During the Covid crisis experts have been quoted again and again and again as a central part of the discussion. Their advice and predictions have often been inconsistent or wrong but that has not stopped them from being an essential part of any commentary by journalists and politicians. It’s made me wonder exactly what we mean by an expert.
I never gave much thought to the term until it began to repeatedly appear in the 80’s and 90’s in my field, psychiatry. Suddenly, practitioners were besieged by treatment strategies that were called Expert Consensus Protocols. In theory, I suppose, there was no harm in getting together well-known academicians and having them vote on the best way to treat various psychiatric disorders. Except there was a problem. Many of the strategies were devised by people who had little experience giving treatment, experience I had from spending thousands of hours trying to help my patients. Some of the protocols were very far off from what I had learned from administering care. There also was another downside to these protocols. They became the standard of care. If something went wrong, practitioners could face grave legal consequences from not adhering to the group think strategies devised by the experts.
A short detour will be helpful here to understand what was going on in psychiatry. For decades Freudian orthodoxies ruled the field. Group think was as prevalent then as it was later to become when “scientists” began to demand correct thinking. The desire for scientific thinking was understandable. Psychiatrists had long been considered the step children of medicine. It got worse during the 60’s and 70’s. Psychotherapy had gained a new foothold in popular culture. Many more people were seeing psychotherapists. And there were more therapists than ever before, some with excellent training, but others with little training beyond catchy slogans for change. Much of the rhetoric of the new practitioners had nothing to do with Freud. Many of them tended to use touchy feely psychobabble. Even if they were wrong about a lot of treatment strategies, at least Freudians demanded a certain rigor. The new practitioners were flying in every direction with their claims and methods.
It was embarrassing. Psychiatrists wanted out. They wanted the prestige other doctors had gained by adhering to the dictates of science. The only problem was there was little incontestable scientific knowledge about how the mind functions. It was no one’s fault. It wasn’t from lack of trying. We can only know what we know.
Then along came Prozac. The first time I used it on patients I was amazed. I had tried a variety of medications before which sometimes brought improvement, but I had never seen anything quite like what happened with Prozac. Patients who were absolutely miserable weeks before suddenly were feeling terrific, better than they had ever felt in their lives, as author Peter Kramer put it, “better than well.” It alleviated millions of people’s suffering.
Prozac increased the serotonin in nerve junctions of the brain. It was hailed as a scientific miracle. Except it wasn’t. Before the drug was discovered, few if any scientists believed serotonin had much to do with depression, anxiety, or the variety of psychiatric disturbances it was later used to treat. Eli Lilly first tried it out as a treatment for high blood pressure, then as an anti-obesity drug, then for serious depression. It was a complete failure until it was tried on people with milder depression. It worked spectacularly for them.
Prozac was a home run, but those who discovered it were swinging half-blindly. It was a bit of luck. Its developers had no problem admitting that was the case. Here is a statement accompanying the Discoverers Award given to Drs. Molloy, Fuller, and Wong, for their work with Prozac. “Human science still falls far short of fully understanding how the brain works. It is the most complex organ in the known universe, and though progress has been made in deciphering some of its secrets, much remains to be discovered.” However, despite their realism about the science, the remarkable efficacy of SSRIs had a halo effect on the reputation of psychiatry.
The general impression of the public was that amazing things were happening in scientific psychiatry, twenty first century discoveries. It was exciting. Psychiatry was finally thought to have answers to questions that needed answering. People were willing to pay fortunes for 15 minutes of a psychopharmacologist’s expertise.
The dominant paradigm became that chemical imbalances were the explanation for a myriad of conditions. Not that these imbalances could be demonstrated in our patients but it was only a matter of time. So great was the power of science that it would be coming tomorrow or before that. In actual fact the chemical imbalance perspective has now been discredited, but at the time it was put forward as certainty, scientific certainty.
Psychiatric literature had long contained rich deeply detailed case histories for us to ponder the complexities and mysteries of human behavior. Analysts did their best to tackle these cases one individual at a time. The process was long and slow and sometimes fruitful. Sometimes not. Suddenly all of the mystery, all of the details necessary to describe patients, became passé. In the literature long case reports were dismissed as anecdotal, of no scientific interest. What mattered came from grouping patients, categorizing them with a specific diagnosis, then gathering accurate statistics about these groups. Numbers not nuance mattered. As part of this new confidence experts stepped forward waving the banner of science.
Let me state clearly that I am not an anti-science, anti-technology person who wants “holistic” or alternative care for patients because science is inherently anti human. Quite the opposite, I would be thrilled if the treatment of psychiatric patients could be reduced to the application of well researched and confirmed scientific findings, which in turn would lead to logical and well thought out treatment. I would relish writing prescriptions that are as effective, as antibiotics are for strep throat, or penicillin is for syphilis. When scientific method leads to an understanding of a phenomenon there is nothing like it in getting the job done. Not only are antibiotics miraculous, so is the polio vaccine, cholesterol reducing agents, and many other lifesaving medicines.
Let me go further. We rightly appreciate firemen as heroes because they put their own life on the line. But, if we want to talk about heroes who have literally saved ten, perhaps hundreds of millions of lives, we cannot ignore scientists as our true miracle workers. Indeed, all reported miracles performed on earth by Jehovah or Jesus pale when compared to what our scientists have been able to accomplish. Never mind walking on water. Scientists have allowed human beings to fly from here to Texas. They have flown some of us to the moon. I don’t want to go too far with the obvious, but as the religious sometimes say as they view a mountain, or a rainbow, or the oceans “this is God’s work,” we should take a look at the miracles made possible by scientists. Before the 20th century there were no refrigerators, no cherries in the winter, no steel and glass skyscrapers, no computers, no internet, no automobiles and TV’s and most pointedly now, no vaccine for Covid 19. We should have a ticker tape parade for the scientists (as opposed to businessmen) working at drug companies. As an old guy self-quarantined for the past year at home, their genius may not only have returned normalcy to me. They may have saved my life.
Science is and should be the modern deity. Best of all, unlike previous deities, the makers of our miracles are not hidden in the clouds or the heavens. They bring forth answers that are pristine and unambiguous. Modern science depends on the clarity of numbers. There are no shades of grey blurring the truth. Numbers pinpoint irrefutable facts. Good or bad, science is clearly the most effective way to understand reality and effect change.
That is, when we have the knowledge. When we don’t we have experts.
In psychiatry “science” was used by the experts to bludgeon doubters into silence. It turned out that many of the experts were hucksters, paid academicians seeking to foster drug treatments which meant billions of dollars for their drug company patrons. Harvard’s Joseph Biederman, Chief of the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at the Massachusetts General Hospital was considered the nation’s leading expert on ADHD. He wrote over 294 articles on ADHD. I don’t know when he had time to see patients but in any case he received the American Psychiatric Association’s Blanche Ittelson Award for Excellence in Child Psychiatric Research, the American Academy of Child and Adolescent Psychiatry’s Charlotte Norbert Rieger Award for Scientific Achievement. He kept the fact that he had received $1.6 million dollars from the pharmaceutical industry secret.
I knew of this man. He was a persistent salesman. Sometimes several times a week over many years I received mailings from the renowned scholars at Harvard Medical School’s psychiatry department. The mailings basically said the same thing. I might be missing adult ADHD among my patients. They were in need of amphetamines and amphetamine-like meds to be fixed. On the streets this fix is called speed.
When experts insist that they know the truth it can be very persuasive. Most doctors (including some very nice, well-meaning psychiatrists, family doctors and pediatricians) follow guidelines from experts because given that they are written by professors who hold prestigious positions in many of the finest universities in the United States, they are likely to represent what is known. Medical practitioners, like everyone else, are very busy and must go on faith for many of their decisions. Even if that weren’t true most psychiatrists are like people in other fields. Group think prevails. They go along with what everyone else is doing. Particularly during the last 50 years, not doing what is accepted as the standard of care will lead to lawsuits if the results are not as expected.
Instead, of wrestling with the many uncertainties facing doctors as they make decisions that derive from the complexity of actual people, instead of turning to their best judgement it is tempting to turn to numbers. There is good reason why numbers are so appealing. Instead of being lost in the mystery of the unknown, when numbers are applied the answers can seem exact, scientific, soothingly accurate. They are the product of experts. However, besides the potential corruption that results from those who harness the power of expert opinion, there are also inherent mental traps. So eager are experts to present needed answers based on statistics that they use them when what they are presenting is irrelevant. As Einstein put it “Not everything that can be counted counts. Not everything that counts can be counted.” Or as Dr. Jerry Muller put it “not everything that is important is measurable, and much that is measurable is unimportant.”
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Psychiatry is plagued by a nomenclature that is perpetually being changed. During the scientific era in psychiatry we have we have had a DSM III, IV, and V, each diagnostic manual carefully defining and redefining what an illness is and is not The main problem is that these diagnoses don’t necessarily correspond to actual illnesses. They refer to symptoms that can be clustered and then labeled. Accurately defining clusters of patients with specified symptoms, is done in the spirit of science, but spirit is not enough. It is window dressing. As hard as experts try, without having the knowledge that comes from scientific understanding, the experts making up the committees cannot get it right. With their votes they can dictate what an illness is or isn’t. But experts love affair with numbers often makes the use of these diagnoses border on the silly. In particular, the statistics that result from med trials using these diagnosis may be accurate, but the use of them to determine what is, and is not, “evidence based treatment” is not scientific at all. It only appears that way.
Penicillin kills Treponema pallidum 99% of the time. It cures syphilis just as we expect it to do for reasons that are well understood. No one speaks of it as evidence based medicine. We reserve that term for treatments where the results are completely unclear. No psychiatric medicine works 99% of the time. How could they? Unlike syphilis we don’t have an understanding of what is happening. Most psychiatric meds work 60-70% of the time. That is better than placebo which sometimes works 40% of the time. 60% is not meaningless. Something useful has happened more often than it would have with a sugar pill. But for all the specificity implied by citing statistics, what is actually happening and why is unknown. Precisely defining diagnoses and carefully collecting data is not enough to claim treatments are evidence based. This is extremely important because using a phrase like evidence based medicine defines the standard of care, which most doctors don’t dare stray from. It implies science has determined the treatment, when, in actuality, science plays no part. It is the shell of science, the language of science. But not science itself. It allows practitioners to convince themselves that they reside in its hallowed halls using methods that have brought miracles. Its main function is to maintain the cache
It gets worse. Some diagnosis such as “conduct disorder”, don’t even resemble a real disease. Committees can accurately define the clusters of symptoms that define it but when experts try to harvest numbers that quantify treatment for misbehaving youngsters the process has become ridiculous. With “diseases” such as these clinicians are often practical. Far better to diagnose someone with ADHD which drug companies have spent a fortune trying to convince everyone that we are dealing with a real biological problem, behavior resulting from the body’s chemicals misfunctioning. It then seems logical to use chemicals to fix it.
The ugly tactics resorted to by drug companies to get everyone thinking that way is particularly clear in the case of Dr. William Pelham, director of the Center for Children and Families at State University of New York at Buffalo In 2002, he was given a lifetime achievement award by the world’s largest ADHD patient advocacy group, Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD). Pelham did a study which involved giving meds as usual but also providing training to parents, and establishing simple behavioral programs in the children’s regular school classrooms. When his paper was in the galley proof stage at the medical journal Pediatrics, Pelham says he joined a conference call with a number of senior people from the corporation he worked for and they lobbied him to change what he had written in the paper. “The people at Alza (Pharmaceuticals) clearly pushed me to delete a paragraph in the article where I was saying it was important to do combined treatments (medication and behavioral) “It was intimidating to be one researcher and have all these people pushing me to change the text.”
McNeil Pharmaceuticals (which copromoted stimulants with Alza) didn’t stop there. The company commissioned a follow-up study on the conversion study mentioned above. This time McNeil did the data analysis and coordinated the paper writing. “I insisted on seeing the analyses and having major inputs into the manuscript and it was like pulling teeth to get wording and analyses changed,” he says. “It was like a whitewash, a praise to Concerta.” Pelham says the company submitted the paper twice to the Journal of the American Academy of Child and Adolescent Psychiatry. Drafts were sent to Pelham several times but he says he never returned anything with his signature. In the end, however, he says the paper was accepted without his knowledge and published with his name on it.
It isn’t only researchers who are affected by the push to see things “scientifically”. It is not uncommon for doctors to change their patients’ diagnosis again and again hoping the numbers cited in the treatment protocols will deliver a cure. In other words, if the patient has bipolar disorder evidence-based medicine tells them to use this drug or that. If that doesn’t work they might choose a different diagnosis and then follow what the numbers tell them to do about that disorder. Their focus isn’t on the patient they are seeing, but on symptoms enumerated in the diagnostic manual. They’ve never really tried to figure out how the drug they are prescribing affects the psychological difficulties their patient is having. How could they? Their patient only appears once a month for fifteen minutes. Their job is to apply a diagnosis and then follow the protocol, guided by the numbers promised for that diagnosis.
Waving the banner of science, citing numbers derived from studies, reassures practitioners that they are being guided by its certainty. The virtues of science, its prestige, can act as a smokescreen. The language, the methods, the trappings of science can be so distracting that science’s core value is overshadowed, absolute clarity about what is known and not known. In psychiatry, considering how much we still don’t understand, our steps forward should be exploratory, investigative, not closed off by the chilling effects of authority. Meaning “science” should not become an authority. Doing this is the very essence of what science is not. Real scientists operate in an environment of doubt. We continually challenge the given and try to prove another version of the truth will prevail. Only by tearing down and reconstructing knowledge with adequate proof do we move forward.
Which brings me to a very hot topic, global warming. Like 99.9% of Americans I am not able to scientifically judge evidence for, or against, global warming. I am not a climatologist. But having seen what has happened when psychiatry has presented itself as scientific I quickly recognized signs that something is wrong with the climate discussion. Those words, science and consensus keep popping up. As weapons! I did a little reading. That 97% of scientists agreeing, the scientific consensus everyone keeps quoting turns out to be nonsense. More importantly, the most striking aspect of the controversy is the deliberate silencing of those who disagree. If anything, there has been even more dishonesty than what has occurred among psychiatrists.
When global warming was first brought to the public’s attention advocates warned that in a hundred years terrible things were going to happen if the problem was not addressed. That brought a yawn. Something had to be done. 2004 was a terrible year for hurricanes. Lives were lost. Billions of dollars of destruction occurred. It was a game changer. Climate change advocates finally had what they needed.
Only they didn’t. The campaign was a lie. Not a mistake, a lie. Chris Landsea, the UN’s IPCC’s authority on hurricanes wrote a public letter of resignation in 2005 after Harvard’s Dr. Kevin Trenberth participated in a press conference organized by scientists at Harvard on the topic: “Experts to warn global warming likely to continue spurring more outbreaks of intense hurricane activity”. The result of this media interaction was widespread coverage that connected the very busy 2004 Atlantic hurricane season with global warming. Landsea was at first confused by the press conference. To his knowledge none of the participants in that press conference had performed any research on hurricane variability, nor were they reporting on any new work in the field.”
Dr. Landsea complained to the IPCC that there was no scientific basis for their claim. The IPCC leadership said that Dr. Trenberth was speaking as an individual even though he was introduced in the press conference as an IPCC lead author. “I was told that the media was exaggerating or misrepresenting his words, even though the audio from the press conference” clearly showed he had said what they reported. Landsea continued. “It is certainly true that “individual scientists can do what they wish in their own rights”, as one of the folks in the IPCC leadership suggested. He agreed. “Differing conclusions and robust debates are certainly crucial to progress in climate science. However, this case is not an honest scientific discussion conducted at a meeting of climate researchers… It “is of more than passing interest to note that Dr. Trenberth, while eager to share his views on global warming and hurricanes with the media, declined to do so at the Climate Variability and Change Conference in January where he made several presentations. Perhaps he was concerned that such speculation—though worthy in his mind of public pronouncements—would not stand up to the scrutiny of fellow climate scientists.” Dr. Landsea continued in his resignation letter “I personally cannot in good faith continue to contribute to a process that I view as both being motivated by pre-conceived agendas and being scientifically unsound.”
Far worse tactics than misrepresentation followed in the case of Roger Pielke. He wrote an article for the Wall Street Journal entitled, “My Unhappy Life as a Climate Heretic.” In it he described the harassment he received for his research, which led him to a conclusion that many climate campaigners found unacceptable. It was the same issue. He thought global warming was real but there was scant evidence to indicate that hurricanes, floods, tornadoes or droughts have become more frequent or intense in the U.S. or globally. Pielke thought it was possible he could be wrong but it was a topic he’d studied and published on as much as anyone over two decades. In 2015 he was quoted in the Los Angeles Times, by Pulitzer Prize-winning reporter Paige St. John, making the rather obvious point that politicians use the weather-of-the-moment to make the case for action on climate change, even if the scientific basis is thin or contested. Ms. St. John was pilloried by her peers in the media. Shortly thereafter, she emailed him what she had learned: “You should come with a warning label: Quoting Roger Pielke will bring a hailstorm down on your work.”
John Podesta, Hillary Clinton’s campaign chairman wanted to drive him out of the climate-change discussion. His papers were no longer accepted by publishers where he had no difficulty before. An investigation of him was begun by Arizona Rep. Raul Grijalva, the ranking Democrat on the House Natural Resources Committee. Representative Gridjalva wanted blood. He was investigating whether Pielke, like Richard Lindzen, (a member of the National Academy of Sciences, an atmospheric physicist and Alfred P Sloan professor of meteorology at the Massachusetts Institute of Technology) and 5 other climate skeptics were being funded by Exxon Mobil. He demanded that their universities investigate their financial support. There were also scientists of lesser renown that he targeted and in some of them Gridjalva’s inquiry created difficulties in their careers. Pielke posted a picture of Joseph McCarthy when he wrote about Gridjalva’s attack on Wei-Hock Soon of the Harvard-Smithsonian Center for Astrophysics.
Fortunately, for Pielke personally, the investigation was not catastrophic. Pielke cheerfully wrote in his article that, “Studying and engaging on climate change had become decidedly less fun. So, I started researching and teaching other topics and have found the change in direction refreshing. Don’t worry about me: I have tenure… No one is trying to get me fired for my new scholarly pursuits.” His current pursuit has been described as a study of sports in society. He is now drawing his tenured pay at the university of Colorado as the director of the Sports Governance Center within the Department of Athletics.
Who can blame him for fleeing the climate discussion? Being a heretic is not the path to a pleasant life. But at least society has made progress. In the Massachusetts witch hunts, 20 witches were burned at the stake (actually they were hung). Still, we cannot be totally optimistic. Writing in the New York Times, Nobel Prize winning economist Paul Krugman took condemnation of climate deniers to a new level, “And as I watched the deniers make their arguments, I couldn’t help thinking that I was watching a form of treason, treason against the planet. To fully appreciate the irresponsibility and immorality of climate-change denial, you need to know about the grim turn taken by the latest climate research.”
Treason? Huh? This from those who go wild about the terrible people who deny science. And this from someone who is even more esteemed than an expert, a Nobel Prize winner.
I’m glad Dr.Pielke has been able to gain a measure of equanimity by fleeing the topic of global warming. But the importance of the issue is not lessened by the fact that he’s personally okay. Scientific issues should not lead to persecution, to fear about expressing contrary opinion. The irony is overwhelming. Science whose very essence depends on doubt being used as a tool to further knowledge, is being used to suppress free thought.
My personal experience illustrates that this issue doesn’t only occur when it falls into the overheated frying pan of political debate. During the period in psychiatry that I described above, I wrote many articles that contained my criticism and suggested alternatives. I couldn’t get them published in main stream journals that would have allowed me to reach the audience that was crucial to how psychiatry was being practiced. Some academicians found me anyway, either on the internet or in smaller publications that were willing to publish what I had to say. Their reaction says it all. Several told me they admired my courage. Courage? It didn’t take courage at all. After a few years in academia I realized it wasn’t for me and that was during the Freudian era when I expressed some out of the mainstream arguments. The point is that since I was not a part of academia I had nothing to fear. It was different for them. That was dramatized by a communication I received from one of those who expressed his admiration. He cautioned me to not use his university email address with my views but to send all correspondence to his personal email.
At the time I hadn’t realized the campaign to keep experts’ opinions pure was that bad. I thought this kind of intrigue was mainly found in the Soviet Union. America is the home of the free, especially in the universities, which is the home of the smart people. This was long before horror stories began to emerge about how political correctness now ruled at even the finest universities.
When I was a child, I mostly thought that book worm kids were kind of nerdy. What many of them landed up doing with their careers made sense. Universities are filled with people who have sought the cloister of ivy walls. They had no taste for slugging it out in a world of Clint Eastwoods, businessmen, and bullies, the tough real-world of people beyond their walls. It seems entirely logical that they are for the most part pacifists, and they favor those at the bottom of society’s esteem. After all, as children, they most likely had been the recipients of abuse by rowdy not book loving kids.
After college my opinion of professors was the opposite of what it was as a child. They now seemed to be our most important body of citizens, rising above the squalor that sometimes characterizes dirty capitalistic competitiveness. I thought it was wrong that corporations usually turned to captains of college football team rather than Phi Beta Kappa members. Intelligence, more than any other quality matters. I still believe that intelligence should be rewarded, that intellectual pursuits should be hallowed but my views have changed about academia.
It is clearly not the home of the free, and certainly not the home of the brave. Political correctness is perhaps worse there than it is among the media and politicians. At least they have an excuse. The media needs horror stories to get the clicks. Politicians’ thinking must go wherever their constituents expect. But why are universities worse than elsewhere? It is because they provide the experts.
I don’t know if universities and professors will ever regain the respect they had until recently. JFK brought in his Harvard geniuses to fix the country. Before that the public didn’t turn to them very often when they wanted leadership. They were more likely to turn to Will Rogers for answers. They chose Ike over Stevenson, precisely because he was from the real world and not an egghead. Meaningful smarts far outweighed book smarts. But after Kennedy that changed. It became automatic to turn to the universities to guide us.
Although I did not fear terrible consequences if I continued to publish my criticisms of the paradigms that ruled academic psychiatry, the effect was the same. Like Pielke I was silenced, not because I was afraid. I got tired of knocking my head against the wall. Like him I have turned my writing energies in another direction. I have tried my hand as a novelist. Like Pielke, I very much enjoy my new focus but that doesn’t mean what I did and Pielke did and undoubtedly many others have done, and are now doing, is a good thing.
Lately, there have been very few articles taking on the media and the experts on climate change. We will be spending untold trillions of dollars to combat it. We will be shutting down coal companies, oil companies, ending gas powered automobiles all trying to save the planet. Great. I am for saving the planet. But before radically changing our economy, are we not entitled to a lively discussion about the science, one that truly has its virtues, relentless questioning until we get to where we need to be, with scientific answers? Especially because the latest IPCC studies are nothing like what our politicians and the media are screaming about. More than ever it has described significant uncertainly about global warming’s effects on drought, hurricanes, and floods.
Apparently, we are not going to get that discussion. The nerds in academia have run true to form. Not many will speak up. I am not talking about those who disagree with critics of global warming. I am talking about the many who have been silenced by fear and don’t dare speak out. I am talking about the truest sign of uncertainty, repetitive virtue signaling. It’s reminds me of what must have been going on in the minds of Hitler’s supporters, their repetitious Sieg heils as they threw out their arms in a salute. That reassured others and themselves that they were true believers. So, does virtue signaling.
It is unfortunate that Trumpians expressed their disdain for experts to the point of insanity. They thumbed their noses at them by refusing to wear masks. What concerns me more is that the distrust of experts will move beyond that fringe to the general public as more and more people notice that what is being told to them by experts is not true.
Mind you I am not unsympathetic to the diversity of opinions that experts express. The more ideas we have the better. Someone is going to guess right. I just want them to not call themselves experts. Simply tell us that this or that is their opinion, their best guess, their judgement. Stop throwing numbers around like they know something that they don’t.
Nor am I unsympathetic to people’s need for experts. We have heard from them ad nauseum during the Covid crisis. But what else could we do? We have been rightfully afraid, in need of explanations that might carry us. Although we didn’t get what we needed, we got what we wanted, what seemed to be trustworthy answers.
Throughout the millennia, alone with their fate, people have turned to faith. Now the experts are our priests. As much as my mind tells me to, I can’t laugh at the universal need for faith in the answers we are given. What choice is there? Lost in the wilderness of Oz, Dorothy believed there was a wizard that could give her what she desperately needed. When Covid 19 took over the world, when things got very desperate, when we didn’t have a clue, we all wished we could visit the Wizard of Oz. That’s when experts appeared from every corner of knowledge land.