Book reviews

Family Practice © Oxford University Press 2002

Vol. 19, No. 6 Printed in Great Britain

Book reviews

The resourceful patient. JA Muir Gray. (173 pages, £14.50.) eRosetta Press Ltd, 2002. ISBN 1-904202-00-4.

attributed to a certain Sir Edward Waine, but modified by Douglas Carnall into “la maladie du grand print-out”! From my perspective as a teacher, seeking to promote patient–centred consulting, The Resourceful Patient will be a first class source of references and quotes. It will be a powerful tool in empowering resourcefulness in the hands of lay members of NHS bodies such as Primary Care Organizations and members of patient organizations, or patient participation groups. Not that these are not already resourceful, but here is a book/web-site/e-book that adds more resources to their resourcefulness! It is a fantastic creation, well worth a visit to the web-site, followed by a visit to a bookshop (or e-bookshop!).

A thousand years ago the Chinese invented moveable type, while Johann Gutenberg developed the printing press in 1450, and now Muir Gray, with Harry Rutter, has created a simultaneous conventional paper, web-site, and electronic (‘e-book’) publication. The format is revolutionary, but what of the content? Pretty radical too! The imbalance, or ‘asymmetry’ of the doctor– patient relationship has been gradually redressed through research such as Tuckett’s “Meetings between experts”, and the “patient-centred clinical method” of Moira Stewart and colleagues, but Muir Gray has taken the process a step (leap?) forward by proposing that patients should have free access to (high quality) information about their health. His position as Director of the UK’s new and emerging National Electronic Library for Health may not be entirely unconnected with this dream. As befits so self-consciously ground-breaking a book, The Resourceful Patient wonderfully reflects the literature of past centuries, from George Eliot’s Middlemarch to PD James’ The Black Tower and from George Bernard Shaw’s The Doctor’s Dilemma to David Sackett’s Evidence-based Medicine. Muir Gray skilfully weaves a story of the rise and fall of medical power, the nature of medical work and then the emergence of empowered, or resourceful, patients. Incidentally, Article 10 of the European Convention on Human Rights asserts that citizens have the right “to receive and impart information and ideas without interference by public authority” (which in the UK includes the National Health Service!). This book seeks to define both the technical and ethical frameworks that would be needed to enable patients fully to participate in their health care decision-making. This draws on McKinstry’s1 study that suggested that 40% of patients would choose to be actively involved in decision-making, and on a North American study of breast cancer patients2 which showed that 22% preferred a patient-led style of decision-making, 44% a collaborative approach and 34% would prefer to delegate responsibility to the doctor. The book’s format also allows free use of web-links, both to book details and literary links, such as “la maladie du petit papier”, a splendid historical gem

PETER CAMPION Professor of Primary Care Medicine, University of Hull 1

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McKinstry B. Do patients wish to be involved in decision making in the consultation? A cross-sectional survey with video vignettes. Br Med J 2000; 321: 867–871. Degner LF et al. Information needs and decisional preference in women with breast cancer. JAMA 1997; 277: 1485–1492.

Bone and joint futures. Anthony D Woolf (ed.). (159 pages, £16.95.) BMJ Publishing Group, 2002. ISBN 0-7279-1548. I wasn’t aware before reading this compact book with its curious title that on January 13, 2000, the WHO formally launched the Bone and Joint Decade. Nor had I been party before to the declaration by Kofi Annan in 1999 that “we must act now” to prevent and treat disabling joint and other musculoskeletal conditions. As GPs, we are currently immersed in the primary and secondary prevention of ischaemic heart disease, the foremost cause of death in the developed world. Yet much of our day-to-day work is concerned with the diagnosis and management of musculoskeletal disorders. We rarely think about prevention apart from perhaps when considering osteoporosis and the management of the perimenopausal patient. Bone and joint futures contains many useful nuggets of information and depressing statistics that indicate we had better start learning that there is more to do than issue a prescription for the NSAID flavour of the month. 709

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Family Practice—an international journal

Consider the following: joint diseases account for half of all chronic conditions in people over the age of 65; about a quarter of patients over the age of 60 have significant pain and disability from joint diseases. But it is not only degeneration and ageing that should be worrying; musculoskeletal trauma accounts for about half of all reported injuries and within 10 years it is estimated that 25% of all health expenditure of developing countries will be spent on trauma-related care. This is not a ‘how to manage’ book but a collection of articles on different aspects of bone and joint conditions including current thinking on aetiology and possible new treatments. There is also an emphasis on prevention, particularly relating to osteoarthritis and osteoporosis. I was surprised to find no mention of glucosamine relating to the former, as this appears to be the high street choice of supplement at the moment. The disturbing implications of our sedentary lifestyle are highlighted. The outstanding chapter is concerned with the management of chronic musculoskeletal pain, a difficult area for both patient and therapist. The author is a professor of primary care epidemiology and writes succinctly on the nature of the problem, its high prevalence and the lack of success of traditional methods of diagnosis and treatment, as well as the theory of pain, psychosocial factors and the use of placebo. Considering all the facts it is obvious that both our undergraduate and postgraduate training are not equipping us adequately for tackling this area of our work. But it is also true that there is a huge public health message to get across about the necessity for safe and healthy exercise. We and the public need to distinguish between health promoting physical activity and that which is more likely to lead to trauma and/or overuse injuries. And as Dr Woolf points out in the first chapter, doctors have to recognize that over-treatment of chronic musculoskeletal conditions may be just as harmful as under-treatment. JILL THISTLETHWAITE Senior Lecturer in Community-based teaching, Leeds

Concise Oxford textbook of medicine on CD-ROM. JGG Ledingham, DA Warrell (eds). (1 CD, £75.) Oxford University Press, 2002. ISBN 0-19268-805-7. I had my laptop stolen the week after I received this CD and when I tried to install the disc on the old heap I use at work, it crashed my system. New wine, old wineskins. I’ve written a few CDs myself and learnt the hard way how to take account of the plodding obsessive, the hypertext phobic, the inveterate icon-clicker and the dyslexic word-searcher. I’d say that in terms of user friendliness this one is pretty good (but certainly not outstanding). What about content? Frankly, it reminded me why I became a GP. Diabetes, for example, is listed as subsection

13 of Metabolic Disorders—subsections 1 through 12 being given over to inborn errors of metabolism, glycogen storage diseases, trace metal disorders and other conditions seen with alarming frequency in the Membership Examination of the Royal College of Physicians and exceedingly rarely elsewhere. Of course, from a pathophysiological viewpoint this taxonomy makes perfect sense but for a jobbing GP it seems plain daft. The paragraph on the epidemiology of Type 2 diabetes alludes to a recent rise in prevalence but gives no indication of the impending obesity-related pandemic. The section on inheritance of diabetes makes much of the single gene disorders that account for less than 1% of the diabetic population, while giving just four lines to the much commoner polygenic inheritance. No help here for the GP who seeks to answer the question that patients with diabetes ask most frequently, “How likely are my children to get this, doctor?”. But it’s probably unfair to criticize a small-print textbook (albeit an electronic one) for focusing on the small print. It would never cross my mind to consult the OTM about the standard forms of diabetes that I see in the surgery every day. But suppose one of my patients did come back from a clinic with a diagnosis of glucagonoma? I would then be able to enter this long-forgotten tumour as a search term and read all about it—or at least, remind myself that it’s a rare cause of diabetes. In a month of using this CD as a reference clinical text, I consulted it mainly for explanations of conditions that, as a part-time GP, I have a statistical chance of meeting once every 50 years or less. My idiosyncratic list included histiocytosis (a good account found), Rett’s syndrome (not in the index), pyoderma gangrenosum (a whole chapter), and the various forms of viral hepatitis (of which there are now twice as many as there used to be— A through E, and G but not F). Some chapters—such as Sir David Weatherall’s on the haemoglobinpopathies—are authoritative, faultlessly written and a pleasure to read. Others (and I won’t name them) are none of those things. The photographic plates reproduce well on screen, though they seem to have been selected mainly from personal snaps taken by the authors on their sabbatical trips. But it was good finally to discover what a Kayser-Fleischer ring looks like and the kids enjoyed the various venomous snakes. The problem with the textbook version of the OTM was always that you risked a sports injury transferring it from the bookshelf to the desk. If this CD has no other advantage it’s that you can carry it round in your back pocket or (assuming your machine measures its memory in gigabytes) leave it in a spare folder on your laptop till you need to refresh your hazy memory on a clinical fascinoma. TRISH GREENHALGH Professor of Primary Health Care, University College London

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The Bellevue guide to outpatient medicine: an evidencebased guide to primary care. Nate Link, Michael Tanner, Danielle Ofri, Lloyd Wasserman (eds). (424 pages, £25.) BMJ Publishing Group, 2001. ISBN 0-7279-1680-7.

The science of the placebo: towards an interdisciplinary research agenda. Harry A Guess, Arthur Kleinman, John W Kusek, Linda W Engel (eds). (343 pages, £15.95.) BMJ Publishing Group, 2002. ISBN 0-7279-1594-0.

This book is the product of a drive to improve primary care delivery to patients in the New York area. It is organized into 41 chapters each dealing with a different problem in primary care. Some are about chronic diseases such as diabetes and atrial fibrillation and some concern symptoms, like dizziness and low back pain. Some common complaints, such as chest pain, are strangely absent. The book also suffers from the typical organizational schizophrenia so common in medical texts: indecision as to categorize by complaint or by diagnosis. Organizational issues aside, as a primary care doctor, I treat patients with every one of these issues on a regular basis and suspect all primary care clinicians do the same. Each chapter is divided into sections with easy to read bulleted points. I needed only a minute or two to flip to the appropriate section and extract the information. This is relevant, significant, and easy to find and read. The references are readily available in a second shaded column. In the introduction, the editors note that the book was constructed in the spirit of evidence-based medicine and they put that phrase in their title. They do have their references (evidence) easily available, but I would challenge them to do more if they want to create an evidence-based text. First, they may consider noting when each chapter was written and when it was last reviewed. The book was published in 2001 but any given chapter could be much older. Explicit inclusion criteria used to include papers as evidence would be helpful. Finally, a level of evidence for each recommendation would go a long way to placing this truly on par with other secondary sources of evidence such as ACP Journal Club or Evidence-based On Call. Of note, there is an electronic version available for personal digital assistants (PDAs). A free sample chapter is available at www.bmjpg.com/bellevue. The potential portability of this book may be one its strongest features for the busy clinician. Unfortunately, portability comes with a price; buying the book does not entitle you to a PDA version. The Bellevue Guide is a great first edition. As it expands it will hopefully add the qualities it is missing in order to become an evidence-based text. Organization may be re-addressed and important chapters added. I am a bit disappointed that I must pay for both the text and PDA versions, but delighted to even have the option. I would be happy to have it on my shelf. It deals with important medical problems and allows a busy doctor or medical student to quickly wade through information for a clinical bottom-line.

This book sprang from a conference in November 2000 on the placebo. Readers are led energetically through this complex subject: “the idea that there could be a physiological basis for an inert pill, sham procedure or symbolic meaning to allay a patient’s symptoms or cure illness was all but unthinkable in orthodox medicine 50 years ago. In the interim, advances in genetics and molecular biology and in the behavioural and social sciences, in concert with ever-improving analytical and imaging techniques, are providing clues to the interactions between mind and body that operate in response to illness and therapy”. The text is well written and aspects covered include historical perspectives e.g. voodoo death, ethical issues, explanatory mechanisms, psychophysiology, clinical trials, and priorities for future research. All are examined with a worthy level of detail and anyone pushed for time may refer to the excellent summary. The difficult gap between art and science is bridged but you need a reasonable grasp of the phraseology of psychology; for example, “Bootzin approached the role of cognition and behavioural mechanisms in placebo effects from a social learning perspective in which learning is seen not as a passive reaction to stimuli, but involves active selection, organization, and transformation of the input”. The contemporary nature of this book is very apparent. The Declaration of Helsinki 6th revision, October 2000 is discussed; authors felt the Declaration makes it very difficult to use placebo in trials where there has previously been a safe alternative, causing difficulty in assessing the importance of the placebo effect to the effectiveness of new drugs. My only criticism is that the book reports on a conference where participants felt placebo effects “often appear real and significant, not make-believe: an emperor with clothes”. In contrast, on the very first page of the book, a recent review of over 100 clinical trials of the placebo published in the New England Journal of Medicine is mentioned and reported to conclude there was little evidence that placebos in general have powerful clinical effects. There is no attempt to refute this article, but seeds of doubt are sewn at the outset, leaving one to wonder how much the authors’ comments are coloured by enthusiasm. Alternative explanations for the placebo effect are offered: natural history, patient bias, investigator bias, regression to the mean. But for me, a GP with an interest in research, the balance did not feel quite redressed.

KARYN BAUM Primary Care Internist and Assistant Professor of Medicine, University of Minnesota, USA

ANDY ROSS GP in Birmingham

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Evolving health: the origins of illness and how the modern world is making us sick. Noel Boaz. (256 pages, £20.95 (US$27.95).) John Wiley & Sons Ltd, 2002. ISBN 0-471-35261-6. Noel Boaz has a PhD and an MD. He is a biological anthropologist and also a professor of anatomy. Does that mean he knows what he’s not talking about? He’s confident enough but I am left feeling uneasy. He has a broad sweeping evolutionary explanation of all human illness and what we need to do to stay healthy. We (that is our species, Homo erectus) became perfectly adapted several million years ago to flourish in our own ecological niche. At that time we were hunter-gatherers who went around in bands of about 25, eating grain, fruit, insects and the occasional large animal we managed to kill. And boy, were we healthy. Life may have been short and brutish, but we were lean and fit and never suffered from the diseases of civilization. Hypertension, coronary disease, cancer, diabetes, even depression, were all unknown. So what’s gone wrong? We have tried to evolve culturally instead of biologically. We drive to the city to do our stressful work and we eat poisonous fat-sodden convenience foods while sprawling in front of the TV. It’s just so wrong. We should eat a healthy, balanced, low fat, low salt diet, stop smoking and get more exercise. Most of this you knew already. But Noel thinks we should also eat insects (the hunter-gatherers did). And don’t be a pathetic vegetarian. Give your gut the protein it has evolved to deal with—there’s no reason why that shouldn’t include the odd rat or squirrel you find killed by the roadside. Noel goes on to tell us that every human disease is associated with a particular stage of our evolution from the primeval Darwinian soup. Virus infections began when we were single cells; cancer only became a problem when our multicellular ancestors started differentiating. The decision of our fishy grandparents to take to the land led to complicated kidneys, problems with salt and water balance, hypertension and arterial disease. And so on. It’s all very ingenious and it certainly made me realize how much physiology I had forgotten. And yet, I remembered enough to get the feeling that Noel’s science is more than a little flaky. I even went back to my text books to check up on a few things. Is hypertension always the primary cause of coronary artery disease? Is prostate cancer due to excessive oestrogens produced by adipose tissue in fat males? I don’t think so. Noel likes to have a unitary explanation for everything and his arguments are not, I fear, entirely evidencebased. If you read this book (and I am not saying you should) it will provide you with a challenging test of your critical reading skills and your recall of everything you learned in medical school. After that, if you still want to go back to being a hunter-gatherer and survive with the fittest, it will be an informed choice. JOHN SALINSKY GP in Wembley and GP Vocational Training Scheme Organizer, Whittington Hospital, London

GP recruitment and retention: a qualitative analysis of doctors’ comments about training for and working in general practice. Occasional Paper 83. Julie Evans, Trevor Lambert, Michael Goldacre. (33 pages, £7.50.) Royal College of General Practitioners, 2002. ISBN 0-85084-276-X. This 33 page Occasional Paper from the Royal College of General Practitioners arrives at a time when the recruitment and retention of GPs is a major issue for many looking for replacements for colleagues retiring or moving elsewhere. Similarly the National Health Service organizing health care units (primary care trusts) are endeavouring to ensure that they have enough GPs to provide a quality service. The plans to increase the general practice workforce in the UK are slowly taking shape but there are workforce problems. This paper is important as we clearly need to learn from the past if we want to attract and retain quality doctors into primary care. The paper documents Department of Health sponsored qualitative research from the University of Oxford. Cohorts of GPs qualifying in 1974, 1983, 1988 and 1993 were studied. The research was based on four surveys (between 1994 and the inception of Primary Care Groups in 1999). The written comments were analysed and provided an interesting perspective on a crucial problem. The analysis suggested that further undergraduate general practice training could promote general practice careers, and that hospital-based general practice training needed to be improved and valued. In general, the general practice-based postgraduate training was praised for good formal teaching, though the skills of individual trainers impacted on the quality of training. Some GPs had encountered difficulties in obtaining practices suitable to their needs. Newly qualified GPs often took work as a non-principal either because they felt too inexperienced or because of their home situation. The major changes to GP workload in 1990 and 1995, along with growing expectations, had resulted in increased work-related stress, low morale, reduced job satisfaction and quality of life. This was noted to have been partly alleviated by the formation of GP cooperatives. The impact of Primary Care Organisations in 1999 as new organizational NHS bodies had not been evaluated though concerns were expressed about this. The study also found that loss of GPs’ time from the NHS workforce was due to four main reasons: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. The main underlying factor for this was pressure of work. The researchers suggested a need for a cultural change amongst medical educationalists to promote general practice as a career. They suggested more flexibility of GP training and a greater variety of contractual arrangements to reflect greater desires for flexible patterns of working. This Occasional Paper is well written with supporting evidence and contains important information for

Book reviews

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strategic planning. Certainly the results have good face validity and even though the data was collected three years ago the results remain as relevant now if not more so. The evidence is presented well—let’s hope it will be used.

educational fields. So I wonder if the distribution of the book is enhanced or restricted by the medical badging. Still, looking at my copy as I type this review, I realize how well thumbed it is looking already—a testament to the active use it has already had.

STEVE HOLMES GP Tutor and PCT Education Lead, Burnley, Pendle and Rossendale, North West Region

ADRIAN DUNBAR GP and Associate Director of Postgraduate General Practice Education, University of Leeds

Prescription for learning: techniques, games and activities. Ruth Chambers, Gill Wakley, Zafat Iqbal, Steve Field. (262 pages, £23.50.) Radcliffe Medical Press Ltd, 2002. ISBN 1-85775-530-8.

Apollo: the human face of medicine. CDs 1 & 2. Peter Toon, Trisha Greenhalgh, Marcia Rigby, Geoff Wong, Will Coppola, Moira Sarsfield. (2 CDs, £50 each; £75 for 2.) BMJ Publishing Group, 2001. ISBN 0-7279-1632-7/8

I was delighted to be given a copy of this book to review. I instantly knew this would be a very handy addition to my educational kit bag. This is not a bedtime read but a manual packed with techniques, exercises, games, advice and tips for facilitating learning. Its authors are experienced medical educationalists and this is a generous gift for others in the field. The authors assert that effective learning should be hard work, challenging and fun; that it should be interactive and based on experience. All the exercises described are designed to achieve this specification. The opening two chapters briefly describe some of the educational theory underpinning the activities described in the rest of the book. The subsequent 22 chapters cover a comprehensive repertoire of educational activities across a spectrum of learning areas. These include managing change, leadership, motivation, time management, appraisal and under-performance. Most subject areas are either timeless or current. There is guidance for running small groups and giving presentations. Most of the activities described were not completely new to me. It is, however, extremely useful to have what I have previously encountered in different areas all assembled within one cover. I found it particularly helpful to read the rationale behind each activity, guidance as to when it might be used, detailed description of ‘how to do it’—including briefing for the facilitator, how it works, what can go wrong, and best of all ‘how to make it better’. Each chapter is systematically arranged in this fashion, which makes for rather dull reading after a while but that is not the way to use the book. It is clearly meant as a reference manual to turn to when the teacher has a particular need. As such I think it is very successful and, had I not received the copy to review, I would certainly have bought it. I think it will become widely and routinely used by medical teachers. This brings me to a final thought, however. The title, and some of the activities, point the book at medical educationalists. However much of the content is generic and relevant to a wide range of

This excellent exploration of the wider issues that face doctors today comes on 2 CDs from the Department of Primary and Population Science at UCL. In these days of smear, moving goal posts, Shipman recrimination and financial pressures, these discs provide a thoughtful broad range of issues from the clinical, ethical, legal and social perspectives, allowing the ‘student’ to ponder and re-evaluate some of the problems we face in every day practice. They are set up to allow the doctor to claim PGEA accreditation for the considerable time needed to explore these matters fully, by sending in written answers/essays to the reflective exercises given at the end of each sector. The authors suggest that the work could be done jointly with a partner—although I suspect that aside from general practice training this may be hardly impractical. This is a well organized teaching aid, so do not be put off by the introduction, where much time is spent with literary examples, media input and inquiring reflective questions on the effect of the legal profession! It may be essential to underline the ways other professionals impact on our lives, be it through professional contact, the media, government directives or literature, but time spent looking at the broader non clinical effect of doctors might be time better spent. Following the introduction, each topic opens with a clinical video clip to illustrate the issue. Sometime these seem over simple. For example, in one clip the female GP assumes that a young woman has come to update her contraception prescription when the issue that she actually needs to address is abortion. It makes those of us weaned on consultation skills training wince, although the issues raised are still perfectly valid. But then after the clinical scenarios come a marvellously stimulating range of ideas and material to review the main questions from a range of different perspectives. Participants are invited to log onto the course website and share their own ideas and reactions to each section. (You have to do this if you want to claim education brownie points.) To explore each topic fully is certainly

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time consuming, but each raises important health, moral and legal points very fully. When practising doctors can actually find the new time that is to be set aside for practice-based learning, these discs will provide a great range of easily accessible ideas and information on which to base personal or group study sessions. They offer worthwhile thought-provoking material in an original way. CLAIRE SAMUEL GP in Leeds

Good people, good practice: a practical guide to managing personnel in the new primary care organisations. Hilary Haman, Sally Irvine. (233 pages, £19.95.) Radcliffe Medical Press Ltd, 2001. ISBN 1-85775-417-4. Today’s primary care managers are faced with an increasing work load and frequent organizational changes. This excellent book will prove most helpful as it clearly and simply explains many issues which often arise and which, without expert help and knowledge, could prove difficult to resolve. Most managers will have attended seminars on best practice and employment law but this book provides an invaluable source of practical examples and solutions to everyday problems as well as allowing the reader to check details of current legislation and procedures. It provides comprehensive, easily readable text on employee contracts, employee rights, staff appraisals, discrimination and redundancy as well as a most informative chapter on people management, an essential aspect of today’s changing NHS. The layout of the text with examples and case studies highlighted in boxes makes it easy to access relevant information quickly. This book should be required reading for all doctors entering general practice and would certainly benefit established principals who, for the most part, seem to have little or no training in either people management or employment law legislation. Reading about this would enable them to appreciate why their managers often seem to be making a fuss over what they might perceive to be matters of little importance—there are some illuminating examples on page 31. The chapter on ‘Capability Issues’ contains sound advice on how to deal with unauthorized or regular absenteeism and gives helpful suggestions on how to approach these matters confidently and with sensitivity. I would suggest that no primary care organization can afford to be without this excellent publication on their library shelves but it is to be hoped in view of the rapid changes taking place in employment law legislation that frequent new editions will be forthcoming. MARJORIE CONDIE Practice Manager at the Pinn Medical Centre, Pinner, Middlesex

Palliative care in the home. Derek Doyle, David Jeffrey. (180 pages, £29.50.) Oxford University Press, 2000. ISBN 0-19-263227-2. This paperback book provides a helpful overview of the wide range of issues involved in caring for patients at home who are coming to the end of their lives. The authors set out to provide ‘a recipe book’ rather than a reference book; the intended readership is the clinician seeking advice and guidance in the management of practical issues at home. For those seeking an evidence base to the advice given, there are useful appendices to the major text on the subject. It is written by two specialists in palliative medicine who have previously worked as GPs. They bring a wealth of experience, both in advice on particular symptoms and on the more general issues of how to approach the care of patients towards the end of life. Perhaps they have now been out of general practice for a little too long, losing touch with some of the current issues in primary care; there is no mention, for example, of general practice co-operatives and out-of-hours care, important issues for optimizing palliative care at home. Around one third of the book is given to the palliation of pain and other symptoms, with a helpful discussion of the approaches used and modern pharmacological and other methods of symptom control. This overview will prove extremely useful to non-specialists in the community setting. There are however one or two omissions. While morphine, hydromorphone and fentanyl are all mentioned, no mention is made of oxycodone, nor is there discussion of the roles of alternative opioids other than morphine. Since publication in 2000, Cox 2 inhibitors are no longer as new as the authors suggest and many GPs would be familiar with the use of gabapentin without discussion with specialists. The discussion of professional stress in palliative care is particularly valuable, as is the chapter on grief and bereavement. Throughout the text there are many pearls of wisdom, born of years of experience and reflection. The chapters discussing psychosocial, spiritual, and religious and communication issues offer a useful and insightful perspective, although there is no discussion of the relevance of different religious beliefs in palliative care, funeral arrangements and bereavement follow-up. Recent years have seen a number of books published concerning palliative care, aimed at the generalist reader. In my opinion, this volume is the best by far and should be found on the bookcases of general practices and community nursing teams throughout the country. STEPHEN BARCLAY GP in Cambridge, Honorary Consultant Physician in Palliative Medicine at the Cambridge Hospice, and Macmillan Clinical Fellow in the University of Cambridge

Book reviews

What is death? Tyler Volk. (253 pages. £20.95, US$27.95.) John Wiley & Sons Ltd, 2002. ISBN 0-471-37544-6. “In the midst of life we are in death.” These words (from the Anglican funeral service of 1662) are for most of us much less true than they once were. Sudden death before 60, other than in accidents, is now rare. When it occurs, people are inclined to see it as a tragedy, almost an outrage, rather than a fact of life. Most GPs in the UK, who still play a regular part in terminal care of the elderly, will have rarely been involved in the death of a young person, apart from a few who worked through the early years of the AIDS epidemic in our large cities. It is therefore easy for all of us to externalize death and for the most part to ignore it. This book challenges that attitude. It insists that death is an inevitable part of life and a consequence of life being transmitted through “selfish genes”, which means that an organism needs a strong justification for continuing to live after reproduction. It argues forcefully (although not completely rigorously) that human consciousness is inherently dependent on the fragile structure of the brain and that neo-platonic ideas of an eternal soul which can survive death are just not tenable. It has many weaknesses. Its rambling anecdotal style and chatty colloquial American English suggests more the self-improvement literature so popular in that strange culture, rather than academic discourse. Many ideas in it are based on personal experiences given a sort of New Age, semi-mystical interpretation. We are a long way from the world of evidence-based medicine here.

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One of its main theses, that without death there would be much less life around, because new life recycles the strictly limited materials out of which biomass can be made, is logically flawed. It is decay after death rather than death as such that allows recycling to occur—one could imagine a death and decay free world with the same biomass as our present one. Such a world would however be strangely lacking in the change and development that we associate with life. It is this perpetual movement and growth that both characterizes life and implies death. Previous generations were brought up to face the reality of death and to look the fact of their own deaths squarely in the face. Many today who have been forced to face this reality comment on how paradoxically lifeenhancing this can be. The importance and benefits of doing this is perhaps the most important message of this book. Reading it may not be the best way to do so (I would personally recommend a visit to the deathclock web-site www.deathclock.com/, equally unsound in its evidence base but much more powerful as a memento mori) but acknowledging the importance of death and facing its inevitability in our own life is certainly something that we should not and ultimately cannot avoid. PETER TOON Senior Lecturer in the Department of Primary Care and Population Studies, University College London