Pseudo-expertise versus science-based medicine

I am a skeptic.

My support for science-based medicine, as important as it is and as much time, sweat, and treasure I spend supporting it, is not the be-all and end-all of my skepticism, which derives from a scientific world view. That’s why, every so often, I like to step back from medicine a bit and look at the broader picture. It’s a good idea to do this from time to time, because to me, many of the topics that I and my fellow SBM bloggers write about are not just manifestations of anti-science and pseudoscience in medicine, but rather of a broader problem of anti-science and pseudoscience in society at large. I concentrate on medicine because it’s what I do and because manifestations of pseudoscience in medicine have the potential to harm or even kill large numbers of people.

Look no further than the anti-vaccine movement if you don’t believe me. Already, a mere decade after Andrew Wakefield’s lawyer-funded, incompetent, and perhaps even fraudulent “study” about a supposed relationship between the MMR vaccine and autism, uptake of MMR vaccines have plummeted throughout the U.K., with some areas of London reporting only 50% uptake, far too low for effective herd immunity. Thanks to J.B. Handley, Jenny McCarthy, Jim Carrey, and the know-nothing band of celebrities and activists, we are in serious danger of having the same sort of thing happen right here in the U.S. Indeed, Jenny McCarthy herself has even acknowledged that, although in her characteristically self-absorbed and vulgar manner, she refused to take responsibility for her part in this impending public health debacle, dismissing her role by saying, “I do believe sadly it’s going to take some diseases coming back to realize that we need to change and develop vaccines that are safe. If the vaccine companies are not listening to us, it’s their fucking fault that the diseases are coming back. They’re making a product that’s shit. If you give us a safe vaccine, we’ll use it. It shouldn’t be polio versus autism.” Meanwhile autistic children suffer from the quackery to which they are subjected in a futile attempt to “recover” them from “vaccine injury”-induced autism.

But it’s not just the anti-vaccine movement. It’s cancer quackery, promoted by “luminaries” such as Suzanne Somers and Bill Maher, given aid and comfort by doctors gone bad such as Dr. Rashid Buttar and Dr. Nicholas Gonzalez, “bioidentical hormone” woo promoted by the aforementioned Suzanne Somers and Dr. Christiane Northrup. It’s all manner of other faith-based and definitely non-science-based medicine so called “complementary and alternative medicine” (CAM, which is neither complementary nor medicine, although there is no doubt that it’s “alternative”) or “integrative medicine” (which “integrates” pseudoscience with effective medicine to the detriment of patients) finding its way into our academic medical schools, even to the point of being mandatory at at least one medical school and being a strongly touted option at many others. Meanwhile, the misbegotten behemoth of woo, funded by your tax dollars and mine, the National Center for Complementary and Alternative Medicine (NCCAM) promotes remedies based on a prescientific understanding of how the body works and what causes diseases, even going so far as to promote “integrative medicine” residencies. Meanwhile science-based medical students face a serious dilemma: Go with the flow or fight.

Although I’ve only been a blogger for SBM for less than two years and its managing editor for less then a year, I have been in this battle for nearly a decade in various forms, and not just in medicine. Indeed, over the last several years, I’ve subjected myself to some of the most outrageous bits of unreason, conspiracy mongering, and pseudoscience. Be it the anti-vaccine movement, quacks, 9/11 Truthers, Holocaust deniers, creationists, or any of a variety of other bits of pseudoscience, I’ve come to appreciate that what distinguishes believers in such nonsense seems to be, as Prometheus so aptly put it, the arrogance of ignorance. Even so, there seems to be more than that going on, and leave it to, of all things, an article in the L.A. Times by James Rainey entitled Childhood vaccines, autism and the dangers of group think. It’s an article looking at Amy Wallace’s excellent article for WIRED entitled An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All, which documented how the arrogance of ignorance has led the anti-vaccine movement to endanger public health, and the exceedingly (and typically) nasty reaction the anti-vaccine movement with which the anti-vaccine movement responded, particularly J.B. Handley’s misogyny.

There are two key passages in Rainey’s article that tell the tale, a tale that is no surprise to skeptics, in particular skeptical bloggers like myself:

“They will say, ‘Who do you think you are to tell me?’ or ‘Who does the government think it is to tell us what is best for public health?’ ” Wallace told me this week. “They say, ‘You can’t know my child like I know my child.’ “

Wallace has run smack into an abiding, perhaps growing, phenomenon of the Internet Age: Citizens armed with information are sure they know better. Readers who brush up against expertise believe they have become experts. The common man rebels against the notion that anyone — not professionals, not the government and certainly not the media — speaks with special authority.

Where it stops, nobody knows. But already we see a wave of amateurs convinced they can write a pithier movie review, arrange a catchier song, even assess our planet’s shifting weather conditions, better than the professionals trained to do the job.

I wish he hadn’t mentioned movie reviews and song-writing. Not to denigrate either skill, one of which I can do (albeit not that well) and one of which I can’t (I’ll leave it to the reader to guess which is which), but in contrast to examining the complex science behind medicine, it is much more possible for an amateur to succeed in these endeavors than it is for an amateur to succeed at analyzing the complex problems science addresses at the highest level of medicine and other sciences. Indeed, writers penned books and articles, and songwriters wrote songs before there ever was such a thing as a “professional” songwriter. Come to think of it, people did science before there was such a thing as a professional scientist, too. The difference, at least today, is that science has become so technical and complex that it is very, very difficult to master and all but impossible to teach oneself, particularly medicine.

However, Rainey’s better at identifying a major contributing factor:

The rise of computer literacy, high-speed Internet connections, blogging and social networks has emboldened the common man to tell his own story and, sometimes, to disdain trappings like a university degree, professional training or corporate affiliation. The citizen activists often frame themselves as truth tellers fighting against an establishment that is hopelessly venal. No matter that the corruption, routinely claimed, is seldom supported by more than innuendo.

This is indeed the cult of the amateur, as the title of a book mentioned in the article goes. There has always been a strain in American culture that is deeply anti-intellectual and suspicious of experts, as documented in Richard Hofstadter’s Anti-Intellectualism in American Life back in 1966, with the same lament being echoed by Susan Jacoby last year in her The Age of American Unreason. Although it can cause a lot of problem, a healthy skepticism of experts is not necessarily a bad thing. Experts are not always right, and “the best and the brightest” have at times led us horribly astray. However, in the process, our nation appears to have somehow devalued not only expertise, but science itself. Science is the “other.” It’s not something that “everyday people” do, or at least it’s not perceived that way, which is all the more sad because anyone with a reasonable level of intelligence should be able to understand the very basics of the scientific method. The same is true of critical thinking. Indeed, in many areas of of life, the “average Joe” is admirably skeptical. For example, many people are more than capable of evaluating the sales pitch of a car salesman or, as my wife and I had to do several months ago, the high pressure sales pitch of a roofing salesman. Yet, in other areas these same people are credulous marks for any conspiracy theory that comes around.

In the case of the anti-vaccine movement, what drives this arrogance of ignorance is an old-fashioned American distrust of authority (often good, but not always) combined with a democratic tradition in which every person is assumed to be equal. The problem is that equality before the law and possessing equal rights (which are the American ideal) do not equate to equal abilities or knowledge. Unfortunately, we as a people seem to conflate the two and assume all too often that, if Paul Offit can pontificate about vaccines, so can we, even though we don’t have any special expertise in the relevant sciences about them. Too many of us assume that a few days or a few hours (or, sometimes, even much, much less) spent in front of a computer studying at the University of Google renders our understanding nearly equal to (or even greater than) that of scientists and experts who have spent their entire lives studying a problem. Celebrities are no different, either. Indeed, fueled by ego and surrounded by yes-men and other enablers, celebrities seem even more prone to the arrogance of ignorance, be they Bill Maher, Oprah Winfrey, Jenny McCarthy, Jim Carrey, Billy Corgan, or Suzanne Somers. Worse, they have a much larger soapbox from which to spread their nonsense. But they’re not alone. Whenever I want to demonstrate what drives this attitude, I like to quote anti-vaccine activist, bully, and all-around unlikable guy J.B. Handley:

I’m not intellectually intimidated by any of these jokers. Their degrees mean zippo to me, because I knew plenty of knuckleheads in college who went on to be doctors, and they’re still knuckleheads (I also knew plenty of great, smart guys who went on to be doctors and they’re still great, smart guys).

I chose a different path and went into the business world. In the business world, having a degree from a great college or business school gets you your first job, and not much else. There are plenty of Harvard Business School grads who have bankrupted companies and gone to jail, and plenty of high school drop-outs who are multi-millionaires. Brains and street-smarts win, not degrees, arrogance, or entitlement.

Except that brains and street smarts count for very little in science if they exist without an understanding of the scientific method and knowledge of the context behind a scientific study or even a scientific consensus on an issue.

From my perspective, the progress made on developing Internet may well be the single greatest development of the last 30 years. When the Internet was first developed, it was used primarily by educational, government, and defense institutions. It wasn’t until the mid 1990s when huge numbers of people started to have access to the Internet, and today in developed countries most people take Internet access for granted. Personally, I don’t know how I’d survive without it. It’s made, for example, looking up articles for my research and writing journal articles and grants a snap, comparatively speaking. However, there’s a down side, and that’s too much information, so much information that it makes it very easy for someone without the requisite background necessary to be able to separate the wheat from the chaff to develop a sense of pseudo-expertise. In other words, they may pick up a lot of facts and be able to cite a lot of studies, but they do not know the scientific context behind these facts and studies. They don’t know why scientists will value one study over another or consider the studies they like to cite to be nothing more than a load of fetid dingo’s kidneys, not worth the electrons that carry the PDF file containing the study to the computer the crank used to download it. Worse, they don’t know how to recognize good studies compared to bad studies or understand that critically examining the evidence against your beliefs is even more important than examining the evidence for them. The result all too often turns into an orgy of cherry picking and confirmation bias.

The result, when combined with someone like J.B. Handley, who thinks that expertise can be so easily dismissed, is the anti-vaccine movement, creationists, Holocaust deniers, 9/11 Truthers, and quacks.

The other driving force behind the proliferation of pseudo-expertise is a very human trait that we all share, namely the tendency to confuse correlation with causation. Once again, this is one of the first lessons in science, not to confuse correlation with causation, but those of us in science forget just how against human nature this is. We are creatures that value personal experience over statistics and science. One good anecdote trumps reams of evidence, hundreds of painstaking scientific studies, even a convergence of evidence from multiple different disciplines. This produces, for example, the alternative medicine maven who swears by homeopathy because the symptoms of their self-limited condition got better after they tried it, anthropogenic global warming denialists who justify their rejection of climate science by their observation that this summer was unusually mild in their area, and deniers of evolution who look at nature and cannot fathom how humans might have evolved from other animals over millions of years because they an only see the pitiful handful of decades each of us is given to walk this earth. It’s what drives Suzanne Somers to believe that her decision to eschew chemotherapy in favor of mistletoe extract after her curative surgery and radiotherapy is what saved her life. It’s what drives virtually the entire groundswell of support for CAM modalities, the vast majority of which do whatever it is they do through placebo effects.

Having said that, let us not forget that, at the level of a single person, correlation sure can appear to be causation. As was pointed out a month ago by Orac, one example is heart attacks and the flu vaccine. More than 3,000 people have heart attacks each and every day, which means that by random chance alone there will be probably several people a day who have a heart attack within 24 hours of being vaccinated for the flu. “On the ground,” to those people it may appear all the world as though the vaccine caused the heart attack, when in reality it really was just coincidence. It’s not enough simply to observe an adverse event happening after something, say, vaccination. You have to show that there is an incidence of that adverse event significantly greater than what could be predicted by chance alone. The same applies to the claim that vaccines cause autism. If you have a child who regresses within a day or so of vaccination, it will appear all the world to you that the vaccine caused the regression. In that case, it is then very difficult even for highly educated parents to accept the results of science, namely that epidemiological studies do not find an elevated incidence of autism after vaccination.

Combine the all-too-human tendency to confuse correlation with causation with the anti-intellectual attitude of a J. B. Handley, a Jenny McCarthy, a Suzanne Somers, a Bill Maher, or any of the panoply of celebrities, celebrity wannabes, or regular people who made it big through the promotion of snake oil with the arrogance of ignorance that pseudoexpertise derived from studying at Google U. produces, and you have fanatical adherence to a crank movement. It all boils down to a basic human need for a perception of order in the universe. We need to identify causes when bad things happen; we need explanations. To the non-scientist (and even to all too many physicians and scientists), “you were unlucky” or “it was just an unfortunate coincidence” are not answers to the question “Why?” that satisfy. They may be the most likely to be true, but they do not satisfy. Blaming something does, be it blaming vaccines for autism or constructing elaborate conspiracy theories to explain how 19 men with box cutters could hijack commercial airliners, destroy the two of the tallest buildings in the U.S., severely damage the Pentagon, and cause the deaths of 3,000 Americans, or why evolutionary biologists do not accept that “God did it” as an adequate explanation for the diversity of life in direct opposition to what preachers and parents have taught.

Becoming a real expert in anything is very hard. As several surgical conferences and Grand Rounds have recently reminded me, it’s been estimated that in general it takes 10,000 hours of practice and study to become an expert in surgery. There are no shortcuts around that. True, it may take somewhat less for surgeons with a natural knack for operating and patient care and longer for those of more modest and average capabilities, the latter of whom often have to work harder and practice longer to achieve the same level of expertise (if they ever achieve it at all), but that’s the average number of hours needed to become a master. The Internet may seem like a shortcut that levels the playing field between experts and the great unwashed masses, but in reality it only gives an illusion of expertise or, as I’ve called it, pseudoexpertise. Similarly, in the past, the lay person just plain did not have direct access to medical studies. Obtaining such studies would require a trip to a medical school library, which may or may not be far away, prolonged searching through Index Medicus, piling journal upon journal on a cart, and then feeding coin after coin into the machine to copy the articles desired. Now, virtually any abstract can be accessed through PubMed, and articles reporting federally funded research are deposited in PubMed Central within a year of publication, where anyone can access them. While this open access to knowledge is appropriate, given that our tax dollars funded the research, it inadvertently fueled the rise of the pseudoexpert.

It’s also been pointed out before that medicine seems particular prone to the depradations of the pseudoexpert. People who would never think trusting “alternative flight” or “alternative engineering” seem to think that, when it comes to medicine, “alternative” medicine should be given a pass on being as rigorously reality- and science-based. Worse, I’ve seen this tendency even in people who really, really should know better. For example, over the last several years, at times I’ve seen a distressing tendency for even those proclaiming themselves to be “skeptics,” even going so far as to join skeptical organizations like the Center For Inquiry or to support skeptical organizations like the James Randi Educational Foundation, to be prone to some serious woo when it comes to medicine. I’ve spoken with self-proclaimed “skeptics” who actually buy into the idea that vaccines somehow cause autism, a pseudoscientific concept that has so much evidence against it that personally I would almost go so far to say that anyone who takes such anti-vaccine propaganda seriously should forfeit the title of “skeptic.” (Actually, forget the “almost.”)

Perhaps the most striking example of this disconnect occurred when the Atheist Alliance International (AAI) bestowed the Richard Dawkins Award upon a rabidly anti-vaccine comedian named Bill Maher. True, Maher holds the “right” position with respect to religion (he’s against it) and science such as anthropogenic global warming (he accepts the science supporting it and ridicules AGW denialists), and evolution (he accepts the science and ridicules creationists). It also appears in retrospect to be equally true that, at the time the AAI chose him for the Richard Dawkins Award, it apparently didn’t matter one whit that Maher is simultaneously as rabidly anti-science as Jenny McCarthy, Suzanne Somers, or Jim Carrey when it comes to medicine, championing anti-vaccine views and distrust of “Western” medicine (which is, as readers of this blog know, usually a derogatory code word for science-based medicine), cancer quackery, and germ theory denialism, even though one of the criteria for the award was that its recipient must “through writings, media, the arts, film, and/or the stage advocates increased scientific knowledge.” It only mattered later, when complaints about the selection started to bubble up too insistently to be ignored.

Truly, even though there are notable and heartening exceptions, such as Phil Plait, James Randi, and our very own Steve Novella and Harriet Hall, all too often science-based medicine is treated like the Rodney Dangerfield of the skeptical movement. Certainly, compared to evolution, we “don’t get no respect.” Or so it all too often seems to me. At the very least, until relatively recently, we didn’t get the same level of attention as creationists, dowsers, and psychics. Even now, with things probably better on that score, I’m still not sure that we do.

It’s not all bad, though. The very same forces that produced the anti-vaccine movement and fuel the panoply of cranks provide the weapons to combat them. It is that easy access to blogs and the web that cranks take advantage of to spread their message that provides scientists and skeptics the weapons to combat cranks. The Internet, while empowering all manner of pseudoscientists, snake oil salesmen, and enemies of public health such as anti-vaccine activists, also allows skeptics and supporters of science-based medicine to band together to counter the madness. That’s what we try to do right here each and every day, to provide a voice raised against the anti-science and pseudoscience engulfing medicine. Unfortunately, it’s a lopsided battle, and not lopsided in our favor. As long as there is Oprah Winfrey, Jenny McCarthy, Jim Carrey, Bill Maher, Suzanne Somers, and other celebrities brimming with the arrogance of ignorance, it will be a lopsided battle. But it’s not by any means a hopeless battle, and it’s one we can’t afford to lose, even though none of us will live to see a victory against pseudo-expertise.

Posted in: Politics and Regulation, Public Health, Science and the Media, Vaccines

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