Experts Among Us

DOI: 10.1200/JCO.2012.47.0641 “It comes down to expert opinion,” she said, “and I am an expert.” Those startling words came from a junior faculty member during one of our fellowship orientation talks. I looked around the room at my classmates to see if anyone else shared my surprise at her statement, but no one seemed to flinch. Admittedly, this claim came 50 or 60 slides into her presentation, and most of the audience appeared dazed. A number of smartphones were out, and people’s fingertips were busy navigating the Internet and social media outlets, their minds likely distracted by thoughts of waiting tasks or evening plans. If the others had heard what she had just said, they had either accepted it as genuine expert opinion or had simply not registered it. But the more I considered her statement, the more unsettled I felt. Calling oneself an expert, especially as a new faculty member just out of fellowship training, smacks of arrogance. Aren’t experts supposed to have at least a few gray hairs? Don’t experts have long lists of publications? Aren’t their names the ones found inside the covers of the big journals? Aren’t they people like Dr Einhorn or Dr Kantarjian—physicians whose work has defined their field, whom few fellows have met but all of us admire? Real experts in clinical oncology are the people who write the National Comprehensive Cancer Network guidelines, speak at national conferences, and are the principal investigators in major studies. To most of us trainees, such physicians seem at times more like celebrities than real people. They are the real experts. This past election year, we were reminded about the distribution of wealth in the United States and the affluent group referred to as the top 1%. This top 1% controls 40% to 50% of the wealth in America. In the field of clinical oncology, I would offer there is also an elite academic equivalent to the US economic top 1%, socially if not numerically: a small cadre of physicians so rich in their knowledge, intuition, and fame that they command a similar disproportionately large stake in our field. Like the wealthy, they have their own exclusive social circles (referred to as politics by those of us on the outside). They publish in high-impact journals often overseen by their friends and work to validate or disprove one another’s results. These influential experts define the standards of clinical care that many of us follow in our daily practice, hoping to provide similarly expert-like care to our patients. Just as society is said to consist of the haves and have nots, our profession can be divided into those writing guidelines and those reading guidelines. Like the diseases we treat, the remaining 99% make up a heterogeneous group. The rank-and-file 99% include physicians with a wide spectrum of talents and interests, such as those with busy private practices, physician-scientists with limited clinical interest or responsibilities (some of whom may be experts in nonclinical areas), junior faculty members, and less-influential midcareer and tenured professors. Although many of these physicians do not aspire to become part of the 1%, some are turned off by the personal sacrifices required or the constant battles; others work diligently in hopes of someday breaking into the upper echelon of our profession. Like members of the top 1%, physicians in the 99% may have an interest or area of expertise that has led to an excellent reputation at the institutional or even regional level. Most in the 99% are familiar with published treatment guidelines, provide excellent care to their patients, and enjoy referrals from their counterparts in the community. Where they fall short, however, is in the national and international recognition and influence associated with those in the top 1%. In his book Outliers: The Story of Success, journalist Malcolm Gladwell discusses three key components of high-level success in any field: talent, opportunity, and initiative. Talent, in our profession, most closely equates with intelligence (which has many dimensions), whereas initiative can be likened to motivation or diligence. Gladwell discusses the 10,000 Hour Rule, a concept based on a study by psychologist Anders Ericsson, as an example of the importance of initiative and persistence. To illustrate this, he describes the Beatles, a wellknown musical group from the 1960s. During a 7-year period before their entry into American culture, the Beatles played shows lasting several hours on a near-daily basis. Their biographer, Philip Norman, proclaimed that after this period, “they JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 31 NUMBER 7 MARCH 1 2013