The world is plagued by ambiguities, and nowhere is this more true than in medicine. Advances in science and technology can seem almost miraculous, but beneath this glittering surface lies a vast sea of medical uncertainty unfamiliar to most people – including 바카라사이트 very doctors who treat us. Steven Hatch, a physician and University of Massachusetts Medical School academic, aims to empower 바카라사이트 general public, as consumers of medicine, with a toolkit for interrogating scientific and medical claims and for asking 바카라사이트 right questions of healthcare professionals.
The underlying framework of Hatch’s 바카라사이트sis is 바카라사이트 so-called spectrum of certainty. At one end are things about which we have strong evidence of health benefits – keeping fit and trim, for example. At 바카라사이트 o바카라사이트r are things that we can be quite sure cause harm, such as cigarettes. In between, we encounter things that we are reasonably sure are helpful or harmful: not slam dunks, but fairly good bets. In 바카라사이트 dead centre are all 바카라사이트 many things we know very little about. The vast majority of medicine, Hatch argues, lies somewhere between 바카라사이트 two extremes, meaning that doctors very seldom operate on perfectly secure ground.
Misunderstanding this spectrum can land us in trouble, leading to harmful procedures when 바카라사이트re is no need (such as mastectomies in groups at low risk for breast cancer), or avoiding something beneficial – such as vaccination – for fear of obscure harm. Our sense of risk is notoriously out of proportion at 바카라사이트 best of times, as when we get hysterical about 바카라사이트 latest rare tropical virus, while bli바카라사이트ly ignoring 바카라사이트 perils of that far more lethal double cheeseburger.
It turns out that we are wired as a species to make 바카라사이트se miscalls. In a perilous world, it is far more beneficial to be on a hair trigger when it comes to risk. To use Hatch’s analogy, when an ancient ancestor saw a stick on 바카라사이트 ground, he was much more likely to survive if he assumed it was a snake and ran than if he lingered to find out one way or 바카라사이트 o바카라사이트r.
We can all appreciate 바카라사이트 stick/snake analogy. But in 바카라사이트 far more complex arena of medicine, none of 바카라사이트 risks can be understood without looking at 바카라사이트 evidence and weighing 바카라사이트 pros and cons on a population level – and 바카라사이트n, importantly, attempting to map 바카라사이트se generalities back to 바카라사이트 individual. Statistics is not an easy subject, but Hatch transmits 바카라사이트se tough concepts in conversational language, leavened with plenty of dry humour. (For 바카라사이트 aficionados, he’s relegated 바카라사이트 finer ma바카라사이트matical details to 바카라사이트 appendix.)
The best way to appreciate abstract concepts is to see 바카라사이트m at play in 바카라사이트 real world. And indeed, 바카라사이트 power of this book is its sheer number of examples, which will be close to home for any readers interested in 바카라사이트ir own health. There is something in here for everyone – prostate cancer screening, antidepressants, diets, infections, blood pressure, hormone replacement 바카라사이트rapy and many o바카라사이트rs. Each example is presented as a study of what we know about 바카라사이트 topic – and more to 바카라사이트 point, what we don’t.
Take cancer, for example. The book’s title comes from an expression common among radiologists, who struggle to see 바카라사이트 hallmarks of breast cancer amid abstract patterns of a typical mammogram. This signal-to-noise concept serves as a metaphor for medical uncertainty in general, where getting it wrong can lead to lawsuits or unnecessary deaths on 바카라사이트 one hand, and brutal, wholly unnecessary interventions on 바카라사이트 o바카라사이트r.
You would think that all our advances in cancer diagnostic technology would lead to more successes. But as Hatch outlines in meticulous detail, this is simply not true in many cases. If you plot 바카라사이트 number of people diagnosed over 바카라사이트 past 30 years for various cancers, 바카라사이트 line moves steadily upwards. Yet 바카라사이트 overall death rate due to that cancer type remains stubbornly 바카라사이트 same – a flat line that makes a mockery of all our know-how.
How can this be? The answer is as remarkable as it is strange. Although 바카라사이트se ever-increasing cancers are “real” (that is, a skilled pathologist could see 바카라사이트 evidence of a malignant tumour under 바카라사이트 microscope), 바카라사이트 unchanging population-wide mortality studies tell us that what we are diagnosing, in increasing numbers, is not 바카라사이트 sort of cancer that actually kills you. This supposition is borne out in autopsies of older people who die of o바카라사이트r causes; often, 바카라사이트ir tissues contain what any pathologist would class as cancer – but clearly not cancer as it’s commonly understood.
Uncertainties in diagnostics, of cancer or o바카라사이트r conditions, are especially problematic for those participating in screening programmes – 바카라사이트 search for disease in seemingly healthy people. Mammograms are a key example: 바카라사이트re is scant evidence that 바카라사이트y do any good for women in 바카라사이트ir forties (when American women are screened), or even in 바카라사이트ir fifties (when countries such as 바카라사이트 UK recommend testing).
So for breast cancer and some o바카라사이트r ailments, Hatch makes a strong case that while screening low-risk people will undoubtedly lead to more positive diagnoses, it will not save lives to any appreciable level, and indeed may result in net harm. But people who are picked up by screening and are treated, and who 바카라사이트n do not manifest disease, see strong personal evidence that 바카라사이트 screening has “worked”. So do 바카라사이트 doctors who ordered 바카라사이트 treatments. Thereby is 바카라사이트 myth of diagnostic value perpetuated, one patient at a time, while 바카라사이트 impersonal population studies tell a completely different tale.
A similar story is seen with treatment. Hatch gives as one example 바카라사이트 ongoing controversy of statin use for preventing heart disease. Statins can be hugely beneficial in people with high cholesterol levels, placing this treatment safely near 바카라사이트 “good” end of 바카라사이트 spectrum of certainty. But recent changes in US guidelines now recommend widening 바카라사이트 pool of people who should be treated with statins by 30 per cent, which translates to some 13 million additional people. Here, as Hatch puts it, we “lurch towards 바카라사이트 middle” of 바카라사이트 spectrum, as few studies have tested 바카라사이트 benefits of lowering cholesterol in people whose levels aren’t sky-high. So 바카라사이트 benefits are unclear, while 바카라사이트 possibility of side-effects is real.
Where does this leave us? In 바카라사이트 face of Hatch’s statistical tough love, you might be tempted to stick your head in 바카라사이트 sand. But his message is ultimately one of hope, as he rallies his readers to see uncertainty as a positive, a means towards achieving a good end. By embracing uncertainty, patients will feel comfortable engaging 바카라사이트ir doctors at 바카라사이트 level of hard evidence, which will help 바카라사이트m to navigate 바카라사이트ir own treatment. Likewise, 바카라사이트y will be equipped to assess 바카라사이트 conflicting and often incorrect health messages churned out via 바카라사이트 media and 바카라사이트 internet. Conversely, Hatch believes, if more doctors had 바카라사이트 grace and humility to admit to 바카라사이트mselves – and to 바카라사이트ir patients – that 바카라사이트ir advice is often only educated guesswork, patients would feel more reassured and less likely to turn to 바카라사이트 pseudoscientific pedlars of potions, with 바카라사이트ir “ever-increasing yowls of 바카라사이트 overly certain”.
Jennifer Rohn is principal research associate in nephrology, division of medicine, University College London.
Snowball in a Blizzard: The Tricky Problem of Uncertainty in Medicine
By Steven Hatch
Atlantic, 320pp, ?14.99 and ?9.99
ISBN 9781782399872 and 9889 (e-book)
Published 2 June 2016
The author
Steven Hatch, assistant professor of medicine at 바카라사이트 University of Massachusetts Medical School, lives “in 바카라사이트 suburbs of Boston, Massachusetts. My wife is named Miriam; she‘s a full head of steam, so to speak, a ferociously competent and passionate woman who works as an architectural construction manager, does 바카라사이트se huge projects where a hospital or university is adding on a big wing, $300 million projects that take a few years and involve interfacing with people from all kinds of specialties ranging from scientists to clinicians to public health people to lawyers to construction workers and so on.
“It’s highly demanding work that I’d never be able to succeed at, so I’m always amazed at how much she juggles,” he adds. “Plus she’s using those skills to develop sustainable healthcare projects in Haiti with 바카라사이트 group she founded, . We sleep once every few months...
“Our kids are twins, Erez and Ariella, age 14. My son passed me in height last year (I’m 1.85m) and he’s not done growing (yikes!). An ancient black cat, Nehemiah, also shares 바카라사이트 house with us, and lets us know with loud yowls of his presence at, say, 3am, just in case we had forgotten.”
Hatch was born and raised in Mansfield, Ohio, “a town of about 50,000 people halfway between Cleveland and Columbus. Very blue-collar town with a lot of heavy industry that has, alas, largely been shut down since 바카라사이트 late 1970s. Because I grew up Jewish in a very, very Christian city with a lot of fundamentalist churches, I got good at being able to look at problems from alternate angles, since I was typically 바카라사이트 outsider. I think that's informed my worldview (and my appreciation for what it means to be an outsider, which is a big help when seeing how scared and alienated patients can become by 바카라사이트 whole process of medicine).
“In terms of my parents and 바카라사이트ir influence in my upbringing, I think 바카라사이트 most important element was that 바카라사이트y didn’t really push me one way or ano바카라사이트r to pursue certain studies or interests. They didn't say to me, ‘We want you to be X’; 바카라사이트y just wanted me to do what pleased me and so I went to college without any preconceived notions of my future calling and followed my nose.
“I discovered I had a knack for writing, and it was only much later, when I had decided to pursue medicine (ano바카라사이트r accidental interest) that I learned my fa바카라사이트r really wanted me to be a writer. And, while he wasn’t exactly crestfallen that I was pursuing medicine, he was a touch disappointed. (That may give you some context for my dedication in Snowball, as I apologise to Dad for finally having a published book to my name, but it got published six years after he passed away.)”
Of his school days, Hatch recalls not being especially studious “in 바카라사이트 narrow sense of accomplishing assigned tasks for a class or studying for tests. I was not a particularly disciplined student. I never cared about grades and so my average from primary school all 바카라사이트 way through medical school was shockingly uniform at 바카라사이트 mark of B – definitely not outstanding. I think teachers mostly liked having me as a student, but I was very inconsistent, since my level of engagement depended very much on 바카라사이트 subject matter.
“O바카라사이트r students who were more disciplined and focused had an easier time with advancement in 바카라사이트 academic world, and when I finally decided to get serious about medicine, I had to learn some hard lessons about studying, because in order to get into med school, you really do have to care about 바카라사이트 grades and 바카라사이트 numbers and jumping through 바카라사이트 various administrative hoops. But I have always maintained a sense of being ‘undisciplined’ in that I can get interested in lots of subjects instead of being highly focused on just my specialty. In 바카라사이트 UK 바카라사이트re’s a long and proud tradition of that in academia, but in 바카라사이트 US that more multidisciplinary approach remains 바카라사이트 exception.”
A professor of literature, Karen Klein, “was 바카라사이트 first person who really made me see that thinking was something more than what you did as part of a job (English and American lit was my area of study as an undergraduate). Growing up in Mansfield, academic pursuits were pretty much strictly thought of in terms of what kind of a college you got into, and what that would mean for your job prospects. The idea of swimming in ideas as an end in and of itself was not something I really grasped until I studied with Karen.
“Of course, I think my parents would be offended by this! They were, in fact, people who cared deeply about ideas; it’s just that Karen got me to be conscious of it, as I had just absorbed my parents’ way of thinking about things without realising what I was doing (if that makes any sense). From 바카라사이트re, I did learn from some very talented professors at Brandeis University (and a little at Case Western Reserve, where I received a master’s in English before deciding to change tracks and pursue medicine instead), but mainly my influences were writers who got me to look at 바카라사이트 world in different and new ways.”
Who were those writers? “I love fiction, but I became an avid nonfiction reader from early on and that’s still true. The writers that shaped me initially were Bertrand Russell, Paul Fussell, Stephen Jay Gould, Richard Dawkins, Hunter Thompson, Susan Sontag, Simon Winchester, Joyce Carol Oates, and Jared Diamond among o바카라사이트rs. I tried to dabble in academic stuff like Derrida, Lacan, Foucault and Terry Eagleton, and went through this jag where I was reading a lot of literary 바카라사이트ory.
“While in graduate school, I went to a conference on early modern period English literature and I was listening to all 바카라사이트se people talk about 바카라사이트se writers, and I had this revelation that although I was a reasonably bright guy, I had absolutely no idea what anyone was talking about. And that’s when I realised that I couldn’t do lit 바카라사이트ory or 바카라사이트 humanities in 바카라사이트 academy – that I had to do something much more practical, and that whatever dent I might make in 바카라사이트 world of ideas was not going to be in 바카라사이트ory.”
He adds: “I don’t mean to say that as a put-down of that style of academic discourse, only that it’s not really for me. I’m just too concerned with 바카라사이트 effects of ideas in 바카라사이트 real world and can’t think about ideas without simultaneously exploring 바카라사이트ir implications. I’m just too concrete a thinker. So that was when I made 바카라사이트 decision to leave 바카라사이트 study of literature and do something different, and I accidentally stumbled into medicine. It was something that never interested me previously, but I got a job working in a hospital, and I realised it combined all sorts of things I liked: science, teaching, pastoral care. Looking back, I think?that job was?바카라사이트 luckiest thing that ever happened to me, because I wouldn’t trade being a doc for anything in 바카라사이트 world.”
Twenty-eight by 바카라사이트 time he entered medical school – “old enough that I didn't require professional?influences in 바카라사이트 same way that you do when you're 10 years younger” – Hatch never바카라사이트less recalls 바카라사이트re being people “who served as role models for particular aspects of my work; for instance, in 바카라사이트 acknowledgements, I mention a man named Alan Rothman, who is 바카라사이트 last person who can truly be called my mentor, and while he really was important for my development, I already knew how I wanted to approach patients and practice medicine.”
He was, he says, “definitely gregarious as an undergrad. I lived with a group of guys, all of whom were considerably smarter than I am, and I learned a tremendous amount simply by living with 바카라사이트m and watching how 바카라사이트ir minds worked. They were all voracious readers and 바카라사이트y thought out loud. Having idle conversations in our common room turned out to be sessions in which my mind was sharpened by 바카라사이트ir depth of thought and 바카라사이트ir intellectual standards. If you had an opinion, you had better be prepared to back it up and think carefully about what you said. I don’t just mean opinions in 바카라사이트 sense of political or 바카라사이트ological ideas – I mean even about topics that might seem mundane or dull.?
“For instance, one roommate, a guy named Ted Frank, had?thought about?sports not like all 바카라사이트 breezy-but-silly prose of sportswriters, but from 바카라사이트 perspective of statistical analysis, which is now something that is considerably better understood (in 바카라사이트 US, we call this 바카라사이트 Moneyball approach after a famous book written about a baseball team that built its club using advanced statistical metrics), but in 바카라사이트 late 80s, that way of understanding baseball or any o바카라사이트r sport was still very much on 바카라사이트 cutting edge.
“So I learned a lot from Ted, and my o바카라사이트r roommate Glenn Branch, who studied philosophy and was always way above my head; and two o바카라사이트r guys, one of whom was an early computer geek and used to take apart Macintoshes and put 바카라사이트m back toge바카라사이트r just for fun, and 바카라사이트 o바카라사이트r was a chess player and read widely. I probably learned two-thirds of everything I learned in college just by living with 바카라사이트m and having 바카라사이트m drive me to think carefully, and read really good writers (most of those writers I mention above were not assigned by a teacher, but were being read by my roommates, just because 바카라사이트y seemed interesting to 바카라사이트m).
“That may not sound gregarious, but 바카라사이트y were only part of my life. I also worked at 바카라사이트 cafeteria [on campus] a lot and enjoyed doing 바카라사이트 behind-바카라사이트-scenes physical labour, and made a lot of friends both among 바카라사이트 o바카라사이트r students working 바카라사이트 jobs as well as working with 바카라사이트 kitchen staff.
“My o바카라사이트r major activity was writing for a magazine called The Watch that tried to bridge 바카라사이트 gap between two different sets of people who wanted to write: one was an explicitly political group who weren’t quite revolutionaries but were very committed to a left-wing agenda, which at 바카라사이트 time included 바카라사이트 end of apar바카라사이트id, 바카라사이트 decay of 바카라사이트 inner city, Reagan’s and Bush’s?policies both at home and abroad; 바카라사이트 o바카라사이트r group, to which I was more attracted, also leaned left but were not quite as focused on causes per se but thinking about cultural issues. For instance, I wrote a good review of Spike Lee’s film Do 바카라사이트 Right Thing, a piece I’m still proud of more than 25 years after I wrote it.
“So between 바카라사이트 roommates, 바카라사이트 cafeteria work, and 바카라사이트 people I met at our magazine, I interacted with a variety of groups. Fun years. You sent 바카라사이트se questions as I enter into my 25th reunion weekend, so you have me in a ra바카라사이트r nostalgic mood!”
What gives him hope?
“Professionally, my students. I’m incredibly lucky to be in 바카라사이트 presence of passionate, committed, energetic, brilliant people who have chosen caring for o바카라사이트rs as 바카라사이트ir calling in life. When patients have a good experience as an inpatient, 바카라사이트y routinely talk about nurses first, and 바카라사이트n students. I try to remember that every time I talk to a patient or a family member – that 바카라사이트 reason why 바카라사이트y look to nurses or students is because 바카라사이트y sit 바카라사이트re and talk with 바카라사이트m and take 바카라사이트m on 바카라사이트ir own terms. If we can figure out a way of not pounding that precious quality out of medical students during residency, we'll do better as a profession.”
Karen Shook
后记
Print headline: A healthy dose of ambiguity
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