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January 23, 2020

The patient experience doctors often overlook (and how to do better)

Daily Briefing
    Editor's note: This popular story from the Daily Briefing's archives was republished on Aug. 23, 2022.

    Regret is a pervasive feeling in most people's lives, and it's the near misses—if only I'd sought medical help sooner—that can cause the most distress and pain, Dhruv Khullar, a physician at NewYork-Presbyterian Hospital, writes for the New York Times' "Well," explaining why it's important for doctors to take this sentiment more seriously.

    The psychology of regret

    Khullar notes that feelings of regret, or "[t]he psychology of 'if only,'" can affect both patients and their family members. Regret is something Khullar encounters frequently in medical settings, he writes. He explains, "In psychology, this type of regret is sometimes called 'simulation bias' because the pain is related to how easily people can envision—or simulate—an alternative."

    Regret is usually most powerful when patients or their families feel there was a "near miss" or a serious medical condition that could have been improved or prevented if the patient or caregiver had acted sooner, Khullar notes.

    For example, Khullar recalls an interaction with the wife of a stroke patient.

    The patient, Khullar writes, "could barely move the right side of his body by the time he arrived at the [ED]."

    As Khullar explained the possible outcomes and treatment options, the patient's wife became increasingly upset, "[n]ot just because of the damage the stroke inflicted, but also because she felt she'd missed a chance to prevent it," Khullar writes.  

    The woman told Khullar that her husband had mentioned earlier that day that he wasn't feeling well but that she didn't call the ambulance until, "his speech grew more garbled and he finally fell to the floor," Khullar writes.  

    The wife, as a result, "felt a deep sense of guilt," Khullar writes.  "If only she'd rushed him to the hospital sooner, she thought, his stroke might not have been as destructive as it was." 

    What physicians can do

    Feeling regret in these situations is normal and not entirely avoidable, according to Khullar, but one way to help patients and their families manage their regret is by acknowledging it and "creating the space for patients to confront and explore this emotion," he writes.

    It's also important for physicians to reassure patients and their family members that they likely made the best decision they could with the little bit of information and medical knowledge they had, Khullar states. "Medicine is filled with uncertainty," Khullar writes, "and even with the benefit of hindsight it's not always clear how, or if, things could have turned out differently."

    To help families and patients minimize future regret, physicians should also explain to patients how their emotional state may affect their decision making, and hopefully minimize their regret in future decision-making. An article in the New England Journal of Medicine described how people make decisions in "hot" versus "cold" emotional states.

    "When we're in a 'hot' state of mind," which is usually when we're upset or scared, "we'll do anything to fix the problem," Khullar explains. That can lead us to "discount risks, overestimate the benefits, and pursue paths we otherwise might not," Khullar writes. When we're in a "cold" state of mind, we tend to misjudge how our preferences may change in the future, causing some patients and families to "forgo treatments we later wish we'd had," Khullar adds.

    In addition, as technology improves, it may play a bigger role in reducing regret, Khullar writes.

    For instance, some hospitals are employing specialized ambulances called mobile stroke treatment units, which are equipped with a CT scanner and other technology that allows neurologists to detect signs of a stroke before a patient with stroke symptoms arrives at the hospital.

    NewYork-Presbyterian hospital found that patients who were picked up in these specialized ambulances received stroke treatment 30 minutes sooner than those transported in regular ambulances.

    "Indeed, had my patient been treated promptly he might have had a different outcome, and his wife may have experienced less regret," Khullar writes.

    However, even with these technological advancements, "we will … never eradicate regret," because it is a "fundamental aspect of being human," Khullar writes. But "there are high- and low-tech steps we can take to ease the sting. Perhaps none more important than embracing regret as part of life, and focusing not on what might have been but on what still is"  (Khullar, "Well," New York Times, 1/22).

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