If there’s one thing that has become clear after 5 months, it is how bad most of us are at predicting how the pandemic will unfold. If you had asked me at Memorial Day how things would look today, I would have been wrong. If you ask me today how things will look heading into October, I’m humble enough to say ‘I have no idea.’ Similar to the stock market, we can all make educated guesses, but no one really knows what the country will look like in 2 months. This is very frustrating. Despite the deep thirst for concrete, black-and-white answers to questions such as: When will there be a vaccine? Should we open schools? When will this all be over? The honest answer is that we don’t know. We can all pull a news article, an anecdotal story, or make an educated guess to support our theories, but the truth is no one knows.
Further, it will likely look different across communities, states, and regions just as we’re seeing today. The South looks different than the Pacific Northwest which looks different than the Great Plains. Each community, state, and region is taking their best guess at how to strike the balance between virus containment and enabling ‘return to normal’ and trying to hit the proverbial sweet spot. There is a wide spectrum of opinion from ‘shut down and do everything to contain spread’ to ‘forget the virus and return to normal’ influenced by how the virus has affected the individual and cultural norms in the area.
As much as we’re all craving answers, learning to live with uncertainty is the unfortunate reality as we enter August.
How do we do this?
When you train in internal medicine, one of the many skills you develop is learning to live with uncertainty. While we’d like to be able to say with 100% certainty the decision to operate, or send someone to the cath lab, or give another round of chemo is a black-and-white decision, the honest truth is that many of these decisions live in the gray. Even when there’s robust evidence and randomized trials to guide decision-making, no two patients are exactly the same and rarely does a decision not come with some amount of downside risks. Thus, you review the risks and benefits of the choices at hand using the best available information, seek the patient’s preferences in what is most in line with their values and goals, and monitor for the downsides of the decision you choose. My advice in learning to live with the uncertainty and make decisions for yourself or your community regarding COVID-19 is to follow the same playbook.
The #1 question I have received in the past few weeks is: “Should we open schools?” I have had many conversations with people who are passionate on both sides. They refer me to studies showing how opening schools will not lead to outbreaks and on the same day receive articles saying opening schools would be grossly irresponsible. The answer lies in the gray. Thus, I’ll use that as the example to walk through my process.
Step one is to recognize upfront there is no silver bullet. The decision to open or close schools both come with downstream consequences. Neither side should convince themselves they are absolutely right in this battle. If we open schools, it is highly probable that community spread will increase. It is likely that someone, whether that be a child or an adult, will be harmed. It is impossible to predict how many and to what degree of harm (hospitalization vs death), but we assume the risk by opening schools that viral transmission will increase.
On the other hand, keeping schools closed to in-person learning creates harm as well. Kids, especially young children, suffer developmentally when unable to interact socially with other kids. It is likely that the educational value will suffer from online classes as opposed to being in-person. Many parents rely on schools so they can go to work, generate income for their families, and serve as a safe place for their kids to be watched 5 days a week. Beyond that, many parents need that time and space for their mental and physical well-being. Keeping schools closed is not a benign decision and will also come with harms.
Once you’ve identified the risks and benefits, you discuss those with the patient to help them make an informed decision in line with their values and goals. This is more complicated when decisions are made at a community, state, or regional level, but the general principles still apply. It is likely that risk tolerance and preferences in New York will look different than Alabama. It also likely that risk tolerance and preferences will be different based on your situation. A parent with 2 school-age kids will likely have a different value judgement than a middle-aged teacher with asthma and diabetes in terms of their risk tolerance and preferences on whether they want in-person learning. It is human nature to look at the downsides of each decision and how they will affect me the individual, more so than how the decision will affect those around me. This is to be expected. There is no right and wrong. Simply different. The key is to recognize that those who land on the opposite side of you in this debate are likely doing it based on what they truly think is best for themselves and their community, and less as a personal attack against you. Everyone has been negatively impacted in some way from this virus.
The last point in living with uncertainty is monitoring for the risks once a decision is made. If we decide we’re going to give a blood thinner, we monitor for bleeding. If we decide not to give blood thinners, we monitor for clotting. In our example of school openings, we should be monitoring for the downsides of whichever decision is made and how we will react.
If the decision is made to open schools, what are we doing to mitigate risk and monitor for increased disease spread? What happens if and when someone tests positive? At what threshold will we re-evaluate to decide if this is still the best path forward? If we choose to keep schools closed, how will we monitor those risks? Will we look at how often kids aren’t showing up to virtual classes? Will we look at test performance to see if knowledge acquisition is worse than prior years? How will we measure the impact on parents trying to keep a steady job when they don’t have schools to drop their kids off? Will we look at unemployment applications, food pantry demand, or other community metrics to monitor the downsides of this decision? At what threshold will we re-evaluate to decide if this is still the best path forward?
Instead of focusing exclusively on making the ‘right’ decision, let’s ensure we have the right processes to monitor outcomes and track data no matter which decision is made. Let’s be willing to change course if needed based on new information and learn as we go. Uncertainty rules the day. Here’s hoping we are able to live with it as best we can.