Book Review

Clinical Preventive Medicine

N Engl J Med 1994; 331:1596December 8, 1994

Article

Clinical Preventive Medicine
Edited by Richard N. Matzen and Richard S. Lang. 1263 pp. St. Louis, Mosby-Year Book, 1993. $85. ISBN: 0-8016-3176-9

The strongest feature of this comprehensive textbook on clinical prevention is the clear presentation in several introductory chapters of the criteria for the evaluation of preventive maneuvers. Multiple sources of error can easily lead to a conclusion that a preventive maneuver is beneficial when it is not. These pitfalls include selection bias, length bias, lead-time bias, and the counterintuitively low predictive value that typically applies to screening for disease of low prevalence. All are discussed in the introductory chapters. Additional strengths of the book are excellent chapters on specific topics, including those on smoking cessation and adolescence. The chapter on the geriatric patient is superbly organized.

Several features detract from the usefulness of the book, however. In many chapters the authors do not establish a clear connection between their subject and clinical prevention. This fault holds true for “Life's Rhythms,” “The Stresses of Living,” “Sleep Patterns and Sleep Disorders,” “Headache,” “The Psychiatric Effects of Medications,” and “Career Development.” In other chapters the authors violate the criteria presented at the beginning of the book for judging a preventive maneuver. An egregious example in the chapter entitled “Proactive and Preventive Laboratory Medicine” identifies the measurements of five biochemical substances (uric acid, calcium, glucose, potassium, and aspartate aminotransferase) as “the rational chemistry profile.” In fact, not one of these measurements qualifies as “rational” if the principles described at the beginning of the book are followed. Similarly, the chapter on nutritional screening neither mentions nor fulfills the criteria for screening.

Because of the rapid pace of change in clinical prevention, the editors may soon produce a second edition. If they do, I have several suggestions. First, they should correct the imbalance between the amount of attention devoted to a topic and its importance. For example, home pregnancy testing receives more space than does the prevention of teenage pregnancy. More attention is given to the prevention of bacterial endocarditis in children than to the prevention of child abuse. In the section on pregnancy, exercise receives more space than avoiding the use of alcohol, tobacco, and other drugs. The authors of “Safety in the Home and Automobile” tell us more about noise pollution than the prevention of domestic violence. The index highlights this imbalance. There are almost as many entries for “performance enhancers” as there are for “primary prevention” and as many for “renal disease” as for “risk assessment.” There are more entries for magnetic resonance imaging than for measles prevention, more for computed tomography than for cost effectiveness, more for “trazodone” than for “tuberculin testing,” and more for “vocal performers” than for “violence.”

Second, I believe the book would be strengthened by eliminating entries that demean the topic of clinical prevention. The chapter entitled “The Preventive History and Physical Examination” currently includes the suggestion that “bunions, corns, calluses, and ingrown toenails [are]... example[s] of often overlooked conditions that can be prevented with attention to early signs of these problems.” A short paragraph headed “Risk Factors and Primary Prevention” in a five-page section on urinary incontinence in “The Adult Female” contains the following recommendation: “Preventive measures may take the form of life-style and environmental changes such as decreasing fluid intake when toilets are not available or in improving access to toilet facilities.” Such inane comments weaken the book.

Finally, the book's organization can confuse and mislead the reader. Urinary incontinence is discussed in the chapter on the adult female and is briefly mentioned in the chapter on the geriatric patient. Should the reader infer that prevention of incontinence should be targeted predominantly to adult women, considered only briefly for the elderly, and ignored for others? The reader interested in the prevention of glaucoma might expect that this subject would be most completely presented in the chapter on ophthalmologic disorders. Although it is addressed in that chapter, a much more complete (and more useful) treatment of the subject appears in the chapter entitled “Special Health Problems of African Americans.” The topic of domestic violence is also most thoroughly addressed in the chapter on African Americans. Although much more domestic violence (and glaucoma) occurs in the United States among persons who are not African Americans, the current organization of this book supports the opposite conclusion.

While waiting to see whether the editors produce a second edition of this book, readers interested in clinical prevention might be well served by the Guide to Clinical Preventive Services of the U.S. Preventive Services Task Force (Baltimore: Williams and Wilkins, 1989), a second edition of which is due to be published late in 1994.

William Taylor, M.D.
Beth Israel Hospital, Boston, MA 02215