Human Molecular Biology: An Introduction to the Molecular Basis of Health and Disease
Authors: L. Wentworth, T. Dornan
Journal: Journal of the Royal Society of Medicine (2003)

Six hundred pages long, fresh from the scientific cutting edge, written by a single author, and bursting with energy and humour, we could not fault the publisher's description of Human Molecular Biology1 as groundbreaking. As predicted, we found ourselves launched into a strange but colourful and exciting world of sonic hedgehogs, frizzles, snurps and Wattanabe heritable hyperlipidaemic rabbits. A glance at the book shows that it merges the fields of molecular biology and medicine, as promised. Richard Epstein advances two main arguments for this adventure. One concerns the nature of health and disease; the other concerns education. Before recommending the book to ‘the new generation of medical students’, those arguments bear scrutiny.

There is no place for holism in Epstein's conceptualization of health and disease. He argues, ‘it is the interconnected working of genes, proteins, and intermediary molecules which define health and disease’. He writes of the limitations of a systems-based approach, on the grounds that systems are interconnected, and arrives after a diversion into educational method at the statement, ‘All biology is now about molecules’. But mightn't a move to holism be an even more logical response to the interconnectedness of systems? Not for Epstein, whose next chapter hammers home the message, summarizing it in ten words, ‘Medicine is now about molecules. Molecules are easy to understand’. Perhaps it was sour grapes because we knew the meaning of no more than one-third of his ‘must know’ terms (age narrowly outperforming beauty), but we felt unsure he had presented evidence for the first point and were more persuaded against than for the second.

On modern medical education, Epstein would not expect a student and a teacher from a medical school with a problem-based curriculum to side with him when he dismisses ‘imbuing trainees with creative insights and self-learning potential’, and praises ‘learning facts’. We politely remind him the two are not mutually exclusive, as shown by a recent study from the Netherlands.2 Facts, Epstein tells us, are as essential to someone learning medicine as an instrument is to learning music. But is he using the right analogy? Shouldn't we consider whether you need a rigorous grounding in music theory to perform well? The success of jazz musicians with little formal education argues otherwise. We heard strong echoes of Flexner,3 from whom the UK General Medical Council is trying to pull us away,4 in his contention that ‘the task of the educator is to teach biomedical sciences from the molecules up rather than from the disease down’. Whether Epstein approves or not, modern medical education puts the student rather than the teacher centre-stage, and impoverished students need to be sure a book is a good investment, so is this skilful enough teaching to justify an outlay of £30? We present our judgments separately, beginning with those of LW, the medical student.

Good visual impression began with the eye-catching cover and continued with the excellent vertical layout of one-third diagram two-thirds text. The pages are colourful and the micrographs make an aesthetically pleasing start to each chapter. Structure and navigation have been carefully thought out. There are two tables of contents, brief or detailed, so a reader can quickly identify the main areas covered within a particular chapter or, if required, locate more specific information. The ‘Read Me First’ page that introduces readers to the colourful icon navigation system is a thoughtful touch, though remember that we never do read books from the beginning, so the explanation will be wasted on many. And are three introductions really needed to outline a book's objectives? There is a glossary to help readers cope with the language of molecular biology but putting it at the beginning means some will never find it. And there is at least one example of a single abbreviation referring to two terms.

A fundamental drawback of the book is that it is written as a narrative, each chapter building on information in previous ones. That would not matter if I could be expected to read it all, but the overwhelming size and level of detail makes that an unrealistic expectation of a medical student. So, many of Epstein's nice educational ideas are doomed. The pharmacy footnotes and clinical keynotes, illuminating science with clinical examples and vice versa, assume prior knowledge of concepts and processes. As the book goes on, the molecular mini-reviews contain information that presupposes degree level knowledge of molecular biology; and to understand the text that follows, you need to have understood the mini-review. Catch 22!

Students doing research projects or special study modules will be grateful for the suggestions for ‘enrichment reading’, and all readers will appreciate the chapter summaries, though they would be better as bulleted lists than paragraphs of prose. Self-assessment is useful, but it is a fatal flaw in a book of this complexity not to give the answers to questions, which means you have to re-read the chapter to find if you have got the answer right—not an encouraging prospect when you have just ploughed through to the end.

It seems Epstein is trying to appeal to the younger market in his use of trendy language, but his style of writing is too much in every sense. Too many adjectives, too much text and too much information. As well as trying to get to grips with an unfamiliar scientific language, I am faced with complex and decorative prose; it is not skilful teaching to write of ‘The Rosetta stone of homo sapiens’. At the other extreme, are medical students so thick they need to be given a definition of vegetable as ‘not animal or mineral’? Give us simple prose, bullet points and subheadings. And simple, illustrative figures. Processes such as the transcription of DNA-tRNA-mRNA, described in detail in the text, would have really benefited from a clear visual aid. I particularly liked the photograph of Burkitt's lymphoma; more of this sort would give the text so much more meaning.

To round off our review, and return to Epstein's central claim that medicine is now about molecules, the medically qualified reviewer (TD) put it to two tests. One was to select a page of the index at random and see what it referred to. There were 31 clinical conditions, 19 of which I have never had to deal with, and many of which I have never heard of. That is surely a distortion of what ‘medicine’ is, and doesn't it perpetuate a problem the General Medical Council so much deplores if Canale-Smith syndrome is given the same priority as basal cell carcinoma? While I was reading the book, a patient whose von Hippel disease I have looked after for over a decade was found to have tumorous lesions in both kidneys. Human Molecular Biology provided a fascinating explanation of the molecular basis of this mishap, but left me unsupported in managing the clinical problem. Should we remove the lesions or watch and wait? Is there a chance he will be left with no kidneys? How should we respond to his fears of not living to see his son reach adulthood, and manage his anger and guilt about the dominant inheritance pattern of the disease? What is the best method and frequency of screening for phaeochromocytoma and cerebellar haemangioblastoma? A decontextualized molecular explanation that does not even acknowledge those issues has as much to do with medicine as I know it—and is as morally appropriate to medical education—as a freak show.

One cannot but applaud Epstein's energy in writing this book, and Cambridge University Press's skill in presenting it so pleasingly. It will be useful to life science students and the occasional bright medical student who is doing a project or is naturally curious, but neither the student nor the teacher who reviewed the book could recognize it as ‘medicine’ or ‘skilful education’.