Despite its pervaisiveness doctors often overlook it.
By Dhruv Khullar, M.D.
• Jan. 22, 2020
They say time is brain: Every minute you’re not treated for a stroke you lose two million brain cells.
It’s a piece of medical trivia which, remarkable as it is, hardly captures the devastation that can be wrought on a body that suffers a stroke. My patient — a jogger, a gardener, a grandfather with stories to delight children for days — could barely move the right side of his body by the time he arrived at the emergency department. As I examined him, I carefully recorded the degrees and destinations of injury.
“Strength, two out of five,” I noted to a nearby colleague.
“Sounds like a failing grade to me,” his wife, a former schoolteacher, said as she entered the room.
We sat down and discussed the possibility of some recovery, but also that it would be a long and uncertain road. As we talked, she became more upset — not just because of the damage the stroke inflicted, but also because she felt she’d missed a chance to prevent it. Earlier that day, he’d said he felt unwell — at his age he often complained of aches and pains — but it wasn’t until after a nap, when his speech grew more garbled and he finally fell to the floor, that she called the ambulance.
She felt a deep sense of guilt. The clot-busting medicine, tissue plasminogen activator (T.P.A.), used to treat strokes must be given within four and a half hours. If only she’d rushed him to the hospital sooner, she thought, his stroke might not have been as destructive as it was.
The psychology of “if only” is one I encounter frequently when caring for patients who’ve had a medical emergency. It’s most powerful when patients or families feel there was a “near miss” — a serious illness that could have been averted or ameliorated if only they’d acted sooner or differently. Metastatic cancer that might have been caught if someone had been screened earlier; broken ribs that could have been prevented if they were wearing a seatbelt. 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.
It’s a familiar phenomenon in many domains of life. People feel more regret if they miss their flight by five minutes than if they miss it by an hour. When you barely miss your flight, it’s easy to imagine making it if only you hadn’t stopped for gas. If you miss it by an hour, there was no hope anyway. You might feel bad if a stock in your portfolio loses value; you feel worse if it tanks the day after you bought it.
Despite the pervasiveness of regret, doctors often overlook it. We often don’t explore the role regret might be playing in the distress many patients and families experience, or acknowledge it when it’s clear that it is contributing to their pain.
Simply naming regret — creating the space for patients to confront and explore this emotion — is an important step, as is reassuring patients or family members that in the vast majority of cases they made the best decision they could with the information they had. Medicine is filled with uncertainty, and even with the benefit of hindsight it’s not always clear how, or if, things could have turned out differently.
It’s also important for physicians to help patients fully explore the risks and benefits of all available options to mitigate future regret. Assuming it’s not a medical emergency, doctors should, for example, encourage patients to consider how their decisions may vary in “hot” versus “cold” emotional states. As Dr. Jerome Groopman and Dr. Pamela Hartzband explore in the New England Journal of Medicine, when we’re in a “hot” state of mind — when we’re scared or hurting — we’ll do anything to fix the problem. We discount risks, overestimate the benefits, and pursue paths we otherwise might not. In “cold” states, by contrast, we misjudge how much our preferences can change over time and, subject to the pull of inertia, forgo treatments we later wish we’d had. By actively envisioning how things could unfold in both scenarios, however, we can minimize the regret we feel after making tough decisions.
Increasingly, technology may also play a role in reducing regret. Indeed, had my patient been treated promptly he might have had a different outcome, and his wife may have experienced less regret. Some hospitals are now using mobile stroke treatment units, or specialized ambulances dispatched when someone calls 911 with symptoms suggestive of a stroke. These modified ambulances are equipped with a CT scanner, a camera, a nurse and medications, including T.P.A. On the way to the emergency room, the patient’s brain scan is uploaded and a neurologist at a nearby hospital can look for signs of stroke on the image, perform a remote neurological examination via telemedicine, and ask the nurse to administer the brain-saving drug if needed.
At my hospital, which started operating its mobile stroke unit in 2016, patients treated in these specialized ambulances receive T.P.A. more than 30 minutes sooner than those transported by traditional ambulances. Research from similar programs has found that patients are six times as likely to receive T.P.A. in the first 60 minutes after symptom onset — the so-called “golden hour” during which the drug is most likely to reverse the ill effects of a stroke.
“It can be the difference between being in a wheelchair and walking independently,” said Dr. Mackenzie Lerario, medical director of the NewYork-Presbyterian Mobile Stroke Unit. “Or between needing constant nursing care and living how you were previously able to.”
Even with advances in medical technology, we will, of course, never eradicate regret. Regret is a fundamental aspect of being human. 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.
Dhruv Khullar, M.D., M.P.P (@DhruvKhullar) is a physician at NewYork-Presbyterian Hospital, an assistant professor of health care policy at Weill Cornell Medicine, and director of policy dissemination at the Physicians Foundation Center for the Study of Physician Practice and Leadership.