True intuitive expertise is learned from prolonged experience with good feedback on mistakes —David Kahneman

Not long ago I saw my cousin Frank at a family barbecue. It had been over 30 years since I last saw him, so there was lots of catching up to do as we stood by the grill sharing food and drink. Frank was in his early 60’s, but you would never know, he looked at least a decade younger. He stood around 5’10”, was medium built, and had a calm demeanor to him. As we stood by the grill his brother—who had joined with others—asked me if I was a Neurosurgeon. I told him I was a Neurologist and explained the difference between the two specialties, namely around $500K. “Anyway, do you know Frank has Parkinson’s?” he said. I stepped back in disbelief, how could it have eluded me? I had been chatting with the guy for a good 20 minutes! “Are you being treated for it?” I asked Frank. “Yes I have been on levodopa for the last ten years” he replied. At closer inspection the picture became more clear to me. He had not moved his left arm much for the time we were chatting. He also had mild dyskinetic head movements, and was slightly stooped. Otherwise, his blink rate was symmetric, he had normal facial expression, and had no resting tremor. “I’ll be darned!” I said. “Your doctor is doing a heck of a job, so just keep doing what you are doing” I told Frank. No sooner had I said this, than uncle Joe—a bright and opinionated engineer—jumped into the conversation. “So Frank, I hope you bought a lottery ticket” he said. Everyone in the group looked perplexed. “Why yes, everyone knows Parkinson’s is an old man’s disease” He said “just ask the Neurologist here!” he added, as his gaze fixed on mine seeking validation. “Well, Late-onset Parkinson’s disease, the most common type, occurs after the age of 50, so Frank is within the age bracket to have it.” I replied.

Curiously enough, I had just finished reading the book “The Death of Expertise” by Tom Nichols, which delves into the concerted attack on expertise and rise of anti-intellectualism as a consequence of the so-called democratization of knowledge. I see this all too often in clinic, when patients present with self diagnosed MS or ALS (the two biggies) based on “their research!” To this I kindly explain the difference between “a Google search” and actual scientific research, and add—tongue-in-cheek—that “thankfully a Google search is no match for a medical education and clinical experience*.” I also mention to patients that if you want to find evidence in the internet that the earth is flat, you will find it! Thus perpetuating that person’s confirmation bias. After all, search engines are nothing more than confirmation bias algorithms, “Pizzagate” being a prime example.

Ten thousand hours is frequently quoted as the time of deliberate practice needed for someone to achieve expertise in a given domain. The idea of the “10,000 hour expertise” is based on the work of psychologist Anders Ericsson, who conducted research on the development of expert performance. Deliberate practice involves intentionally focusing on improving specific aspects of performance, seeking feedback, and constantly pushing oneself to improve. Yet with the internet more and more experts appear to be coming out of the woodworks! From Lyme disease to COVID-19 vaccines, there is no shortage of “experts.”

As I was ready to leave the barbecue, another cousin approached me “Hey cuz, can I ask you a question about my mother? You know she was diagnosed with Alzheimer’s disease!” My brother who was with me immediately, and without hesitation interjected “so sorry to hear about auntie, but you know there is nothing to do, right!” said my sibling, as he turned towards me seeking affirmation. I looked at my cousin and said “the lawyer is right!” I turned around and left the party.

*According to Google “Med-PaLM2 its medical large language model or LLM was able to perform an expert test-taker level performance on the MedQA dataset of the US Medical licensing examination (USMLE) -style questions, reaching 85%+accuracy.”