The Death of Expertise

Several months ago, a patient of mine asked me about starting a GLP-1 agonist to help her lose weight. I spent thirty minutes explaining the proposed mechanisms of action, the common side effects, the risks, and the potential benefits. I told her I thought she would be a good candidate. Then I spent another twenty minutes answering all her questions. At the end of our visit, she thanked me and said she would go home and “do her research,” after which she’d get back to me with her decision about starting the medicine.

With what I hoped was a genuine, if slightly amused smile, I replied, “You know there’s no internet source—no influencer you could listen to or article you could read—that will offer you better or more accurate information than what I just gave you, right? I’ve read and analyzed all the original studies on these medicines and have been prescribing them to help people lose weight for years.” After a pause, with a sheepish smile, she admitted, “That didn’t even occur to me.”

I told her I didn’t blame her for her instinct to “do her research.” With the advent of the internet, we all have more information at our fingertips than at any time in history. With a few keystrokes, I can learn how to repair an airplane’s fuselage, the basic principles of architectural design, and what side effects a medicine can cause. But that doesn’t make me an engineer, an architect, or a physician. What makes me a physician are the years I spent training and then practicing in the field. As one of my fellow physicians likes to say, “Please don’t confuse your Google search with my medical degree.”

Yet often that’s exactly what patients do. I’ve had to spend more time in the last five years shooting down nonsensical ideas about medical care than I have in the entire twenty-five years that preceded them. Often, these discussions become contentious, patients choosing to believe a YouTube influencer they’ve been following instead of me. I find this irritating, of course, but I understand it.

We all struggle to tame our cognitive biases:

• confirmation bias, the unconscious tendency to attend to and believe evidence that supports what we already believe;

• motivated reasoning, the tendency to believe what we want to believe;

• narrative bias, the tendency to believe a well-put-together story over data; and finally,

• authority bias, the tendency to believe written text (and probably produced videos) because of our unconscious assumption that if someone took the time to produce a text or video, they must possess an authority, or expertise, that makes what they’ve produced true.

Introduce the internet with its text and videos that tell us what we want to hear using stories that make logical sense, and you get what we now have: a world full of people who believe a Mount Everest amount of bullshit.

These biases and others explain why we fear the wrong things (a terrorist attack in our neighborhood) and fail to fear things we should (traffic accidents). It’s why we refuse safe, important interventions like vaccines (while nothing is completely without risk, vaccines in general remain among the safest interventions in all of medicine) but think nothing of injecting peptides, which have almost no good studies in humans to support their use.

In the age of misinformation, we don’t have an uneducated population. We have something worse: an uneducated population that thinks it’s educated. It’s the Dunning-Krueger effect at a world population level (a finding in the psychological literature that an incompetent person’s incompetence extends to their ability to evaluate their own competence--meaning, people lacking expertise in a particular area are least likely to be able to correctly judge their own, or another’s, level of expertise).

I know. You’re thinking I’m a cynic (and a self-important doctor). But I consider myself a realist whose attitude has been honed by over three decades of medical practice, seeing fads and ideas come and go. The only difference now is how much faster and farther bad ideas spread. I’ve found it disheartening (demoralizing might be more accurate) just how thoroughly patients delude themselves, clinging to ideas the medical literature has proven to be worthless. Still, I often can’t help myself from asking: if you’re going to change your behavior—start ingesting that new supplement, plunge into that freezing ice bath once a day, inhale hydrogen peroxide into your lungs, start doing anything differently from how you do it now—shouldn’t the strength of evidence that it will have the desired effect be proportional to the effort you’re required to make? And shouldn’t the proof that what you’re doing is safe be even more rigorous? (Optimism bias, anyone?)

The internet has only magnified the destructive power of social proof, which is as alluring as it is unreliable. For example, currently everyone is talking about increasing lifespan, a discussion borne of an excited optimism based on real research but an optimism magnified to ridiculous extremes by people who have no knowledge, training, or expertise (“Don’t die,” Brian Johnson tells us) but who can tell a good story and often have something to sell us.

So, here’s the best advice I have to give to strike a blow against false belief everywhere:

1. Learn to criticize your own thought processes. When you see that ad on Facebook disguised as an expert telling you what you should do to gain muscle mass, or get your post-menopausal sex drive back in order, or live twenty-five percent longer, watch how interested and even titillated you become, and dunk that excitement in a cold bath of skepticism. That’s right: your first thought upon hearing a new idea—especially one that appeals to you—should be, “Bullshit.” It’s amazing to realize how many things we think are true are in fact false. So much more so the things we want to be true. Probably most things we do to help ourselves don’t work. And when they do work, they often don’t work the way we think they do.

2. Learn to think statistically, not anecdotally. When we hear about a plane crash on the news, we worry more than we should that the flight we’re scheduled to take that afternoon might crash. The story grabs hold of our emotion—and make no mistake: even the most educated and intelligent among us make decisions based on emotion, not logic—but it shouldn’t. (See the discussion on narrative bias above.) We consider risks based on probability, not stories. Every adult should acquire a basic working knowledge of statistics. Nothing will help your decision-making more.

3. Pick the experts you choose to believe very, very carefully. I cannot stress this enough. Most of us have a built-in tendency to trust people, especially when they tell a good story, have real credentials, and publish their ideas somewhere. But good storytelling is easy compared to rigorous thinking, and even well-credentialed people can be fools, charlatans, or misguided. Does the expert have a reason to convince us that what they’re saying is true (like they want to sell us something)?

As the saying goes, “A lie can travel halfway around the world while the truth is putting on its shoes.” Sorting out truth from fiction has never been harder. We conspire to fool ourselves constantly. It takes a lot of work to examine our own biases. It takes a lot of work to remain skeptical. Yet in this age of misinformation, where we seem to have become disdainful of genuine experts, no armor will protect us from folly more effectively than a healthy dose of disbelief.

Alex Lickerman, MD is a former faculty member at the University of Chicago who now runs a direct primary care medical practice.

Photo by Abhishek Tewari on Unsplash