This post and the #HealthXPH tweet chat on December 2, 9 pm PHT is inspired by an article published in the New England Journal of Medicine, The Power of Regret, by Dr. Jerome Groopman & Dr. Pamela Hartzband last October. In it, regret is defined as having two essential elements –
… imagining that the present situation would have been better if one had acted differently, and self-recrimination for having made a choice that led to a bad outcome.
Groopman & Hartzband point out that without self-recrimination, results that fall short of what is expected is only disappointment and not regret.
As a subspecialist (I’m an endocrinologist), I often see patients asking for a second opinion. A few express regret over how their illness was managed by their previous physicians. Sometimes, they also regret not having been more vigilant in self-care or not playing a more active role in making healthcare decisions. Regret can arise with both poor and good outcomes, and Groopman & Hartzband speak of two kinds of regret:
- Process regret. The physician presented treatment options and the patient made an informed decision. In the example given, the surgery was unsuccessful but the patient was only disappointed. He was not regretful as he would have been, had he not been given the information needed to make a choice. At clinic, I try my best to explain options for my patients. But often too, I am told, Whatever you think needs to be done, let’s do it! Or You’re the doctor, not me. Let’s go with whatever is best. What should the physician do in such cases?
- Role regret. The example was that of a patient who was pressured by family to undergo a thyroidectomy for atypical cytology on a biopsy. The patient was aware that the nodule could still be benign as it was stable on ultrasound. It did turn out benign after an uncomplicated surgery. The patient experienced regret for what was now felt to be an unnecessary procedure and for taking a passive role in the decision made. I have seen such patients! They abdicate decision making to the family member who pays for the medical expenses. They may also give in to a doctor’s recommendation without considering their own doubts, because surely, the doctor knows best.
Groopman & Hartzband also discuss omission bias which can lead to anticipated regret and commission bias which can result in experienced regret. In omission bias, those who feel healthy may skip preventive measures such as the flu vaccine in anticipation of getting sick from the injection. While in commission bias, a patient may be compelled to do something instead of nothing, overestimating benefits and underestimating risks – a potent combination for regret when a poor outcome is experienced. How can physicians help patients make better decisions, and not decide in the heat of the moment? Is avoiding commission bias harder for physicians? Uncertainty has always existed in medicine, which is perhaps why it is often said that it’s practice is an art as well as a science. In my experience, it is harder to explain to patients that doing nothing which means regular monitoring (perhaps a repeat thyroid ultrasound in case of nodules) or periodic clinic visits for a physical examination – so it’s really not doing nothing – is a viable option.
Patient regret in the context of surgery has been studied with 73 studies included in a 2017 meta-analysis by Wilson et al. One of 7 surgical patients self-reported decisional regret, which was both patient- and procedure-related. Physician regret and how it can affect decision-making is less studied with Wilson et al only finding six studies, which mostly used hypothetical case scenarios. I am not a surgeon but I do need to refer my patients to surgeons. I must admit that I choose who to refer to as I have regretted some referrals where the outcomes were poor, whether or not the surgeon was to blame. I realize that is unfair, but I think surgeons may feel the same way of their referrals to internists like myself.
Groopman & Hartzband invites us to think more about the positive impact of regret in making better decisions –
As physicians, we can help our patients make better decisions by understanding the power of regret in all its forms.
Hence I invite you to join the #HealthXPH tweet chat on Dec 2, 9 pm Manila time (8 am EST) to discuss the following:
T1. How can physicians help patients avoid anticipated regret from omission bias? Ex. not getting the flu vaccine in anticipation of getting sick from the injection.
T2. How can physicians help patients avoid experienced regret from commission bias? Ex. deciding on a procedure/treatment because doing something is better than doing nothing (observation/monitoring).
T3. Have you experienced physician regret? Can you describe it? How does physician regret impact patient care?