In the Sunday Series, we bring to you  another article from our archives that deals with a sensitive aspect of a doctor's life. Clinical studies have demonstrated that even for the best clinicians, the finite capacity of the brain can lead to misdiagnoses and errors which further gives way for guilt to set in.

Regret, an unavoidable consequence of clinical practice and generally perceived as a negative emotion, shadows many a clinical decisions. It is the emotion that occurs when one feels another course of action would have been preferable. It sometimes can be understood only in retrospect whether the clinical decision was right or wrong. Doctors are probably one of the most overworked professionals in the world, and hence, some lapses of judgment and missing signs and symptoms which would otherwise strike them as serious can sometimes go unnoticed by even the best doctors.

An article in The Lancet speaks about a telling incident at a major American hospital, a resident in a major hospital once was presented a patient who was only 38 years of age, having sharp pains in the chest at dinnertime. His clinical history and examinations showed no particular problem and he was hence discharged only with some careful instructions. Two hours later, the patient was found dead with an aortic dissection. Naturally, the resident was overcome by guilt.Most hospitals in the West now hold debriefing sessions wherein other peers speak about their experiences. In the case of this resident, his peers agreed to the fact that there could be nothing more that could be done in this case. 

Reason: Regrets with misdiagnosis

Studies show that a correct diagnosis is missed or delayed in nearly 1 out of 20 cases, and diagnostic errors occur in nearly one out of five to ten cases.

The studies especially note that autopsies often find undiagnosed conditions or problems during an autopsy, which were absolutely not reported during the person’s treatment regimen. All of this signifies that doctors are committing many more errors than they can fathom and that the problem lies not in their intentions, but in their ability to remember the endless amount of information that medicine now possesses about human illness and disease. According to an article in the BMJ by Scott (2009), nearly a third of the identified adverse events have been because of not taking appropriate action on available clinical information and investigations. A lot of these errors are due to human error and not due to environmental factors. Doctors now possess knowledge of nearly 4000 medical and surgical procedures, while they have a battery of nearly 6000 drugs to choose from

Regret, a seemingly benign emotion can impact the patient and the doctor alike.Doctors who experience regrets due to error experience symptoms such as sleep disorders, depression and may tend to relive those experiences leading to burnout. Such problems have a direct impact on patient care as well, with doctors displaying increased acceptance for potentially preventable errors and sometimes ordering unnecessary tests and investigations which can lead to more harm than good.

Remedy: Handling Regret

Suma Chand, a clinical psychologist specializing in cognitive-behavior therapy is also an associate professor in the Department of Neurology & Psychiatry, School of Medicine, Saint Louis University explains that acceptance is the key. It is okay to be imperfect.She stresses that "It’s OK to make mistakes simply because it is impossible for humans not to make mistakes and experience some regret."

Brian Goldman, a prominent advocate for patient safety and transparency notes that it is extremely important to have frank, non-accusatory discussions about the mistakes each doctor has made and this is especially important for doctors working together, since this creates environments which are more conducive to bringing about effective change with regards to reducing medical errors and reducing the unnecessary consequences of regret among doctors. Dr. Goldman especially notes that sharing mistakes creates a repository of errors which other doctors are then likely to avoid, often creating a mental “red flag” in their minds to avoid an error they have heard about earlier. Vulnerability is a human trait that needs to be acknowledged, and this is the first step towards creating an effective mechanism for redressal of such errors.

A study by Djulbegovic M et al in 2015 concluded that the tendency to seek and use empirical data in decision-making leads to less regret among physicians. The study noted that regret in physicians is strongly associated with their tendency to maximize; i.e. the tendency to consider more choices among abundant options leads to more regret. The inclination of the physician to accept a "good enough" solution - leads to lesser regret.And therefore the team of researchers says that the promotion of evidence-based reasoning may lead to lower regret.

Given that regret is unpleasant, it is best to prevent it. 

Dr. Atul Gawande, a surgeon, medical researcher, and writer, also the director of the WHO panel to reduce surgical deaths and medical errors, is one of the foremost voices to speak out on medical errors occurring due to unavoidable human error.For reducing errors, Dr. Gawande recommends simple solutions such as checklists, because he believes that everyone in medicine is now participating in procedures and systems which are too big for them to understand alone, and checklists will enable them to focus more on the quality of their tasks rather than the necessary steps (administration of antibiotics, accounting for surgical instruments etc.).