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Am Fam Physician. 2000;61(9):2909-2913

Ethics in Clinical Practice

By Judith Ahronheim, Jonathan Moreno and Connie Zuckerman. Pp. 508. Price, $55.00. 2d ed. Aspen, 200 Orchard Ridge Dr., Gaithersburg, MD 20878, 2000. Phone: 800-638-8437. ISBN: 0-834-21075-4.

The second edition of Ethics in Clinical Practice offers an excellent treatment of ethical challenges faced by family physicians and other generalists. The book is well-written, engaging and easy to follow. The authors bring a wide range of expertise and background to this edition, and this strength is evident throughout the book.

The text begins with background on the cases that follow. These introductory sections offer an invaluable and succinct summary of the core features of ethical theory as it relates to clinical ethics. Introductory chapters also describe more recent challenges to established theory and variations in the application of theory to patients throughout the life span. Of these introductory chapters, the latter promises the most immediate clinical relevance for family practitioners. Useful, too, is a chapter that describes and critically evaluates some of the common distinctions that clinicians make in practice, such as those between “ordinary” and “extraordinary” care. The authors' analysis does a great deal to clarify the ethical issues that underlie these intuitive distinctions.

The most useful section is the case-based discussion that makes up most of the text. The text devotes one chapter each to a protean variety of ethical challenges—31 ethical cases are described in detail and analyzed. Although some topic areas like ethical issues created by medical errors appear to be underrepresented, the breadth of the cases is nevertheless quite impressive. Where appropriate, case discussions are supplemented by mention of legal precedents and related ethical issues. For all cases, the authors provide a reasonably up-to-date reference list and a bibliography of suggested reading.

As with any text comprising cases, Ethics in Clinical Practice may be somewhat difficult to use as a reference because clinicians may not readily perceive connections between the cases at hand and the cases in the text. That is, a case-based book may not be the best reference for physicians dealing with real clinical problems. However, the detail and depth of the cases in this book easily compensate for this limitation. In addition, this book should be a valuable teaching tool for medical students, house staff and health care professionals, as well as essential reading in the field of bioethics.

Atlas of Pediatric Clinical Diagnosis

By Binita Shah and Teresita Laude. Pp. 512. Price, $79.00. Saunders, The Curtis Center, Independence Sq. West, Philadelphia, PA 19109, 2000. Phone: 215-238-7800. ISBN: 0-721-67639-1.

Clinicians often value the experience of connecting written descriptions of diseases with visual images that help them stick in the memory. Shah and Laude's Atlas of Pediatric Clinical Diagnosis does just this, as it seeks to emphasize the “clinical essentials that help one quickly diagnose and treat common diseases of children.” Furthermore, with its helpful figures and concise text, it is compiled with the busy community-based physician in mind.

This book's greatest strength is the format. Its fifteen chapters address many common and uncommon illnesses and conditions that affect children. But unlike some texts that lose you in verbiage, pediatricians Shah and Laude, who are also board-certified in emergency medicine and dermatology, have condensed their descriptions into readable outlines, lists and charts of essential information. For instance, recently, I admitted a child to the hospital with Kawasaki disease. Looking up this condition in Shah and Laude, I found an outline containing synonyms for the disease, a brief definition, and short passages on the etiology, epidemiology, pathogenesis, key clinical features, laboratory tests, complications, treatment and prognosis. Tables and charts addressed variant clinical features, the differential diagnosis and atypical presentations of Kawasaki disease. Eleven pictures illustrated features of the examination, including a comparison of the typical rashes associated with the disease and a 2-D echocardiogram showing a coronary aneurysm.

Another strength of the book is the picture selection. Some atlases provide one or two pictures showing typical clinical presentations of a condition. However, Shah and Laude provide additional pictures demonstrating conditions that commonly present with similar findings but are very different. For instance, periorbital edema with proptosis could be the result of cellulitis or acute bacterial sinusitis. Shah and Laude compare these two conditions using radiographs and computed tomographic images to highlight the distinctions, thus reinforcing the use of these modalities for accurate diagnosis.

The book also brings home the meaning of many clinical descriptions we hear in medical school, which are often meaningless in our own clinical experience. In their discussion of intussusception, for example, a picture of a diaper with a “currant-jelly stool” is shown next to a diaper with actual currant jelly in it. Many clinicians know this description and have correctly supplied it on tests but have never seen either one.

While this text thoroughly addresses the topics it covers, several oversights are worth mentioning. Entire categories such as cardiology, pulmonology, nephrology, gastroenterology and nutrition, and allergy and immunology are omitted. Some of their attendant conditions are included in other categories (e.g., Hirschsprung's disease in urology and surgery, allergic conjunctivitis in ophthalmology, and minimal change nephrotic syndrome in a “miscellaneous” section). However, no mention is made of such classic and common pediatric conditions as asthma, croup and allergic rhinitis, or less common but still important conditions such as pyloric stenosis, cystic fibrosis and inflammatory bowel disease.

One oversight of particular concern for the family physician is developmental pediatrics. Family physicians see many well children and would benefit from written descriptions and illustrations of the abnormal developmental findings likely to be encountered in a well-child examination. Another criticism is that some of the pictures, especially those depicting dermatologic conditions, are of extreme conditions. While it is important to know that tinea capitus can cause severe scarring and alopecia, the family physician is more likely to see subtle and, therefore, more difficult to diagnose cases. Including pictures of the latter would have been useful. Furthermore, many of the pictures are black and white. More color plates, especially those demonstrating skin lesions, would better suit this kind of text.

Some people will compare this book with Zitelli's Atlas of Pediatric Physical Diagnosis (Lippincott-Raven, 1997, 3d ed.). While the comparison is reasonable, the two books seek to meet different needs. Whereas the Zitelli book seeks to be comprehensive, making extensive use of narrative descriptions, Shah and Laude seek to be readable and accessible. With detailed outlines and tables instead of narrative descriptions, and with the addition of useful supplementary pictures, radiographs, charts and drawings, the Shah and Laude book is an extremely clinician-friendly resource.

Shortcomings notwithstanding, this is a thorough text, with a unique format that makes it easy to use and a helpful alternative to the Zitelli book. In fact, this book is so easy to use that I would like to see a version of it on CD-ROM for those of us who prefer to access information by computer. While I would also like to see some of the additions and changes outlined above, this book achieves its purpose by emphasizing the “must-know” clinical essentials of common pediatric problems in a format that makes the information easily retrievable.

Such an approach makes this a valuable resource for busy clinicians, whether in practice or in training, who care for children but don't care to wade through paragraphs of text to find a pearl.

Also Received

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Prostatic Diseases and Their Treatments

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