“What would you do, doc?”
It’s a question I get all the time as a family doctor practicing full-scope primary care after describing an intervention like taking a daily aspirin to prevent a heart attack or deciding about a repeat C-section versus trying for a vaginal delivery. I often have a clear recommendation rooted in what evidence-based medicine has taught me.
I remember hearing the term evidence-based medicine for the first time. I was a brand-new medical student, sitting with my eager first-year colleagues in a large, fluorescently lit lecture hall. The topic was presented like a revelation, a huge achievement. I didn’t really get what the big deal was — what other kind of medicine would one practice, if not a type based on science and data?
But then I learned that it wasn’t until the early 1990s that the concept of evidence-based medicine was widely accepted. Before that, clinical decision making was based on intuition, experience, and rationalizations. Now we have trials, data, and evidence to guide our decision-making.
But I have come to learn in my training and practice as a family physician that even the all-powerful evidence-based medicine cannot protect us from the reality that, just as in the rest of life, there are almost never right answers in medicine. We may have data and expert recommendations, but everything is still a matter of weighing the costs and benefits, and assessing our own risk tolerance for different outcomes as individuals.
Am I more scared of the heart attack or the life-threatening gastrointestinal bleed that the aspirin may cause? Am I more worried about the harms of a C-section or the risk of my uterus rupturing in trying for a vaginal delivery? Am I more heartbroken about the idea of dying of cancer or losing my quality of life to the debilitating side effects of chemotherapy?
The numbers can guide us, but ultimately the decisions are deeply personal.
And now more than ever, during this time of Covid-19, we are operating in what doctors and scientists refer to as a data-free zone. Not just for the big questions like how to treat patients with coronavirus, whether survivors have immunity, and what type of vaccine will give us the best chance of getting out of this pandemic quickly and safely. Thankfully there are legions of clinicians and basic scientists working to answer those questions.
But the small questions, the ones that dictate day-to-day life, feel even more unanswerable. In this unprecedented moment in science and history, we have best guesses, expert recommendations, and our own intuition — but truly no data — to guide us.
Over the last decade, I’ve gotten used to fielding calls from friends and family about everything from kids’ rashes, to blurry vision, to serious diagnoses, to dying loved ones. Even if I don’t have any expertise in a particular issue, my broad training has usually given me the ability to offer something, whether it’s reassurance, resources, or advice.
During these last two months, these texts and calls have only increased. Do you think it’s OK if I send my kid back to day care? Can I go on a walk with my best friend if we both wear masks? If there aren’t any slots available for grocery delivery, can I go to the store? But now, my response is always the same: I don’t know. I’m struggling with the same questions. There’s no playbook. We’re in a data-free zone.
When confronted with these types of questions for which there are no right answers, I find myself turning to the decidedly unscientific guidelines provided by my head, my heart, and my gut. Can my parents, who live in New York City and are recently recovered from Covid-19, fly to the West Coast this summer to meet their soon-to-be-born granddaughter? My head scolds me that their doing so would be unsafe. My heart breaks at the idea of losing precious moments with my aging parents. My gut churns and flip-flops.
For the last two months, many people’s lives have looked similar as we stick with the same strict social distancing guidelines. As the world starts to reopen, our lives and choices will increasingly diverge, which I find both refreshing and deeply uncomfortable as loved ones and strangers make decisions different from mine.
We should try our best to be gracious and generous about these differences, because we’re all doing the best we can with the limited information we have.
My group text chain with cherished women friends from medical school has been particularly active over the last two months. We’re all physicians with the same amount of training and years of experience, yet we have drawn entirely different conclusions about what is right and how to balance our own quality of life with risks we take for our families, as well as risk we may pose to others.
Some are seeing extended family or have expanded their “quarantine bubble” to close friends, others have not. One is hesitant to cross county lines to go for a hike, another drove from Idaho to Southern California to shelter in place with some sunshine and relaxation. After a series of texts last week about the ways we’re going stir crazy and considering loosening our restrictions, one of the wisest among us pointed out that we had entered the “bargaining” stage of the coronavirus grief response. She was absolutely right and yet, in this world of ambiguity that we’ll be entering for the foreseeable future, what other option do we have?
A few nights ago, as my husband and I spoke about planning a party for our 10-year anniversary a year from now, my 6-year old told us we couldn’t do it “because of coronavirus.” Before I left for work the other day, my three-year old cried when I hugged him with my clean scrubs on because he was worried I’d get him “dirty with the germs.”
Perhaps I should let them decide about the choices we’ll have to make in the coming months. After all, they have just as much information as I do.
Alison Block is a family physician, writer, and executive producer of The Nocturnists, a physician storytelling event series and podcast.