Monday, February 04, 2013
The Land of Oz
"I never knew I had an inventive talent until phrenology told me
I was a stranger to myself until then."
The question of expertise is a fascinating and vexatious one. Who gets to be an expert? More accurately, who is allowed to be an expert? And what happens when expertise is, for lack of a more polite term, betrayed by one of its own? A recent New Yorker article pillorying Dr. Mehmet Oz provides some interesting lessons in this regard.
Most expertise, it can be reasonably argued, is cultivated and deployed within the context of occupational professions. For the purposes of created a baseline for the following discussion, let’s define a profession as “an organized body of experts who apply esoteric knowledge to particular cases.” This is according to Andrew Abbott, whose The System of Professions (1988) is the current sociological heavyweight when it comes to theorizing about professions.
Abbott contends that, in order to theorize this phenomenon effectively, sociology must look at professions in a holistic manner: prior research, which focused on the structure and function of individual professions, missed the larger point that the success or failure of any given profession was largely contingent upon the results of “interprofessional competition.” That is, when considered in isolation, professions make claims concerning their relevance for addressing social needs through the formation of associations, credentialing, the courting of favourable regulation, and so on. However, when viewed as a larger social phenomenon, it is apparent that these claims are subject to constant contention by other professions. There is, in fact, an ecology of professions.
As an example, while one might consider alcoholism to be an objective phenomenon centered around the over-consumption of drink by an individual, the subjective nature of alcoholism as a social phenomenon has been viewed alternatively as a moral or spiritual problem, a medical disease, a legal matter, and as a mental disorder. Respectively then, the responsibility to treat alcoholics was claimed by the clergy, doctors, lawyers and police, and psychiatrists. What is worth noting is that these professions actively partook in poaching the objective phenomenon at hand from one another. When a particular profession failed to deliver results, an opening was created for another group to take over, thereby adding to its social legitimacy and influence.
Abbott is very precise about what signals the vulnerability of one profession to another. Professions are, in the most generic sense, proficient at diagnosing problems within their domain of expertise, inferring various winning scenarios, and prescribing appropriate treatments. One profession can attempt to claim territory from another if the former fails to control all three of these phases. While accurate diagnoses and measurable, successful treatments are obviously essential, inference is particularly vulnerable. Constituting the profession’s internal work, inference connects diagnosis to treatment, and can be thought of as chains of analysis and decisionmaking, which ought to be neither too short (leading to ‘deprofessionalization,’ or in today’s world, automation via computers) nor too long (implying irreproducibility of results).
Paradoxically, professions that can revisit specific problems for an unspecified number of “second chances” are particularly vulnerable to this kind of competition. Consider the luxury that doctors have when treating a patient with high cholesterol over the course of many visits, versus military strategists, who have only one opportunity to fight a single battle. While the doctor can tinker with various drug regimes, the strategist has only one chance to triumph in a confrontation that is unique and unrepeatable. In this sense, a surfeit of second chances presents any competing profession with subversive opportunities, such as when a patient hears of a new treatment and demands that his doctor prescribe it. Thus a large portion of the profession’s claims to cultural legitimacy may come under threat. As Abbott writes in The System of Professions,
Societies have little time for experts who lack cultural legitimacy, irrespective of their success rates. This issue ultimately undid the homeopaths in their competition with regular medicine, although medicine’s recent narrowing of its legitimation to science and technology has proved dangerous, since late twentieth-century cultural values increasingly conceptualize health as quality of life (p54).
This thought, written 25 years ago, sets the stage nicely for the above-mentioned New Yorker article.
In “The Operator,” Michael Specter profiles Dr. Mehmet Oz, known to fans of Oprah Winfrey as “America’s Doctor,” as riding the wrong side of the tracks of popular medicine by breathlessly entertaining “experts” (read: quacks) and “miracle cures” on Oz’s wildly popular TV show. In turn, Oz defends his self-appointed responsibility, “because the currency that I deal in is trust, and it is trust that has been given to me by Oprah and by Columbia University [where he practices surgery], and by an audience that has watched over six hundred shows.”
Oz maintains that “Western medicine has a firm belief that studying human beings is like studying bacteria in petri dishes. Doctors do not want questions from their patients; it’s easier to tell them what to do than to listen to what they say. But people are on a serpentine path through life, and that is the way it is supposed to be.” In his incarnation as “America’s doctor,” he inhabits precisely the gap that Abbott identified above, where complementary medicine addresses itself in a sympathetic way to the desire patients have for “quality of life.” As such, he combines a charismatic presence with a media-savvy show that impacts the health decisions made by millions of Americans.
While much of his advice is entirely sensible, he also takes the opportunity to promote theories and products that are, at best, lightly supported. This is what Specter cannot countenance: “When he tells his audience, with no credible evidence, that red palm oil may reduce the risk of Alzheimer’s disease, is he empowering people? Or is he encouraging them to endanger their health with another ‘miracle’?”
At points, Specter can barely contain his incredulity. “How was it Oz’s ‘biggest opportunity’ to introduce [osteopath Joseph Mercola,] a guest who explicitly rejects the tenets of science? …I was still puzzled. Either data works or it doesn’t…Surely you don’t think that all information is created equal?”
But is precisely Abbott’s lengthy “chains of inference” and “second chance” opportunities, so characteristic of medical practice, that provide the opening for Oz’s guests to make the claims they do (e.g., that vaccines can cause AIDS). If medicine has given up on its collective bedside manner and retreated behind the chart and microscope, the alternative medical professions will smell the weakness and unhesitatingly pounce. As Oz himself says, “It becomes difficult for us to agree on what we think works, since so much of it is in the eye of the beholder…It’s my fact versus your fact.”
We have seen this movie before. Writing in the American Sociological Review a few years before Abbott published his book, Thomas Gieryn postulated that scientists engage in ideological boundary-making for at least three reasons: when the discipline is attempting to make claims on new territory; when consolidating still-tenuous claims; and when secured territory is under threat, for example by defunding. Gieryn illustrates the second scenario by recounting the power struggle that occurred between anatomists and phrenologists in early 19th-century Edinburgh.
Since its founding earlier in the later 18th century, phrenology had gained great popularity. Nevertheless, the more established scientists saw phrenology as a distinct threat, not least because it promoted itself as a complete science – more complete, in fact, than any other. Phrenologists for example felt capable of reforming prisoners and finding the most suitable employment for them; they promised even a greater understanding of Christianity. This constituted a distinct threat to anatomists, who concerned themselves solely with physiology, and their academic colleagues, the moral philosophers. That the church would not be pleased to see “science” incurring on its own turf was also a not-insignificant factor. But most importantly, it was the upstart discipline’s “democratic ideal of certifying truth by popular opinion [that] challenged the authority of scientific experts.”
The anatomists mounted a campaign to discredit phrenology. Articles appeared in the Edinburgh newspapers attacking it, especially for its religious and political ambitions. William Hamilton, an adversary of the phrenologists, conducted experiments, using the scientific method, to disprove phrenology’s scientific claims, He even asked George Combe, its most ardent proponent, to “produce a single practical anatomist who will consent to stake his reputation on the truth of phrenology…Combe replied that “experts” could not serve as dispassionate judges of phrenology because most had previously expressed their contempt for it” (Giervyn, 798). All in all, the anatomists made short work of phrenology:
George Combe was denied the chair of Logic at Edinburgh University; phrenologists were not allowed to use the lecture halls at the Edinburgh School of Arts; phrenological issues were rarely admitted to the proper forum for scientific debate, the Royal Society of Edinburgh; Combe was not allowed to form a “phrenological section” in the British Association for the Advancement of Science. Selected phrenological ideas were incorporated into the legitimate science of physiological psychology without admitting Combe to the scientific community, thus avoiding threats to professional authority.
Here the anatomists’ actions anticipated Abbott’s notion that academia is the most direct route to cultural legitimacy for any profession, including science. More cynically, they were not shy about appropriating what worked for themselves, but stripped of any incriminating ideology.
Oz’s adversaries may take cold comfort from this study, however. The fact that Oz has emerged from within the profession itself brings up the interesting case of what happens when an exemplary representative of a profession “strays” from the jurisdictional claims of his métier and clearly, deliberately invites, as per Abbott, interprofessional competition. Nevertheless, he is, by all accounts, a motivated teacher and scholar who has published hundreds of papers; a fine surgeon who has performed thousands of open-heart procedures; an alpha male thriving in a profession populated only by alpha males. It’s just that his side-gig isn’t building ships in bottles.
By his own admission, Oz is on a crusade to break down the barriers that maintain the hard-won claims that medicine has come to enjoy in this country. For the moment, there is little the profession can do to stop him – in this era of instant media and communication, there is no lecture hall from which to ban him. One need only witness Glenn Beck’s recent post-Fox successes to understand how little exile matters to those whose audience has achieved a critical mass.
Quixotically, in this case, the profession at risk seems to have resigned itself to using journalism as its best available enforcing mechanism – a tactic that, putting it mildly, attaches its own set of problematics. For Michael Specter is himself neither a doctor, nor a scientist, and the New Yorker is not a peer-reviewed journal. This kind of bourgie tut-tutting cannot really touch the plane of popularity on which Oz is operating.
More problematic, however, is the fact that the media is itself guilty of exactly the same kind of breathless glorification of most any kind of science that will sell papers, ad space, personal information, or whatever passes for currency in journalism today. Reporters are expected to produce regular features about our inevitable progress towards freedom from disease or just plain discomfort, so if there is a “study” that affirms something exciting, it will find its way onto the front page of the science section, if not the front page itself. Scientists are in turn all too happy to publicize their findings, however tenuous they may be, since university administrators reward visibility with more funding.
For their part, industry groups are thrilled at the prospect of skyrocketing demand for, say, red palm oil, oatmeal or anything else. If it's a new pharmaceutical, drug companies and doctors are happy to have something new to prescribe. And years later, when follow-up studies refute or negate or trivialize these findings, there is no one to take the call, because that is simply old news, and who wants to hear that we really don’t know much more than we thought we did? Specter may be an angry-yet-noble enforcer for the positivist cause, but his colleagues across the board ought to accept the responsibility for having created a world in which someone like “America’s Doctor” is not just a possibility but an inevitability.
Posted by Misha Lepetic at 12:20 AM | Permalink