Book Review

The Practice of Medicine in Adolescence

N Engl J Med 1994; 330:1095-1096April 14, 1994

Article

The Practice of Medicine in Adolescence
Edited by Charles G.D. Brook. 283 pp., illustrated. Boston, Edward Arnold, 1993. $95. ISBN: 0-340-54850-9

Adolescent health care is coming of age as a new medical subspecialty. Several new textbooks have recently been published, a testament to the need for physicians to understand better this unique population, wedged between conventional pediatrics and traditional adult medicine. The epidemiology of health problems among teenagers is distinctive, and health issues take on a flavor all their own when viewed through the teenage patient's eyes. Their perceptions of time, self, and the relations among actions, responsibilities, and consequences make caring for the health of adolescents a challenge.

Here is a concise, well-intentioned book, aimed at helping to orient the nonspecialist to the special qualities of adolescent health care. Organized around introductory discussions of standard medical conditions likely to afflict the teenager, the book focuses on such topics as physical and psychological development, chronic diseases, risky behavior among adolescents, and contraceptive choices. Throughout the book the more than 30 authors, most of them British, weave an understanding of adolescent growth and emotional development through their discussions of the effects of chronic illnesses on teenagers.

Several early chapters present general approaches to medical problems encountered by teenagers and discuss the need for the clinician to be sensitive to the patient's psycho-social milieu. Concise overviews showing how adolescent patients differ from other age groups are provided. Successful maturation is a process of passing through developmental stages and mastering psychological tasks. This process is nicely presented. The authors provide a compact introduction to cognitive and emotional changes typical of the teenager and familiarize the reader with concepts inextricably linked to the world within which the adolescent lives (such as self-esteem, sexual identity, independence, family dynamics, and noncompliance).

Some of the more recent theoretical work in the behavioral sciences, however, is noticeably absent. Few references in this book date from later than 1989. In some areas the reader must take care to differentiate scientific certainty from inadvertent innuendo. For example, readers may be provoked by unsubstantiated statements such as this: “The accommodation to [testosterone's] effects is highly advantageous to the long-term success that men seem to achieve over most women in terms of career.”

Chapters relating to traditional subjects such as pulmonology, cardiology, endocrinology, hyperlipidemia, and diabetes mellitus are strong adjuncts to standard medical textbooks. The importance of inflammation in asthma might have led to an emphasis on the expanding role of oral and inhaled antiinflammatory agents in ambulatory management. Unfortunately for American readers, many of the pharmacologic agents discussed are more commonly used in the United Kingdom, as is the case with salbutamol (albuterol), terbutaline, and nedocromil sodium. In addition, readers in the United States may find the exclusive use of SI units in the chapter on hyperlipidemia frustrating.

Much of the time spent by a physician with an adolescent patient involves taking a detailed social history along with focused counseling with regard to high-risk behavior. The book offers no clues to helpful history taking and guidelines for routine care and immunizations. When and how to screen for sexually transmitted diseases is the focus of much current research. The recommendations in this book may differ, however, from widespread practices in the United States and from those published in the American Medical Association's Guidelines for Adolescent Preventive Services. American clinicians might find some specific recommendations inconsistent with usual practice, such as the advice to screen patients routinely with serologic tests for hepatitis B and human immunodeficiency virus antibody, Pap smears every three years, and routine male urethral-swab specimens for Gram's staining and Neisseria gonorrhoeae culture (rather than rely on noninvasive leukocyte esterase screening and a careful history of exposure, symptoms, and signs).

Immunization of all adolescents against hepatitis B virus, which is arguably desirable, is not proposed. The recommended treatment and management of several sexually transmitted diseases differ from standards in the United States and recommendations by the Centers for Disease Control and Prevention. Pragmatic management guidelines, such as recommendations about restrictions on athletics for teenagers with common orthopedic problems such as patellofemoral disorders or suggestions for the workup of a patient with possible Marfan's syndrome, would have been helpful.

Much of this book's strength lies in its tone: one of sensitivity to issues such as compliance and psychiatric stress. It differs from other recent works like Lawrence S. Neinstein's 1991 Adolescent Health Care: A practical guide (2nd ed. Baltimore: Urban & Schwarzenberg), which is a succinct primer useful in making day-to-day decisions about the management of many teenage health problems, and Elizabeth R. McAnarney's 1992 Textbook of Adolescent Medicine (Philadelphia: W.B. Saunders), a comprehensive textbook of adolescent health care. Chapters are short and peppery, but limited in scope and practical management guidelines.

Roger W. Spingarn, M.D.
Elizabeth R. Woods, M.D., M.P.H.
Children's Hospital, Boston, MA 02115