On Good Authority: Emily Oster
What can the domain of parenting and pregnancy teach us about expertise and trust-building?
Tamara Moellenberg in conversation with Emily Oster, Economist, Author and CEO of ParentData
Tamara Moellenberg: There is so much disagreement over what truth is in our culture today. To what extent is this playing out in the domain of parenting and pregnancy?
Emily Oster: In the domain of parenting and pregnancy, a lot of what we do when we give people advice is we tell them what to do without explaining why or how we know something. For a very long-time people were told not to give their kids peanuts before they were one or two, because peanuts are a common allergen. Then, in March of 2015, all of a sudden, the advice completely switched to not only is it okay to do this, but it's very important to do it. And that is a very jarring way to be given advice. If you're going to do that, you need to tell people why. And if you're going to change your mind, you need to say, “look, we thought this before for this reason, but then there was a new study, and here's what it said. And this is why we've changed what we are saying.” There's so much resistance in expert advice to admitting uncertainty and this generates distrust because people feel that you're not being honest with them.
Tamara Moellenberg: I think that's a fascinating observation. Another thing we've seen in so much of our work is how transparency can help repair and build those trust ties. From the perspective of experts, whether they're medical experts or nutritional experts, – anybody who's giving parenting advice – what do you see as the key steps or key principles to abide by as you're interacting with parents?
Emily Oster: There are two things I would really like to see people change. One is I would like to see more emphasis on the level of certainty about a particular recommendation. So, trying to help people understand, “This is a piece of what I'm saying, which we're really confident is true,” and “This is a piece which we have less evidence for, but it seems like it would be true,” instead of saying everything with 100% certainty. A closely related point is that we are very unwilling to help people understand the second best. So, here's a concrete example: when we give people advice about baby sleep, the way that safe sleep advice is couched is, “Your baby should be sleeping on their back in their own crib, in your room, with nothing else in the crib.” Maybe that's correct in the sense that that's the absolute safest thing. But we never then tell people, “If you can't do that, here’s what would be the next best thing.” We just say, “There's this option or the outer darkness, and every other option is equally bad.” And that's not true. Some factors are way more important than others. People find themselves in an impossible situation. By not giving people choices, they end up almost in the worst option because they're trying to achieve something that is impossible. If we helped people navigate within the constraints that they face, we would be in a much better position for getting good outcomes.
There's so much resistance in expert advice to admitting uncertainty and this generates distrust
Tamara Moellenberg: In those situations, people then often go looking for other sources of authority who might be giving them those other options.
Emily Oster: Absolutely – people turn to the Internet. They turn to Reddit. They turn to Google. And there are sources there. But there are also sources that are unhelpful. What is particularly unhelpful is when you go down a rabbit hole where everybody disagrees and feels that if you don't do the thing that they say, everything will go terribly. Co-sleeping is a good example of this. If you're up in the middle of the night, and you're thinking, “The only way my baby will sleep is in my bed. Let me just get on Google and ask about it,” half the people will say, “Not only is this fine, but you should definitely do it because it's the way to make your kid love you.” And then half the people will say, “If you do this, your kid will die immediately.” The answer is somewhere in the middle.
Tamara Moellenberg: I'm thinking of the different organisations we work with in financial services, for instance, where you similarly have very complex, sometimes opaque information you're trying to communicate to folks. What advice would you have to providers looking to communicate this information?
Emily Oster: We too often assume that people would like to just be told. This gets back to the question of authority and expertise. I think we too often assume that people are both comfortable with and want experts to say, “I'll tell you what to do.” I don't think that's what people mostly want. I think they want help making their own decisions. I think there's a way to combine expertise with preferences that I think people want help with.
Tamara Moellenberg: We also do a lot of work in healthcare. One of the things we've observed is that doctors are so pressed for time as opposed to midwives for example, who can present options and explain the rationale behind those options. What are some of the ways in which the system can better support providers to better support parents?
Emily Oster: Economics do not favour giving people more time with their obstetricians. Doctors’ time is valuable. They could be doing surgery. There's a lot of other reasons why we're not likely to get more time with our doctors. What we therefore need to do is use that time better. I think we could use the time better if people were better prepared for what was going to happen at the visit. In my newest book, which is about complicated pregnancies, we spend a lot of time talking about scripting and saying, “You're going to need to talk to your doctor about these details. Here is how you should structure that conversation. Here are the questions you should ask. Here are the things that are important.”
Tamara Moellenberg: So, we've talked about what providers can do to better support parents in their decision-making and build that trust. Now we're starting to flip and talk about parents. What advice do you give them to really find and discover their own authority and their own confidence in making these decisions?
Emily Oster: I think one thing is to be prepared. The more you can be prepared for interactions with the medical system and know what you're asking, the better. I think the other piece is there is a kind of authority that doctors have. There are many things that they learned, and sometimes we can push too far towards the idea of the patient doing their own research. There are ways to combine the expertise that the patient has in their own values and preferences with the expertise that the doctor has on the medical side. An example of this is the decision about whether to have a vaginal birth after a C-section, or whether to try for a vaginal birth after a C-section. There are some really important medical considerations that would make you a better or worse candidate for that, which your doctor will know. For example, what kind of C-section did you have before? What were the circumstances of the C-section? There are some things that make you more or less likely to be successful. Then there are some things the patient brings to the table, like, “Is this important to me to have a vaginal birth? How many more children do I want to have after this?” There are a set of patient preferences and values. Those are both kinds of expertise. They're not the same but they should come together in decision-making.
There are ways to combine the expertise that the patient has in their own values and preferences with the expertise that the doctor has on the medical side.
Tamara Moellenberg: Finally, how can we arrive at this place of shared decision making, which ultimately, requires trust between patients and providers?
Emily Oster: I think I would just come back to what we talked about at the beginning, about being clear when we are not sure. There's an analogy someone gave me once that I really like about what they do when there's a wildfire. So, when there's a wildfire every day there's a press conference, and the fire marshal gets up in front of reporters, and they say, “Here's the map. Here's where the fire is today. Here's where we think the places it might go tomorrow, and I'm going to come back tomorrow. I'm going to tell you where it went. And I'm going to tell you what we think then.” We don't do that communication. We too frequently say, “I'm sure, about this,” and then, “I'm sure about another thing,” rather than saying, “There's a little bit of evidence to suggest this, but you know, we're not really sure.” That's where you lose people's trust.