I was in a meeting last week with other dialysis unit medical directors. One of our colleagues was presenting a pathway for managing metabolic bone disease in dialysis patients. For the uninitiated, this topic involves at least five, and perhaps six, lab tests, each of which can be manipulated by combinations of patient behavior, dialysis prescription, and medications. The problem is that the clinical impact of metabolic bone disease is delayed well into the future for most patients and we do not have good information on the benefit of manipulating the lab values. There are several possible responses to this dilemma. One is to “chase the numbers” and assume that it matters, at least to those who are looking to demonstrate we are providing quality care. A second assumes that the best approach is to synthesize a common pathway to guide usual care, and be prepared to take the patient off protocol. The third assumes that most patients won’t live long enough to develop clinical problems, and the whole thing is a matter of avoiding extremes for the two to three years the average patient will survive on dialysis. What was of interest was not that all three positions were verbalized, but the intensity with which the younger doctors defended their current decision against what was perceived as the threat of a “mandate” rather than a pathway. The older doctors have been here before, and recognize we all must decide what we are going to do, but none of us really know what the right answer is.
I commented at the time to a senior corporate administrator that the aggressive comments were stimulated by the anxiety the doctors felt at not “knowing” the right answer. However, I read an article published last week by Groopman and Hartzband titled “The Power of Regret.” They comment regret is usually experienced after a bad outcome and two essential elements lead to this feeling: “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.” Although the article is focused on the patient’s sense of regret, it occurs to me that regret as well as anxiety may be driving the observed behaviors.
The authors cite the work by Kahneman and Tversky highlighting circumstance that can increase regret in the face of a negative outcome. These authors concluded “bad outcomes from recent action are more regretted than similar outcomes from inertia.” Although they were using economic models, it certainly applies in medicine. I have known from early in my careers that bad outcomes resulting from the disease were less bothersome than bad outcomes resulting from my interventions. They also note results of studies showing both “omission bias”—the tendency toward inaction or inertia—reflects anticipated regret. Certainly, many patients experience this. On the other had there is also “commission bias”—the tendency to believe that action is better than inaction—which can lead to experienced regret later in the process. Certainly, many physicians believe this. Their bottom line:
“As physicians, we are acutely aware of the element of uncertainty in medicine, but we less often recognize its close companion, regret. Regret in all its forms can be a powerful undercurrent, moving patients to act in ways that may baffle us.”
I would add we should be aware that we also wish to avoid regrets, although I would contend it is inevitable that we will experience it from time to time. I would also add that focus on “the numbers” does not mitigate either the risk or the feeling. “Well, at least we tried,” is an attitude I often hear doctors express, and have said myself, and sometimes it is even a realistic response to dealing with impossible situations. But regrets will occur; it is one of the costs of being human, not just being a physician.
If this were just about emotions, it would be important, but an article published this week on Kaiser Health News shows failure to recognize the impact of regret is associated with a lot of medical care costs. The article focuses on patients with breast cancer with the common theme that over-testing, over imaging, and over-treating were all common. Several patients were interviewed, and all expressed “regret,” about some aspects of their care and the harm they experienced as a result. After reviewing a recent paper estimating 21% of medical care as unnecessary, she goes on to cite the litany of reasons why changing practice behavior is so difficult.
“Many doctors cling to outdated practices out of habit,” said Dr. Bruce Landon, a professor of health care policy at Harvard Medical School. “We tend in the health care system to be pretty slow in abandoning technology,” Landon said. “People say, ‘I’ve always treated it this way throughout my career. Why should I stop now?’”
Many doctors say they feel pressured to order unnecessary tests out of fear of being sued for doing too little. Others say patients demand the services. In surveys, some doctors blame over-treatment on financial incentives that reward physicians and hospitals for doing more…
“Reimbursement drives everything,” said economist Jean Mitchell, a professor at Georgetown University’s McCourt School of Public Policy. “It drives the whole healthcare system.”
Smith-Bindman, the UC-San Francisco professor, said the causes of overtreatment aren’t so simple. The use of expensive imaging tests has also increased in managed care organizations in which doctors don’t profit from ordering tests, her research shows.
“I don’t think its money,” Smith-Bindman said. “I think we have a really poor system in place to make sure people get care they’re supposed to be getting. The system is broken in a whole lot of places.”
All these statements are partly true, but from the perspective of a practicing physician, all fail to account for the fact that we, patients and providers alike, are struggling to decide on courses of action where our various biases come into play and where we are all motivated to avoid regret—either for bad outcomes or for unnecessary care. The process will always be fuzzy, and frustrating to the purists both academic and economic.
25 October 2017.
 Groopman J, Hartzband P. The Power of Regret. N Engl J Med 2017; 377(16):1507-1509. doi: 10.1056/NEJMPp1709917.
 Kahneman D, Tvesky A. The Psychology of Preferences. Sci Am 1982:246(1):160-173.
 Szabo L. So Much Care It Hurts: Unneeded Scans, Therapy, Surgery, Only Add to Patient Ills. 23 October 2017. https://khn.org/news/so-much-care-it-hurts-unneeded-scans-therapy-surgery-only-add-to-patient-ills. Accessed 25 October 2017.
Is empathy the value we have tossed out as part of "improving" health care?
Medical evidence is a four-source: guidelines, registries, data mining and " in my experience". Different clinical situations use different types of evidence and have different implications for provider behavior. These implications are considered in detail.
More on Biases
A recent series of articles in the New England Journal of Medicine provide more insight into the issue of bias in medical decision making.
A consideration of the interactions of patient preferences, evidence-based medicine and peer review.
The One Best Way
Dealing with uncertainty is at the core of practicing medicine. Have we tried to escape this reality?