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Wednesday, June 22, 2016

How expertise dies: of character, credentials, and crap

Perhaps no topic better illustrates the enormous gap between knowledge and ignorance, and its profound importance to the ambient understanding of all humanity vital to advancement at the most basic level, than evolution. The story of evolution by natural selection is, effectively, written, in vivid detail, in the language of molecular genetics. If you can read this language, the tale it tells is clear, decisive, and irrefutable; the facts presented about as prone to denial as sunrise.

Nor need you be literate in molecular genetics per se, any more than you need learn Russian to read Crime and Punishment. There are highly proficient translators in both cases. A bounty of books on evolutionary biology have been written by the unassailably erudite for the decidedly less so among us. Complex science has been translated into the lingua franca.

What, then, is the basis for denial in all its shades of gray, from intelligent design, to young earth creationism? In a word, ignorance. But not ignorance of the traditional “I really wish I knew, but alas, I don't” variety. Rather, this is generally ignorance of the “my eyes are covered and my ears are plugged, so you must be wrong” variety.

The only way to dispute the evidence for evolution is never to look at it in the first place. The fossil record is itself almost astonishingly replete, given what is required to preserve the faint impressions of fleeting life in dust and mud over millions of years. But the fossil record is all but irrelevant, mere icing on the cake. The cake is baked of our DNA, which provides an encyclopedic account of life's recipe.

So, permit me to reiterate: the only way to dispute so incontrovertible a case is to ignore it. Now, of course, you cannot ignore the content of an entire domain and achieve any recognition by peers, credentials, expertise, or even rudimentary understanding. Ignoring leads only to ignorance. Actual experts can and do, of course, disagree in their interpretations. But those interpretations require knowledge and understanding. Knowing is prerequisite to interpreting. Disagreements born of expertise are interesting, and resolving such tensions is in the service of progress.

Not so the dissent of non-experts. Asserting the deficiencies of a field one has never mastered is tantamount to the claim that any language you don't speak is just gibberish.

The problem is indeed acute for evolutionary biology, but by no means unique to it. In every field, from evolutionary biology, to biomedicine, to political science, the cries of non-experts populate cyberspace: listen to us, too! We've only ever read what we already decided to believe—if we've read anything at all—but listen to us just the same.

The long-standing tendency to repudiate understanding not on the basis of alternative understanding, but on utter lack of understanding and, for that matter, never attempting to learn, is massively amplified by the Internet, the ultimate leveler. Nobel laureates, and consummate nincompoops, have recourse to the same megaphone. This is where expertise goes to die.

But how does it die? There is famous concern about ending with a whimper rather than a bang. Sadly, we are well into the realm of a demise more tiresome still.

Non-experts routinely assert their opinions to refute the views of experts they simply don't like (this may refer to the views, the experts, or both). If challenged for want of expertise, they label it an attempt at character assassination. They allege that their legitimate, alternative view is being suppressed. In other words, they whine, 140 characters at a time.

But credentials are not character; that's a load of crap. Credentials, whether formal or informal, are the price of entry into any legitimate debate. Expert debate actually requires expertise on both sides. Two literary scholars might differ in their interpretations of Crime and Punishment, or War and Peace, and an interested audience might benefit from the exchange. But the audience is forgiven for restricting its interest to debaters who have actually read the works in question. Participation in the vein of, “I never read it, but I know it stinks,” would be reliably less illuminating.

Confront the pretenders for what they are, and you find yourself in the morass where credentials are conflated with character. They may also charge at you under an anti-elitist banner, implying that expertise is really just prissy privilege in disguise. But that campaign reeks of hypocrisy. Find me the anti-elitist willing to let any untrained, highly opinionated stooge perform neurosurgery on their child, and I will give up my day job for hula dancing.

So, yes, our culture seems tolerant to the substitution of fatuous hearsay for genuine knowledge, earned the hard way (is there any other?). Yes, our culture is implicated in the death of expertise.

It dies neither with a bang, nor a whimper. It dies silently, drowned in the endless echoes of incessant cyberspatial whining by those conspiring, ignorantly, to kill it.

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.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

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.

Everything Health
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.

Glass Hospital
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.

Gut Check
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.

I'm dok
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.

Informatics Professor
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.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
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.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

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.

Technology in (Medical) Education
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.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

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.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

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

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