, descrip- informed the physician that the forest Arnold Melnick, DO, MSc, DHL (hon) tions of, and background information Professor of Pediatrics, Department of ranger had returned to the emergency on the physicians and patients involved Pediatrics, and Professor of Public Health, Public department that morning with an acute in the cases. For example, in chapter 4, Health Program, College of Osteopathic myocardial infarction. The physician, Medicine; Executive Vice Chancellor and “Gatekeepers,” Dr Groopman writes Provost (ret), Health Professions Division, Nova noting that he was stunned by the news, the following about a physician: Southeastern University, Fort Lauderdale, Flaࡗ told Dr Groopman the following: JudyAnn Bigby is a compact woman Clearly, I missed it [the ranger’s with a round face, alert eyes, and a Editor’s Note: Dr Melnick writes the unstable angina] ... And why did I lilting, almost musical voice that often monthly “To the Point” column on miss it? I didn’t miss it because of breaks into laughter. She was raised medical communication for The DO any egregious behavior or negli- in Hempstead, Long Island. When gence. I missed it because my she was a child, hers was one of the and is one of the American Osteopathic thinking was overinfluenced by how first African-American families in Association’s Great Pioneers in Osteo- healthy this man looked ... Happily, town ... Her father worked as a pathic Medicine. For more information he didn’t die. mechanic for United Airlines and regarding the Great Pioneers, please only later in life did her mother, a see http://www.osteopathic.org/pdf/pub The physician then explained: homemaker, return for a high school _do0708pioneers.pdf. equivalency degree. The unstable angina didn’t show on the [electrocardiogram], because fifty Besides discussing examples of mis- percent of such cases don’t ... His takes made by physicians, Dr Groop-

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