American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, January 5, 2016

How experts agree while looking like they don't

I have been gratified by, and fascinated with, the extensive media coverage since the recent, groundbreaking Oldways Common Ground conference on healthy eating. That the conference was legitimately groundbreaking is a case I have myself made. What other journalists have chosen to highlight varies widely and is the source of my fascination. Those who chose as their focus the product of the conference sounded a lot like me, noting the remarkable consensus achieved. Those who focused on the process tended to dwell on discord rather than consensus.

That these journalistic perspectives are complementary rather than competitive, rather like the diverse views of the participating nutrition scientists themselves, is the grist for today's milling.

To make the case without premature activation of any native passion on the topic, and thus the selective deafness that can follow, I will avoid the topic of nutrition altogether. Let's consider instead the matter of bridges, and how building them might look surprisingly like burning them.

Let us imagine a conference on advances in the building of suspension bridges. To add a patina of verisimilitude to this thought experiment, I Googled “conferences for industrial engineers” just now, and sure enough, they gather in the very way we are about to pretend. I added “suspension bridges,” and yes, that specific topic is addressed at some of those conferences. We are good to proceed.

We may reasonably assume that the audience at such a conference is rather exclusive to those with deep interest and expertise in the particulars of bridges, industrial engineers, structural engineers, architects, and so on, and that the roster of speakers represents even more rarefied expertise in those same areas. Who else would go?

Is it likely the conference would open, assert a common understanding of the one, best way to build a suspension bridge, and then adjourn? Obviously not; there would be no point whatever in going to the trouble of convening a conference in the first place for such an anticlimax.

One may confidently presume that the experts at any such conference would opine at some length, offering insights about different methods, different materials, and preferred refinements. That would be the very point of holding a conference, devoted to advancements in the understanding of bridges.

If any of those experts were asked, perhaps right after his or her keynote, about the “best” way to build a suspension bridge, they could be forgiven for proffering their own. After all, that's part and parcel of being an expert; you develop deeper knowledge of, and along with it deeper personal attachment to, a given topic than a non-expert. That's what expertise is.

As an expert, it would make little sense to devote your years and energy to any aspect of your field that you found less promising, interesting, or important than another. You would, reliably, allocate those precious resources exactly where you saw the greatest opportunity. When asked what matters most, you would tend to talk about what you do, because you would tend to do what you decided matters. The reasoning here is all the more robust for going around in so vivid a loop.

This, of course, would be true for all speakers in roughly comparable measure. For any given expert, years focused on some aspect of a larger field that began with passion and preference, and resulted in more of the same, would produce a predictable response to: What is best? The answer from all really should be some variation on the theme of: my way! Why on earth, when asked about what matters most, would you indicate anything other than your own, career-long devotion? If you actually thought some other aspect of your field mattered more, you would, presumably, have long since rerouted your career in that direction.

So, simply asking scientists to express their devotion to the work they do can create the appearance of discord; each expert indicates some particular preference at odds with all the others. If we ask Expert 1 if her method is the best, she will undoubtedly say yes, and tell us why. If we ask Expert 2 if Expert 1's method is the best, he will doubtless say no, and tell us why his is better. Few responses hint at commonality with the penuriousness of “yes” and “no.”

But ask different questions, and an entirely alternative reality unfolds. Would these experts agree that they both use materials and methods more alike than different? Why, yes. Would they agree that the other is, in fact, a genuine expert? Well, certainly. Do they respect one another? Indeed. Would they be willing to drive their family across a bridge constructed by their counterpart? Assuredly so, with confidence and calm. Would they be willing to drive across a bridge constructed by a random citizen with no relevant training or expertise in their field? Heaven forbid!

It's just the same in nutrition. I know in part because I have done something rather analogous to driving across suspension bridges with many of the world's bridge experts; I have shared meals with many of the world's nutrition experts across an expanse of conferences, decades, and continents. When it comes time to opine to the public, we can sound like we differ radically about everything, because we each emphasize that thing we do. But when it comes time to sit down and eat, our plates, inevitably, look remarkably similar to each other, and nothing like the “typical American” meal.

The notion that no 2 nutrition experts agree about anything is wrong. The contention that any individual nutrition expert's opinion changes every 20 minutes is also wrong. In fact, these are not merely false propositions, but profoundly, abjectly so. The fundamentals of understanding in nutrition are remarkably time-honored, spanning, believe it or not, millennia, to say nothing of recent decades. There is not just a general agreement about those fundamentals; there is a massive, global consensus among stunningly diverse experts. I have proof.

We may concede, however, that the stability and unanimity of expert opinion sure is hard to see. Partly, that's because of experts themselves emphasizing what makes each of us unique, rather than what makes us alike. Mostly, however, it is because there is profit to be had, enormous profit, in obscuring the truth about diet, and the consensus about it.

The way experts express expertise may make it seem as if the only thing we ever do with bridges is burn them. In reality, we may have been building them all along, with methods and materials far more alike than different.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

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John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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One of the most popular anonymous blogs written by an emergency room physician.

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