Oxford Textbook of Clinical Pharmacology and Drug Therapy, second edition

Abstract

With the publication in the UK of new General Medical Council guidelines on undergraduate medical education, there will be considerable debate between curriculum committees and heads of medical school academic departments as to the definition of "core" versus "optional" subjects. Clinical pharmacology and therapeutics occupies an interesting position in this debate. There is, I hope, little doubt that medical students will continue to need a firm foundation of knowledge of both mechanisms of drug action and of when and how drugs should be used in clinical care. In addition, the economics of drug use remains an important area of concern in professional circles and the public domain. Exactly how clinical pharmacology should best be taught to medical students is less certain. In the past the teaching of clinical pharmacology has been thought of by some clinicians in the same terms as a basic science-a necessary if somewhat boring evil and, in any case, students will learn therapeutics on the job after they qualify. Fortunately, this attitude is now far less prevalent. Yet it is still difficult to encourage students to take a particular interest in clinical pharmacology when they are struggling to understand the complexities of physical examination and clinical medicine. Even pathology seems more exciting when the student is confronted with the choice between a post-mortem demonstration and a lecture on the pharmacokinetics of phenytoin. Presentation is all important and the way in which clinical pharmacology is presented to the medical undergraduate will determine how much time they will be prepared to spend on the subject and how much of it will be retained for future use. Textbooks play a vital part in this strategy. Getting the balance right between overburdensome factual information and the presentation of the important basic principles is not easy. The Oxford Textbook of Clinical Pharmacology, despite its unimaginative title, goes a long way to achieving this difficult balancing act. The text is divided into four sections. First, and probably most important, are the basic principles of clinical pharmacology, which can be simply divided into: what do drugs do to the body and what does the body do to drugs? This part is well written and the introduction of the student to the notions of pharmaceutical, pharmacokinetic, pharmacodynamic, and therapeutic processes is clearly and concisely presented. However, I remain sceptical about the need to include 40 mathematical formulae in the pharmacokinetics section. We may be guilty of shooting ourselves in the foot over this issue if the end result is that medical students see pharmacokinetics as being of little direct relevance to their needs. The main body of the text deals with disease-oriented clinical pharmacology. This multi-author section is again well written with clear subheadings and several helpful figures and tables to distract the student. My only serious criticism of what is otherwise a valuable textbook in this area is the inclusion of the section entitled "Pharmacopoeia" of almost 200 pages (about one quarter of the total text excluding the index). In this section the authors list "... those drugs which are most commonly used in clinical practice (a total of about 300 compounds)". The definition of a commonly used drug is loose and includes some that are rarely encountered by most clinicians and others that are probably never now used by any. That aside, I question the need for inclusion of material in this format which adds to the bulk and cost of the book without an equivalent increase in usefulness. Similar information is available in standard formularies that are more regularly updated and are free of charge. The success of most textbooks rests with students and not with their teachers. Students must feel that a particular text satisfies their need, in terms of both content and readability. In a competitive market, the Oxford textbook is well placed. The first description of what was probably anaemia is found on a papyrus dated 1500 BC. In England, known as chlorosis until the nineteenth century, it was the "green sickness" of Shakespeare's heroines. Iron seems to have entered therapeutic practice 350 years ago and today is freely added to foodstuffs to combat iron deficiency anaemia. But can one have too much of a good thing? The authors of this polemic believe that the answer is yes. They train their sights on a single target, striding geographical space to examine peoples living in different environmental conditions and on vastly different diets. They pace evolutionary time, investigating porotic hyperostotic lesions in neolithic hunter-gatherers and the ills of our own sedentary, settled style of life, with its increased incidence of disease. The viewpoints are many but, irrespective of whether their data are palaeoanthropological or collected by studying the Afro-Americans or Kung populations of today, the authors conclude that the hypoferric anaemia associated with settlement is more likely to be due to increased pathogen load than to inadequate dietary iron intake. Because, in the anaemia of chronic infectious disease, witholding iron deprives pathogens of the iron required to prosper, it is of paramount importance to differentiate true iron-deficiency anaemia from that of chronic disease by measuring serum ferritin concentrations (which are normal or raised in chronic disease). The administration of iron in such cases may serve only to thwart the body's natural defences. Diet, Demography, and Disease is a notable attempt to provide information through multidisciplinary networking. The modern haematologist, though aware of the theories, should find much of interest. Others, not least the family