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The sins of expertness and a proposal for redemption

BMJ 2000; 320 doi: (Published 06 May 2000) Cite this as: BMJ 2000;320:1283
  1. David L Sackett, director
  1. Trout Research and Education Centre at Irish Lake, Markdale, Ontario, Canada

    Two decades ago I was an expert on the subject of compliance with therapeutic regimens. I enjoyed the topic enormously, lectured internationally on it, had my opinion soughtby other researchers and research institutes, and my colleagues and I ran international compliance symposiums and wrote two books, chapters for several others, and dozens of papers about it. Whether at a meeting or in print, I was always given the last word on thematter.

    There are still far more experts around than is healthy

    It then dawned on me that experts like me commit two sins that retard the advance of science and harm the young. Firstly, adding our prestige to our opinions gives the latter far greater persuasive power than they deserve on scientific grounds alone. Whether through deference, fear, or respect, others tend not to challenge them, and progress towards the truth is impaired in the presence of an expert. The second sin of expertness is committed on grant applications and manuscripts that challenge the current expert consensus. Reviewers face the unavoidable temptation to accept or reject new evidence and ideas, not on the basis of their scientific merit, but on the extent to which they agree or disagree with the public positions taken by experts on these matters. Sometimes this rejection of “unpopular” ideas is overt (and sometimes it is accompanied by comments that devalue the investigators as well as their ideas, but this latter sin is by no means unique to experts). At other times, the expert bias against new ideas is unconscious. The result is the same: new ideas and new investigators are thwarted by experts, and progress toward the truth is slowed.

    Chastened by these realisations, in 1983 I wrote a paper calling for the compulsory retirement of experts and never again lectured, wrote, or refereed anything to do with compliance. I received lots of fan mail about this paper from young investigators, but almost none from experts. I repeated my training in inpatient internal medicine, spent muchmore time in clinical practice, and applied my methodological skills to a new set of challenges in appraising and applying evidence at the bedside.

    As before, the experience was challenging and exhilarating. Working with gifted colleagues, first at McMaster and later in Oxford and throughout Europe, I became an expert in an old field with a new name: evidence based medicine. Because interest in these ideaswas so great, especially among young clinicians around the world, my writing and editingwas published in several languages, and when I was not running a clinical service I was out of town demonstrating evidence based medicine at the bedside and lecturing about it (over 100 times in 1998).

    Although acceptance of my views was not universal, once again my conclusions came to be given too much credence and my opinions too much weight. And newcomers to the field who regarded me with affection faced an additional deterrent to challenging my expertness: they feared hurting my feelings as well as earning my disapproval. Two clinical signs confirmed that I was once again an expert. The first was the reception of an honorary degree and the second bears my name: “Sackettisation,” defined as “the artificial linkage of a publication to the evidence based medicine movement in order to improve sales.”

    As before, I decided to get out of the way of the young people now entering this field, and will never again lecture, write, or referee anything to do with evidence based clinical practice. My energies are now devoted to thinking, teaching, and writing about randomised trials, and my new career is as challenging and exhilarating as its predecessors.

    Is redemption possible for the sins of expertness? The only one I know that works requires the systematic retirement of experts. To be sure, many of them are sucked into chairs, deanships, vice presidencies, and other black holes in which they are unlikely to influence the progress of science or anything else for that matter. Surely a lot more people could retire from their fields and turn their intelligence, imagination, and methodological acumen to new problem areas where, having shed most of their prestige and with no prior personal pronouncements to defend, they could enjoy the liberty to argue new evidence and ideas on the latter's merits.

    But there are still far more experts around than is healthy for the advancement of science. Because their voluntary retirement does not seem to be any more frequent in 2000 than it was in 1980,I repeat my proposal that the retirement of experts be made compulsory at the point of their academic promotion and tenure.


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