This piece originally appeared in The Timmerman Report.
The Death of Expertise by Tom Nichols, 2017, Oxford University Press.
If you’re reading this, chances are you’re an expert or well on your way to becoming one. The Timmerman Report is tailored by content and intent to be valuable to those with the knowledge, experience and interest to make biopharma news worth reading. Experts, in other words.
This isn’t a trivial point: for the vast majority of people—that is, those non-expert in biopharma—news in sites like this one or STAT or Endpoints is as useful as scuba equipment to an octopus. And that’s fine; that’s how our knowledge-based society works. Individuals become experts in specific fields, they take the time and effort to master a specific area and they build up the intellectual framework to enable advances, discoveries and explanations. Specialization underlies the technological, societal and scientific wonders we take for granted today. There are just too many fields of study for any one person to master, the Maesters of a Song of Ice and Fire aside. Divide and conquer isn’t just for Roman governance philosophy; it also makes for progress.
The natural corollary is that we are all affected by what experts outside our field say and do. Lacking a working and academic knowledge of biopharma does not immunize a person from the impact of the kinds of issues, news, and discoveries discussed and reported here. Drug pricing, innovation, access and healthcare quality and affordability have huge impacts on everyone in the US.
And boy, do many of them have opinions about that! Opinions that they hold tighter and higher than the words of experts. Opinions that influence the ways in which they speak, act, think and yes, sometimes, vote.
This growing issue is at the heart of Tom Nichols’ book, The Death of Expertise. Nichols, a professor in National Security Affairs at the Naval War College and adjunct at the Harvard Extension School, is a former Senate aide and an expert in Soviet studies. I first became familiar with his work when, after last year’s US Presidential Election, I started consciously expanding the circle of thinkers I listened to. Like Daniel MacArthur and many others of a more liberal bent, I’ve tried to find and listen to people on the center and right.
Tom Nichols was one person who I started following on twitter (@RadioFreeTom), as much for his entertaining and sarcastic put-downs of his trolls as for his considered opinions about the current Republican administration. I don’t agree with all of his analyses, but they make me think. His current book, with which I do largely agree, came out a few months ago and is an exploration of how “the United States is now a country obsessed with its own ignorance.” Inflammatory perhaps, but not wrong. His book evaluates causes widely, pointing to human tendencies (with a nod to behavioral economics), the commoditization of higher education, the ways in which technology can provide the patina of knowledge to anyone despite the metal underneath being mere brass, the media as entertainer, and experts themselves. The last chapter tries to look to solutions although by that point the author (and the reader) find this a challenging reach.
Probably the crucial element underlying the current problems with how the public views expertise can be found in this passage: “One of the most basic reasons experts and laypeople have always driven each other crazy is because they’re all human beings. That is, they all share similar problems in the way they absorb and interpret information.” Behavioral psychology has surfaced many ways in which human behavior is predictably irrational—Michael Lewis’ recent narrative, The Undoing Project, about Amos Tversky and Daniel Kahneman is a good, accessible starting point on these kinds of cognitive biases.
Nichols points to two specific cognitive biases: confirmation bias and the Dunning-Kruger effect. The former is the tendency of people to look for and believe information that agrees with their pre-existing beliefs, while discounting that which does not. The latter describes how people of low skills and expertise in a given area tend to both believe their own ability is greater than it is, and in similar fashion to discount the opinions of those with true ability. Think of Homer Simpson as an exemplar.
From those descriptions it doesn’t take much imagination to understand how laypeople in a given field could gravitate toward feeling their ideas, opinions and theories are just as valid as those of the talking heads on TV, those learned scholars writing public health advisories or policy analyses or educational proposals. This New Yorker cartoon, which circulated shortly after the election, was a perfect encapsulation of the jaundiced eye with which expertise is viewed by many.
The logical extension of this insight to biopharma (because, let’s face it, we’re all human and have these biases too) is that we need to guard against these kinds of biases when making business and scientific decisions such as which targets to move forward, which companies to partner with, and which indications to pursue. As an example, the desire to move a target to the next stage (and get that hefty bonus) could easily lead to a confirmation bias mentality in which supportive data are held up and troublesome results downplayed. Ashutosh Jogalekar (@curiouswavefn), a fine commentator on things biopharma, has started a series of posts about cognitive biases in drug development and confirmation bias is one he calls out right away. Whether the Dunning-Kruger effect similarly affects behavior and decision-making in biopharma (spoiler: I think it does) will be a great future topic for exploration.
These tendencies, however, aren’t unique to the 20th and 21st centuries. If these cognitive biases have some basis in biology and evolution, then know-it-alls and scoffers have always been among us. Nichols points to other cultural and social elements that have served to make these tendencies more pernicious. One culprit is how higher education, once a very limited and difficult path for anyone to follow and therefore a strong filter for the ability and drive to develop expertise, has become less a crucible than a summer camp. In a subsection entitled, “College is Not a Safe Space,” Nichols decries the movement toward protecting students from thoughts that might alarm, challenge or offend, corroding “the ability of colleges to produce people capable of critical thought.” He points to the marketing of the college experience as having led both to more students going to college than might be appropriate, and to schools themselves compromising that dedication to critical thinking in the name of chasing tuition dollars. Uncomfortable to be sure, especially today when it’s clear that knowledge workers will drive the economy of the future (including the biopharma industry) and ideally we would like to have more trained workers getting advanced degrees. But if the end result of commoditizing college is that college no longer teaches the intellectual skills to succeed in a knowledge-based society, and because of this we lose faith in advanced credentials, this would be a Pyrrhic victory.
A related problem Nichols describes is the parallel commoditization of media. I remember when there were three TV news networks. Today’s balkanization of 24/7 cable TV news stations feeds directly into both confirmation bias and the Dunning-Kruger effect. People self-select the news that agrees with what they already “know” to be true, and the bits and soundbites they get from anchors allow them the language to sound superficially informed without really understanding the ramifications of, for example, a border adjustment tax.
This problem of a balkanized media has some about specific implications for the biopharma industry. As I’ve explored elsewhere, one big challenge for the biopharma industry is reputation. That poor reputation, notwithstanding recent high-profile efforts by some companies and CEOs and a big advertising push by PhRMA (Go Boldly? Are you serious?), is an ongoing problem. The basic cognitive biases detailed in the Death of Expertise, however, offer a depressing view on whether that reputation can really be rehabilitated. Cut-throat media must give negative and sensational stories the most attention. This doesn’t serve biopharma’s reputation well at all. Confirmation bias leads consumers to remember every bad story that reinforces the view that biopharma is a group of greedy profiteers. Having Martin Shkreli on trial and prominently in the news (and will he ever shut up!) doesn’t help either. The good stories? Not so often recalled or retained. Add to that, a person who has googled for a cure for anything has been deluged by a wave of sites offering testimonials, garbled facts, and pseudoscience that puff up her or his sense of knowledge and personal expertise, leading to behaviors that, in the end, may decrease the efficacy of real medicines and treatments they’re receiving.
Experts themselves don’t escape scrutiny of their own culpability. Nichols describes several anecdotes in which experts gave strong opinions, findings and predictions which turned out to be false, were later contradicted, or never occurred. We are all familiar with similar issues in biomedical science, whether it’s the “should they, shouldn’t they” debate about mammograms in younger women, red wine is good for you and/or bad for you, or the replication crisis in research. Here Nichols doesn’t castigate experts for being wrong; expertise is no guarantee of success. Instead, he points to the messaging, both of findings and of errors, and of the need for real humility on the part of experts. However, the existence of corrections and contradictions, while evidence of the real rigor of the expert community, nevertheless becomes another crack in the reputation of expertise, the outlier example used to prove the thesis that expert opinion is worthless. Credibility drops.
Credibility matters. Being credible doesn’t mean one is always right, but there’s a baseline of respect and trust on which productive debate can occur. As Chris Hayes has discussed in his book, Twilight of the Elites, without credibility, people become flat-out disinclined to trust the elites and experts, breaking the covenant of trust that allows a democratic, division of labor system to work.
Biopharma would be smart to pay close attention to this trend, and act accordingly. We should spend more time being humble about what drugs really can and might do, and not raise hopes. And yes, I realize there’s tremendous pressure on the startup (or even the major company) to raise more money, boost the stock price, beat the quarterly sales numbers, and secure positive press. Being humble and circumspect doesn’t help achieve those goals. But those who damage their credibility on the road to their short-term goals will find it next to impossible to achieve the long-term goals of the company, and the industry. There are worrying signs this is already happening.
But I’d argue the largest contributor to the death of expertise is the internet. Probably everyone working in drug development has, at least a few times in her or his career, met a person who, once learning what it is we do, expounds on a fantastic, cheap, miracle cure that they’ve read about, may even use, and often swear by (when by rights they should be swearing at). I had to rub my eyes when I saw the recent article in the Washington Post on a “Lectin-free diet.” Like every technology, the things that make the internet great (easy access, reducing barriers, spreading information, speed, communication, search) also make it the best propaganda vehicle ever made. And those negatives are damn hard to uncouple from the positives, as companies like Facebook are realizing. One current, relevant example is the lifestyle magazine (I really can’t call it a health tool) Goop which has come under fire, and deservedly so, for advocating treatments that are dubious at best, and possibly harmful.
With the internet you can always find an opinion, study, voice that supports your viewpoint or gives you an alternative view. With the internet the positive feedback can be as endless as you want it to be, and if you see a fact you don’t like, you can click away or launch a broadside attack anyone or anything that stands against your stated view. With the internet anyone with access to freeware and ten bucks to pay to a hosting site can set up a slick-looking website that screams credibility even while offering no certifications, validations, peer-reviewed publications, or hard, verified, analyzable data. When people spend time surfing the web, they report becoming more confident, not less, in their level of expertise and understanding, even when web analytics show all they do is read the first few sentences of each article before clicking to the next.
So against this, what can be done? As a scholar of governments and international relations, Nichols focuses on the implications for a democratic society. They aren’t pretty. As he postulates:
“The relationship between experts and citizens, like almost all relationships in a democracy, is built on trust. When that trust collapses, experts and laypeople become warring factions. And when that happens, democracy itself can enter a death spiral that presents an immediate danger of decay either into rule by the mob or toward elitist technocracy. Both are authoritarian outcomes, and both threaten the United States today.”
Some of the things that could help, including much better political and intellectual knowledge across the populace, are unlikely to be easy to carry out. I’ve had many colleagues from other nations become naturalized citizens. It’s no exaggeration to say their knowledge of our political system, documents and processes dwarfs mine, even though I’ve lived here my whole life. I think I’m typical of many people in this country. Civics education in our schools has largely gone by the wayside, following Physical Education and Home Economics and Shop out the door (For what it’s worth, Home Economics and Typing are two of the most important and useful classes I took in middle school). Getting people to learn and engage about civics in the middle of their already busy lives would be futile.
Worse, many seem trapped in their disengagement. Recent books like J. D. Vance’s Hillbilly Elegy, or the writings of Chris Arnade (@Chris_arnade), or Luke Timmerman’s own conversations with his childhood friend portray how a large segment of society has been left behind by today’s global economy, by the experts and elites, by those who have come to view value primarily through an economic lens. Some of the disengaged are resentful, some are despairing, some are resigned. But there’s little motivation or reason for them to become more engaged. For these people, as Nichols sees it, it’s unclear what to do.
Still, it’s useful to identify a potential hypothesis for the cause. And that’s another lesson I see for biopharma. This is not the only book to try and diagnose THE cause for what happened in November 2016. I’ve read about racism, sexism, poverty, disenfranchisement, geography, education, and history. A quite good explainer in Vox.com was aptly titled: “Everything mattered: lessons from 2016’s bizarre presidential election.”
Those are good words to mull over for biopharma as well. Approaching diseases requires a holistic view, and an understanding that trying to change a complex system arising from multiple contributing factors may also require similarly complex interventions. The drive to combination therapies is the harbinger of this in drug development. I think this trend will only increase and spread to other indications. It’s harder, no doubt, but just as when trying to cure societal problems, no single intervention is likely to lead to a lasting cure. There’s a lot of humility we’ll have to continue applying as we tackle the biggest, most intractable health problems like obesity, cancer and infections.
I wish the answers to trying to resuscitate expertise and by extension preserve our political and social system were clear, obvious or easy but that’s not the case. This is one area, frankly, in which this book struggles. The prescriptions for experts—do a better job of communicating about findings, predictions, failures and roles, make a clear differentiation between expertise and policy—are useful but seem like pebbles wedged into cracks in the crumbling foundation of a mansion. The broad engagement problem is far bigger and more fundamental, not least because many of these people don’t feel there’s something they should learn, or accept the reasons why. When the holder of the most important office in the world signals every day in word and deed just how little he values experts and expertise, the problem compounds.
Still, at least the firefly of hope is blinking out there in that people are grappling with this problem from many directions. The recent March for Science was an energizing event that I know has led different scientists and science-supporters I know to become active in civic organizations. Many scientists are thinking of running for political office. For those of us in biopharma, I urge action. Go out. Talk with people. Listen, don’t try to defend. Be humble about the boundaries of our specialized knowledge. The hope for a resuscitation of expertise is going to come down to people, to rebuilding trust. And to give you some motivation on dealing with this, well, I’d point out that for industries like ours that rely so heavily on the continued generation of experts, it’s not just a societal and political problem, but an existential one too.