Having just finished Emily Oster’s new book Expecting Better, I’m happy to share my thoughts. Her book has stimulated a national conversation about safe pregnancies. I think it’s a good thing anytime a book comes out that forces us to step back and talk about how patients are being cared for.
Before we get into the details of what I think Oster is right about and what I didn’t necessarily agree with, we need to take a moment and say, What is this book really about? At the end of the day, it seems that Oster didn’t get what she needed during her pregnancy in terms of information and explanation. She clearly wanted data, facts, and studies—to her, these were comforting.
To that respect, this book is about the importance of communication. She felt she wasn’t being told what she needed, and if that is the case, we as doctors need to think about how we can do better communicate the facts that our patients want.
We act conservatively because the majority of our patients expect us to do that. This is not to say we act paternalistically, making choices for women, but rather we should discuss data with patients and at the end of the day counsel how, when we lack perfect evidence, we must go with what we have.
But before we start handing out summarized articles to every patient, we must pause and think.
The point I might make to Oster is that while patients like her certainly exist (and I was like her, to a small degree!), there are just as many who are scared by that detailed level of information. More importantly, were I to hand out charts with chances of miscarrying by week to every prenatal patient I see, I would quite frankly offend and anger a good number of them. For every patient who worries about complications and sees pregnancy as a potentially scary time, there is a different patient who views pregnancy as a natural continuum in a woman’s life and does not believe pregnancy need be defined by potential illnesses, complications, or statistics. They do not want to be frightened by worst-case scenarios.
How do we meet the needs of these different types of patients? Communication. If a patient walks into my office and wants to know the percentages of miscarrying after a car accident and wants more concrete data than my answer, it is my job to get her that information (and it’s OK to say, “I’ll get back to you tomorrow!” if I need to look it up). However, if a woman is presented with the options of genetic testing and stops her doctor mid-sentence with, “I’m sorry, I don’t want to talk about chromosomal abnormalities, and for me testing is useless,” then we should listen to her there, too.
Oster says in her book that she wants to give information to women so they can make their own informed choices. She then goes on to make recommendations about alcohol, caffeine, and other hot-button issues that the media has chosen to highlight. Her main point about alcohol is that we don’t have any studies pointing to definitive harm when it comes to certain types of consumption, so based on that, a pregnant woman is safe to drink a daily alcoholic beverage in the second and third trimesters, with occasional drinks in the first trimester.
This is where we disagree. I don’t really need to go into the specifics of why I think that recommendation is made much too liberally; the National Organization on Fetal Alcohol Syndrome did a fantastic job of addressing the specifics of her argument. I urge you to read their response to better understand why I, as a member of the American Congress of Obstetricians and Gynecologists who also strongly supports this view, whole-heartedly agrees that pregnant women should not drink alcohol.
I think her view on this issue and a few other topics highlight how Oster comes at this as an economist, and not as a physician. I think this difference needs to be emphasized. It is a crucial factor.
While I fully respect Oster’s training in economics, her description of how we can use economic principles to purchase a house and how this can be compared to making choices in pregnancy are far off the mark. No one dies if you purchase the wrong house. Make a poor decision, though, in pregnancy or in caring for a pregnant woman, and there can be severe consequences.
As a physician, I took an oath to “First do no harm.” This is always our guiding principle when we are not absolutely sure if something is good or bad, safe or not safe. We act conservatively because the majority of our patients expect us to do that. This is not to say we act paternalistically, making choices for women, but rather we should discuss data with patients and at the end of the day counsel how, when we lack perfect evidence, we must go with what we have and protect the two patients we care for. Sometimes that is being overly cautious, but if we disclose this to our patients, a dialogue can begin. Our patients are part of the process but understand we cannot be so casual when it comes to making certain recommendations.
Medicine is an art. It is the art of combining objective facts with subjective hunches. The art of communicating. The art of tailoring your technique to each individual patient. Even though Oster acknowledges that all choices involve the combination of facts and going with what is best for you, she truly gets to make these statements from a too-safe place. She is not responsible for patients, and she will not be held accountable if she says something wrong.
I think Oster does get a lot of things right. I agree with her discussion regarding the lack of evidence for bed rest in pregnancy, that it can actually be harmful. I also think she nicely explains the timing of when to have sex to get pregnant, and she is clear about the dangers of smoking in pregnancy.
And I absolutely agree we must communicate better with our patients. Oster made multiple references to the idea that she was preparing for a fight in her OB office and on labor and delivery. No pregnant woman should continue care in an environment where she constantly feels she is doing battle. That is not what pregnancy is about. To that end, I wish she had a better experience and if she chooses to become pregnant again, I certainly hope she finds more peace.
Reviewed by Dr. Jen Lincoln, November 2018