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"Even while ‘on duty,' residents might indulge themselves to show the tender side of their masculine nature. Here members of house staff in 1904-5 pose with babies born in the Burnside Lying-In wing." Reprinted by permission of University Health Network, Toronto, Ontario, Canada.

See Figure 1.

Health Food Junkies is a smart, funny, insightful exposé of a new eating disorder that the author calls orthorexia nervosa. The term is a combination of ortho-, meaning straight or correct, and orexis, appetite, reminiscent of anorexia nervosa. The disorder is characterized by obsessive attention to food quality or by food cultism.

The book describes a progression from the genesis of orthorexia (often a desire to improve health, treat illness, or lose weight) through the spiritual compensations of enduring a strict diet. "[A]s orthorexia progresses," the author writes, "a day filled with wheatgrass juice, tofu, and quinoa biscuits may come to feel as holy as one spent serving the destitute and homeless." In the full-blown stage, "within the orthorexic is a grim sense of self righteousness that begins to consume all other sources of joy and meaning."

Considering himself a recovering orthorexic, Dr Bratman provides unsparing descriptions of his own fanaticism and recovery. Worth the cover price alone is the chapter 1 account of his stint as a commune cook attempting to satisfy diverse factions who refused to eat many types of food, including food cooked in pots that had previously contained meat, food cooked in aluminum, any cooked foods, nightshades (potatoes, tomatoes, and eggplant), alliums (onions and garlic), and any out-of-season foods.

The author presents a screen for orthorexia, which includes the questions "do you sacrifice experiences you once enjoyed to eat the food you believe is right?" and "does your diet socially isolate you?" He makes the point that the extreme diets favored by food faddists are often misattributed to Eastern countries. Veganism, for example, which excludes not only meat but also milk, eggs, and other animal products, is not the traditional diet of any cultural group. Even macrobiotics, while it includes traditional Japanese ingredients, is not a traditional Japanese diet. (I would expand this concept to say as well that no culture consumes food only for health reasons).

Bratman's anecdotes about his own experiences and those of his patients and friends are honest, poignant, useful, and sometimes funny. He describes a visit to the United States by the Buddhist Karmapa (a Tibetan spiritual leader), who turns down the vegetarian feast prepared for him by American Buddhists and instead insists on trying a Big Mac. Other tales of revered figures telling American zealots to lighten up on the food fanaticism serve as modern fables, illustrating the pitfalls in importing philosophies only partially comprehended. The overzealous adoption and adaptation of exotic customs may create cultural chimeras unrecognizable to the people from whose cultures these precepts supposedly sprang.

Some food fads, of course, were born in the West, and the book includes a fair-minded analysis of a variety of dietary concepts, including food allergies, the Zone diet, and the blood type diet (which the author elegantly skewers).

Health Food Junkies should help all of us to improve the relationship between food and life. Having read the book, I suspect that orthorexia is a far more common eating disorder than anorexia nervosa and bulimia. In the author's words, "Whereas the bulimic and anorexic focus on the quantity of food, the orthorexic fixates on its quality. All three give to food a vastly excessive place in the scheme of life." You will recognize people you know within these pages.

My only minor criticism is that the book seems a bit mixed as to its intended audience. Some portions appear directed to orthorexics, others to a general audience, and still others to health care practitioners. The entire book, however, is both edifying and readable, well worth perusing by anyone caring for patients. I hope that Bratman will publish some version of his theory in the medical literature; he makes an excellent case for the term orthorexia nervosa to enter the medical lexicon.

Stalking is defined as the unwanted or surreptitious following of a victim for the purposes of harassment or other criminal activity. Awareness of stalking increased in the 1980s when several highly publicized cases catapulted the phenomenon into the public consciousness, notably, the 1980 murder of John Lennon by an obsessed fan, John Hinckley's attempted assassination of President Ronald Reagan in 1981, and harassment of the actress Jodie Foster.

In reality the phenomenon of stalking dates far back in history. Centuries of literature have portrayed individuals with obsessional attachments, romantic or otherwise, to specific individuals. In many instances the victim was a woman identified as a love object by a male stalker. Since the 1980s, however, awareness of stalking as a form of harassment and criminal activity has greatly increased, with enactment of antistalking laws in most US states.

One of the difficulties in defining and understanding stalking has been confusion over the type and severity of activity that would merit criminal prosecution. The standard has changed over time. Further complicating the social definition of stalking is that it has received relatively little scientific investigation. A number of studies have been published by investigators looking at small numbers of perpetrators. Most of these studies have involved stalking of celebrities rather than other forms, eg, stalking involving domestic violence and workplace violence. With its fuller treatment of the subject, Stalkers and Their Victims provides a welcome addition to the understanding and investigation of stalking.

The authors have taken a historical, descriptive, and phenomenological approach to understanding this contemporary problem. They rely on extensive data from Australia and the United States and use case histories and clinical vignettes to illustrate their findings. They define the phenomenon, classify it with respect to both victims and perpetrators, and then devote individual chapters to the major categories of stalking. Each chapter is well-written, clear, and fully referenced.

The first chapter provides an excellent overview of the history and changing conceptualizations of stalking. Views of stalking have changed from the romanticized image of "the unrequited love of the persistent suitor who merely admired from afar the unattainable perfections of the loved one" to contemporary portrayals of stalking as invariably linked to assault or domestic violence. In chapter 2 the authors examine the impact of these changing definitions in the context of epidemiology.

It has been widely thought that most victims of stalking were either celebrities or women. In chapter 3 the authors expand the scope of victimization by examining the type of relationship the victim had to the stalker. In their scheme victims of stalking are categorized as ex-intimates, casual acquaintances and friends, professional contacts (including physicians stalked by current or former patients), workplace contacts, strangers, and celebrities. Viewed thus, stalking might occur in almost any social or occupational setting. This broader approach has many advantages over previous oversimplified views of stalking.

Chapters 4 through 9 comprise the greatest strength of the book. The authors provide a comprehensive classification system for stalkers and devote individual chapters to each of the primary types in their scheme. This contribution is significant because, historically, the classification of stalkers has been a difficult undertaking. Many researchers have proposed various classification systems, all having significant limitations. The authors propose a system based on the stalker's motivation and the personal needs met by the activity. Categories include rejected stalkers, resentful stalkers, predatory stalkers, intimacy seekers, incompetent suitors, and stalkers with erotomanias and morbid infatuations. Each category has unique characteristics and may be associated with certain types of psychopathology. The authors provide extensive discussion of the psychiatric disorders and syndromes commonly found among stalkers.

Interesting variations are presented in chapters 10 and 11. In stalking by proxy the stalker uses other persons or agencies to contact or harass a victim, such as having a private investigator follow or videotape an intended target, ordering unwanted goods and services for someone else (eg, magazine subscriptions), and using physicians or their office staff as proxies to gain medical or other personal information about a target. False victims of stalking represent another variation, in which false claims of stalking are made to gain attention or obtain revenge. Unwarranted criminal charges and other legal difficulties may result from false stalking claims.

The remaining chapters focus on the connection between stalking and violence, strategies to reduce the impact of stalking, and prosecution of stalkers. Once again, the authors present guidelines for understanding the phenomenon and thoughtful discussion of complicated legal and social issues.

Stalkers and Their Victims provides an excellent comprehensive overview of stalking. It is a well-written and concise work that has considerable relevance for physicians and provides an excellent reference for those interested in this topic.

Medical interviewing is an enormously complex task. Physicians must ascertain symptoms, make diagnoses, get to know the patient in a broader psychosocial context, develop a therapeutic relationship, and counsel the patient about behaviors and therapies. Recent studies show the importance of doctor-patient communication for patient satisfaction, compliance, and clinical outcomes. All this depends on a 15 minute visit!

Students of the doctor-patient relationship know that specific techniques help in carrying out the interview's various functions. Platt and Gordon's Field Guide to the Difficult Patient Interview is a useful tool that summarizes practical techniques and strategies to improve our interactions with patients.

The first of the book's six sections lays out the authors' general schema for interacting with patients and emphasizes basic skills used in most interactions: listening, nonverbal communication, translation, and education. The other sections focus on a wide range of encounters and situations that physicians are likely to find difficult—difficult relationships, difficult emotions, end-of-life discussions, conversations about risky behavior, and problems brought on by rapid changes in technology and health care financing. Each chapter is organized around five P's: the problem; principles for approaching the problem; procedures for discussing the problem, using actual doctor-patient transcripts; pitfalls that may occur in the conversation; and pearls that summarize the chapter's main points. Up-to-date references are available for those who want to delve into a topic in more detail. Each chapter is only three to five pages long, making it particularly useful as a reference in a busy clinical practice.

In format the book is clear, concise, and practical. It is small, easily carried in a coat pocket, and provides accessible guidance that can be perused or reviewed during a busy clinical day. The authors briefly enumerate strategies, describing both theory and practice. We found the procedure section, in which the authors provide examples of exactly what a clinician can say, particularly helpful. Students and residents can use the examples to get started with their own patients.

A number of chapters are particularly useful. Many of us become frustrated with patients we label as noncompliant. The chapter on ambivalence dispels the myth of the noncompliant patient. The authors suggest strategies for dissecting the feelings behind the patient's resistance, telling us that "the best tool for working with ambivalence is empathy." The steps outlined in this chapter are extremely helpful for clinicians trying to persuade their patients to take medications, change lifestyle habits, or agree to undergo testing. Trainees will learn techniques to help them and their resistant patients pass beyond these roadblocks.

We found the chapter on dealing with angry patients useful even for experienced clinicians. The authors comment that "anger, especially anger aimed at you, is an attack and you will feel it as such," a reminder of the importance of the clinician's emotional reaction in the patient encounter. Also useful is the description of empathy and how it differs from agreeing with the patient and from sympathy. Finally, colleagues who used the chapter said that they found the examples of empathic paraphrases ("If I'm hearing you right," "Let me understand if I understand you correctly," "Sounds like") easy to incorporate into their practice.

The book has some minor flaws. After a recent month in the office, we especially would have liked chapters on patients who are also physicians, how to deal with being set against another physician, and how to negotiate with health insurers. We also worry that students may use the book in a rote manner. In the book, the authors' use of empathic techniques always results in the patient becoming calmer and "more reasonable," but in practice one empathic statement is not enough. A chapter on what one might do when "nothing" seems to be working would be a valuable addition. Moreover, students need to understand that words alone are not enough. One has to be genuinely interested in understanding the patient's viewpoint, or the words will come across as manipulative or condescending.

The authors offer something for everyone who deals with patients on a regular basis. Medical students and residents will derive many useful tips from the chapters "Basic Interviewing Techniques," "Nonverbal Communication," and "Listening." More experienced clinicians will find help with specific types of patients and encounters, in such chapters as "Somatization" and "End-of-Life Discussions." Educators and program directors can use the book to improve the communication skills of their trainees. We found it a useful companion guide to reviewing videotaped clinical encounters of trainees.

We know of no similar practical guide to negotiating the communication problems that vex clinicians. Field Guide to the Difficult Patient Interview is an important resource as doctors struggle to attend to their patients amidst the noise of health insurers, administrators, and increasing technology.

Permissible Dose: A History of Radiation Protection in the Twentieth Century, by J. Samuel Walker, historian for the Nuclear Regulatory Commission (NRC), is a well-researched account of scientific, political, and public interactions in the development of protective standards for ionizing radiation for the Manhattan Project and its successor agencies.

The author does not discuss standards development for workers exposed to radium, radon, and medical x-ray (just mentions them) or the influence that corporate profits have had on the setting of permissible doses for some radiation exposures and many chemically toxic agents. For radiation in government settings, agencies can pass the cost of enforcing low exposure standards on to taxpayers, but, in the private sector, that cost affects profits, and corporations are known to delay the setting of standards and work to keep permissible doses high.

Until the late 1960s in the United States, strong evidence, such as a statistically significant number of deaths, was usually necessary to trigger official control of a new industrial hazard. This routine was observed with early x-ray, radium, radon (uranium mining), tobacco smoking, and asbestos, among others, each resulting in disaster. According to Walker, the use of radiation by the Manhattan Project and its successor agencies was an outstanding regulatory exception. The Atomic Energy Commission (AEC) accepted the recommendations of official radiation protection organizations, which issued their first tolerance dose standard in 1934. Such terms as tolerance dose and threshold dose were later replaced by permissible, in recognition of the probability that any amount of radiation might be harmful. The AEC encouraged independent organizations to use the best scientific advice in making recommendations for radiation safety control. The recommendations were then accepted and enforced wherever the federal government had jurisdiction.

The reason for the difference in standards and enforcement between radon in mines and radiation in federal nuclear laboratories was that the AEC was charged by law to maintain radiation safety in its operations, but uranium mining was not included in this charge. Congress, wanting no federal intervention, had traditionally kept occupational safety in the hands of individual states. The Atomic Energy Act represented the first exception to keeping occupational safety out of federal hands; other exceptions were to follow.

Most of Permissible Dose is a well-referenced summary of the activities of the national radiation safety organizations and their continuing efforts to incorporate the latest scientific data into their recommendations. By use of such data, the AEC maintained the confidence of both workers and the public—until the fallout controversy. Because testing of nuclear weapons in the Pacific area was so very expensive, the AEC decided that it must have a testing area in the continental United States. To prevent public demand for abolition of these tests, the AEC gave some false assurances of safety. When the risks were later revealed, the public lost confidence in both the AEC and standard setting agencies. The public could not appreciate the numbers showing very low risk from low exposures but took seriously the endlessly repeated statement that all radiation is hazardous. This public concern led to a lowering of permissible doses for public exposure and halted the building of nuclear reactors for electricity generation. It also led Congress to pass new laws regulating radioactive waste on land, in water, and in air. These new laws added to the problems of uniformity in how different federal agencies handled radiation safety, especially the NRC and the Environmental Protection Agency. Agreements between agencies are uneasy, despite several attempted remedies.

As the author recounts, there had always been a tacit understanding among radiation safety experts that they need not be concerned about radiation levels that approached natural background levels. Some new laws (1985 and later) seemed to require control of some radiation exposures at levels below natural background. To many people, some of these new requirements seemed to be a waste of resources. The NRC led an effort to set a legal radiation level that could be regarded as "below regulatory concern"—abandoned after a firestorm of opposition.

New calculations of exposures and risks from the Japanese A-bombs have led to new interpretations of that data, which has influenced new standards. After reviewing this and other studies of low-level exposures, Walker concludes by stating that "radiation safety organizations and federal agencies that followed their recommendations acted responsibly and judiciously to protect radiation workers and the public from the risks of low-level exposure from industrial, medical, and other civilian applications." Most radiation safety experts would agree. Publicized injury has come from accidents, military applications, nonradioactive beryllium (which was used with uranium or plutonium in making bombs), or from radiation exposures outside federal jurisdiction.