Claire - I have given up listening to vox pop programmes of any kind as they just make me cross / despairing, or both. I love Radio 4, which is an oasis of grown-up rationality amid a media maelstrom of crap, but I turn off Any Answers when it comes on. As Sharon says, local radio phone-ins are particularly brain-numbing, but Radio 5 is barely any better, and the presenters on Radio 5 (particularly the insufferably self-satisfied Nicky Campbell) are practically as aggressively ignorant and opinionated as the people who phone in.

You are right about real experts often being quite down-to-earth and modest people. One of the characteristics of the best doctors in particular is that they “wear a lot of knowledge lightly”, and don’t lord it over others who know less (whether patients or colleagues!) by copping a high-handed attitude. In fact, I reckon the ability to do this is one of the key identifiers for the really top-notch ones. This certainly holds true for many of the medics I have worked with in research.

Woebegone - thanks for the link to the Harry Collins piece. I had never come across him before, but he talks a lot of sense, e.g. about “tacit knowledge”. It makes a change to come across any sociologist looking at science and scientists who does not start from a position of post-modernist relativism.

The one point where I would disagree with Collins’ analysis is in his critique of people like Richard Dawkins, and equating what Dawkins does in speaking about religion to what (e.g.) the creationists do in speaking about science.

Dawkins, and other scientists who run into trouble with creationists like P.Z. Myers, mostly tend to get into statements about religious questions via spending their time rebutting religion-inspired nonsense from the “other side”. This nonsense commonly purports to be “a contribution to scientific debate” but is actually religious ideology clothing itself spuriously in scientific camouflage, like Intelligent Design (ID). I might personally find Dawkins a bit shrill - I take a more Stephen Jay Gould-ian view of religion and religious belief myself - but I can see why, after years of having to listen to clergymen and the ID lot talk ill-informed rubbish about evolution, Dawkins was tempted to give a definitive counterblast and set down his views on religion in The God Delusion.

Reading The God Delusion I was reminded of a teacher of mine way back in the 1st yr of secondary school. This teacher was both our maths teacher and our “form teacher” (who took the register). The school had a policy that the form teachers in yrs 1and 2 also had to cover the one weekly Religious Education (RE) class. My 2nd yr form teacher the following year (coincidentally also a maths teacher) was fairly clearly a devout Christian, but the 1st yr one, looking back, was less obviously but fairly certainly a thorough non-believer. The thing that comes back to me is him setting us the following RE homework exercise:

“Suggest alternative non-supernatural explanations for the Twelve Plagues of Egypt”

One point I’d make -

“Who are the people most likely to know all the studies, all the background, all the factors influencing the trustworthiness or otherwise of individual studies, and all the hidden catches in comparing different patient groups and studies?

Well, for me, it’s no contest - the answer is that I would put Professors of Obstetrics & Gynaecology (O&G), or experienced hospital O&G consultants, at the top of the expert scale for this particular issue, and Joe and Joanna Public at the bottom.”

I suspect that Joe Public is actually better informed about a given topic than people who know lots of facts about it, but try to fit them into a certain agenda, that is to say many (but by no means all) “interest groups”. The public may know next to nothing about something, but this is better, in most respects, than being seriously misinformed about it. Simple ignorance is easily remedied with education but misplaced convictions are much more durable…

Likewise, a member of the public knowing nothing about the background, assumptions and “tacit knowledge” common to epidemiologists and immunologists, might be *better* placed to evaluate the evidence about vaccine safety than someone who has read lots of papers but who has a deeply false set of assumptions (e.g. someone for whom all papers which disagree with them are a priori judged to be either fraud or flawed.) The average person would, I suspect, just take most published research at face value, which is wrong, but less wrong than rejecting it outright.

As I extended my formal education, one important lesson I received was just how much more there always is to know in even a small area of specialisation. I gained an appreciation for people who are experts.

For medical matters, there has to be a collaboration between the patient and doctor in discussions, but the patient must understand that the doctor really does know more about medicine than the lay person, unless the doc becomes a quack that is. Doctors sometimes are wrong about certain individual conditions; e.g. I have heard of and read some examples of docs and others making outdated assumptions about autism. But not every doctor can be expected to know the latest research on everything! I’d still want a doctor telling me what to do if my child becomes ill or injured. My OH is a doc, and he will always take the advice of other consultants about areas outside his own speciality.

I know how Claire feels about listening to radio phone ins, and that on Radio 4 is one of the less awful examples too! For some reason, local radio phone ins seems to bring out the really stupid, deluded, bigoted and smug.

I regularly lose the will to live when listening to things like ‘Any Answers’ on Radio 4 - there are some callers with insight but depressingly many eager to broadcast their ignorance and prejudice. On the other hand, I have met a few people who could be regarded as genuine experts in their medical fields, and what I find striking is how ready they are to say that they don’t have all the answers; and how painstaking and careful they are when speaking about issues they justifiably feel they have a good handle on.

I wasn’t so much meaning as in “you the patient / consumer can have no relevant input into the discussion” as “you the patient / consumer need to have an awareness of where your knowledge or understanding is insufficient to make an informed choice, or to tell which factors should weight the decision most, and know who to ask for help”. Or in the terms you put it, one needs to understand that being a “stakeholder” is not the same as being knowledgable.

The danger of “empowering” people and telling them “YOU, the consumer, must choose” is that you run the significant danger of asking them to make decisions about things they simply don’t know or understand enough about to make really rational choices. I know this meets one definition of “respecting autonomy”, but in some ways it wouldn’t meet a definition of “fully informed consent”, as it may be largely uninformed. For instance, if people don’t understand statistics (and most don’t), they will either ignore them in reaching the decision, or simply fixate on the (mis) quoted stat that supports the view they already arrived at (see e.g. homebirth).

And with the expert patients, I would suspect that part of their expertise is knowing precisely where their expertise ends…!

There is an argument to be made, I think, that the Thatcherite and post-Thatcherite “we are all individual consumers of services for everything, with choice in all things” mantra actually hides a kind of disempowerment: people are overwhelmed with the imperative to make choices about loads of things they really don’t want a choice in. The result is that people give up and feel paradoxically powerless.

Personally I think people could do with less choice, but to be focussing on making choices about the things that really matter, of which healthcare is one. But we still need “expert advisers” to help us make the decisions, particularly in guiding us to sufficient understanding to make the decision sensibly. And to repeat my central point, once we start buying into the idea that the experts are another brand of salesmen, where on earth do we go for informed advice?

On the “specific and useless” aspect, it’s one of the charms of science in particular that you can find people who are experts in the weirdest and most obscure things, like fossilized dinosaur poo. How cool is that?

It also bears saying that you simply don’t know if a complete biomedical science “specific and useless” backwater will suddenly become important and super-fashionable.

An example: I know a guy who spent his late 20s and most of his 30s working on amino acid uptake from the blood in various organs of the body. It was solid work, but was widely regarded in the trade as being pretty uninteresting. When I met him he had been doing this for at least a decade. He and his colleagues routinely had a tough time persuading the funding agencies it was interesting enough to be worth putting money into. I mean, who cared about arginine uptake?

And then c. 1990 nitric oxide (NO) suddenly became the flavour of the year, central to vascular biology etc etc. The precursor for NO production is arginine So pretty much overnight arginine uptake from the blood into cells became scientifically ultra-hot, and the British Heart Foundation showered my buddy with grant money. He surfed the wave and is now a Professor of Vascular Physiology.

His take from this is usually “Keep plugging away - every dog has his day.”

Richard Feynman, as so often, had a good take on this. He wrote to one of his ex-students who was wondering why (the ex-student) was plodding along in research as an anonymous cog:

“The worthwhile problems are the ones you can really solve or help solve, the ones you can really contribute something to… …No problem is too small or too trivial if we can really do something about it.”

Gimpy and Dvn - agree about the inherent problems of presenting things. The illusion of “balanced coverage” has a lot to answer for.

I do think “debate radio” works much better than “debate TV”, which is almost always a complete bear-pit of shouting idiots. I think the shouting is effectively encouraged by the TV producers, who don’t want intelligent debate when Jerry Springer-lite Shout-o-rama is doubtless a better ratings-getter. I am with David Attenborough all the way about the dumbing down of intelligent programming over the last decade or so. I still live in hope that some producer will give Ben Goldacre a series, a bit like a more science-y version of Penn and Teller’s Bullshit show.

I think single experts in the “rubbish vs. science, you the viewer decide” can do something, but they have to be very well-drilled and media-savvy to get the wider message across, i.e. that they are there representing a vast body of evidence, while the other side is representing little–to-no evidence and a ton of Man-in-the-Pub (Man/Woman In-the-Healthfood-Store?) opinion-izing. Some talking heads are better at this than others. It also helps a lot to have a presenter who can at least tell, and better still care about, the difference between reality and nonsense,

Claire – agreed on both counts. One of the most annoying things about doctors who sell out to the PharmaCos is that they undermine all the other doctors (and scientists) who are doing their best to be honest. It undermines confidence in the whole of science and medicine. I wish the PharmaCos would wise up to this too. If a drug is actually good, and fills a real unmet need, it largely sells itself as doctors will want to put their patients on it – the advertising, and data-tweaking, and cheating is all greatest for the drugs where the benefit is highly marginal. They should simply do it honestly, and if they make a bit less profit, que sera sera. But then I’m a hopeless idealist.

Sadly, as long as there are sales to be had, and shareholders to be paid dividends, I doubt the PharmaCos can be rewired. But as a scientist it is the PharmaCos’ tame doctors and (less often) scientists that really depress me.

Also agree that patient groups often tread a dangerous line. Some, like one or two of the ME groups, are basically a clearing house for Alt bonkers-ness and loathing of mainstream medicine. And don’t get me started on Electrosensitivity. But even the mainstream ones sometimes lose the plot. Few things have depressed me as much recently as the sight of the Alzheimer’s Society lined up alongside Pfizer and Eisai’s fairly transparent attempt to neuter NICE and sell not-much-good-at-all “cognitive enhancers”. I feel the Alzheimer’s Soc were used by the two PharmaCos, with their connivance, for commercial gain. If the people in charge at the Alzheimer’s Soc can’t see that then they have no business running the show, IMHO. For a good look at this one you can read a real consultant psychiatrist’s take on it here.

jdc – of course I agree about the po-mo microfascism line. Scientific debates are not about who has the best rhetoric, or props, or jokes, or the most baying supporters in the audience. They are about whose ideas are nearer to the verifiable physical reality.

This paragraph in particular struck a chord -
“Personally I think there is a lot of danger in folk who cannot see that there are people who know more than them (or even concede that such people probably exist) when looking at this and other issues to do with interpreting research. To repeat it again, you have to be aware of how much you know, and how much you don’t, if that doesn’t sound too Donald Rumsfeld.” - this reminded me of the Kruger and Dunning paper and also seems to link in to dvnutrix’s comment regarding the PoMo idea that each opinion carries as much weight as the next.

‘Tis but a short step to accusations of fascism (or microfascism) - see http://www.badscience.net/?p=284 or http://www.plos.org/cms/node/99 for discussion of the Holmes paper.

Peer-review? Fascistic. Evidence-Based Medicine? Fascistic. The guy who fought fascists in the 30s? Fascistic.