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Snowball in a Blizzard: A Physician's Notes on Uncertainty in Medicine - A NYJB Review by Dr. Ll


Dr. Steven Hatch is an infectious disease and immunology specialist who has written a complex exegesis to try to make comprehensible the uncertainty (and complexity) he asserts is "the greatest unspoken secret of medicine." He compares medicine's uncertainty to what he contends to be the certainty of rocket science and chemical engineering.

After over 40 years as a physician, while I am uncertain as to what is our greatest unspoken secret, I don't think it is uncertainty. And I don't know of any field, rocket science and engineering included, that is spared uncertainty. Medicine has its share of uncertainty, for sure, but we don't win Best In Show.

Yet Dr. Hatch is the kind of doctor I would want to visit. He is highly informed and makes plain that good medicine is a true partnership between patient and doctor. But once he gets before a keyboard he seems to forget who his audience is. He tells us he wants to provide a "survey of the landscape of uncertainty" in a manner that will elude the language of ivory tower of academic medicine, yet his prose exudes it.

But he loves detail and is prone to the language (jargon) of his field. His prose, thus, suffers, and his readers will be too often lost in the weeds of his otherwise thoughtful garden of examples and stories. For example, the chapter on causation and correlation—where because things may occur together does not mean one caused the other—is 27 pages long.

In another example, there is a 19-page appendix he titles "A Very Nonmathematical Description of Statistical Significance," which has one arcane table but no graphics or illustrations; a picture would be worth 1,000 words. The book is too light for academics and too heavy for the general public.

If you or a loved one are wondering about the controversy over breast cancer mammography screening, or long term antibiotics for Lyme Disease, or new guidelines for when to treat hypertension, then reading the specific section that pertains to you may be a bit rough going but useful. But writing of such prolixity full of technical detail for an entire book is too hard a slog.

The book's title, Snowball in a Blizzard, refers to how hard it is to find a tumor in an X-ray of breast tissue because the ostensible snowball, the tumor, will be readily lost to view among the blizzard of other tissue revealed on the radiograph. In the field of medicine, that calls for more definitive diagnostic efforts, which like with therapeutics, is the history of progress in science and medicine.

As sanguine as Dr. Hatch is about medical care and its march to greater certainty, his book too often leaves the reader lost in the density of his material—a blizzard of information—when clarity and brevity would help us discern the snowballs we want and need to see.

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Published on March 10, 2016, in The New York Journal of Books

Lloyd Sederer, MD, is Medical Editor for Mental Health for The Huffington Post, Adjunct Professor at the Columbia/Mailman School of Public Health, and Chief Medical Officer for the NYS Office of Mental Health. The opinions expressed here are entirely his own.

Dr. Lloyd’s two new books are now available: Improving Mental Health: Four Secrets in Plain Sight (2016) and Current Controversies in Mental Health and Addictions: An Expert’s Anthology (2017)


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