Adam Cifu
I am not sure that the gap is closing, but I know that they can be harder to tell apart.
The Charlatan
Healthcare charlatans are polished characters who, despite having no real expertise, pitch themselves as experts. Their ultimate goal is not to help people but to increase their own wealth and fame. The internet has been a boon to the charlatan. Instead of driving covered wagons from town to town, they can reach thousands (millions?) of marks with well-placed Instagram posts, tweets, or TikToks.
The charlatan’s skill is that we don’t know whether they believe in their products. While I assume the traditional snake oil salesman didn’t use his products, some of today’s might be using the peptides, hormones, and full-body scans he (or now she) promotes.
The Expert
Unlike the charlatan, the expert traditionally stalked the halls of the academy, published in journals, and “presented papers” at meetings. He (she’s were rare) worked only for people’s health; there was little else. There wasn’t much money associated with success, and — unless you were Lister, Fleming or Salk — no chance of fame. Of course, before the era of evidence-based medicine, some of the theories and treatments promoted by experts (lobotomy, pyrotherapy, diethylstilbestrol) might have been as worthless (or worse) as those promoted by charlatans.
Why it is now harder to differentiate the expert and the charlatan
Experts can still be wrong, and the modern world can make experts look like charlatans. Evidence-based medicine (EBM; the expert’s tool) integrates clinical experience and expertise with the best available evidence from systematic research. Room for error remains in EBM: clinical experience can mislead; experts can be seduced by bioplausibility; studies can be flawed or wrong. Drug and device makers spend freely to influence experts and encourage experts to influence. The internet offers fame the tweed-vested academic of yesteryear could never have dreamed of. Look at people like Emanuel, Topol, and Hotez, with their books and online/media presence.
Just because the charlatan and the expert look more alike these days does not mean they are. We hope today’s experts still work single-mindedly in the interests of people’s health. Yet with the inherent (and necessary) flaws of evidence-based medicine, and with wealth and fame tempting experts, I worry they are more likely to be wrong. I believe the expert and the charlatan differ in intent. The expert might be wrong, but s/he is certain s/he is doing the right thing. If this is not the case, the expert becomes a charlatan.
Vinay Prasad
