Experiencing and Coping With Regret After a Patient’s Poor Outcome

Regret After Poor Outcomes

The patient-physician relationship is rooted in what some call a “covenant of trust,”¹ which obliges physicians to provide high-quality care that promotes the welfare of their patients.^2,3,4,5 To that end, physicians dedicate their professional lives to ensuring the well-being of their patients; however, despite their best efforts, some patients will ultimately experience a poor medical outcome for reasons both within and beyond physicians’ control, including individual physician medical error, health system breakdown, and inevitable circumstances. Regardless of the reason, it is common for physicians to feel regret in the wake of a patient’s poor outcome, and feelings of regret may be heightened when they believe that the poor outcome was due to their error.⁶ This article considers how the American Medical Association (AMA) Code of Medical Ethics can support physicians while they cope with regret due to a patient’s poor health outcome.

Expectations Can Contribute to Regret

Participating in the medical decision-making process is a large component of physicians’ responsibilities and a foundational component of the patient-physician relationship. Decision-making happens through a thorough process in which clinicians share information; come to understand patients’ values, goals, and beliefs; and evaluate patients’ physical or mental condition with an overall goal of improving health outcomes. The importance of the shared decision-making process is reflected in the AMA Code’s emphasis on various ethical principles, such as respect for patient autonomy and informed consent, and rights, such as physician exercise of conscience and patient rights (eg, refusal of treatment).^7,8,9 However, no matter how thorough a decision-making process is and how confident a physician is that the chosen medical plan will improve the patient’s health and realize the agreed-upon medical goals, the possibility of error always exists. Medical decisions made using the best available evidence do not guarantee their anticipated outcomes; however, the goal or expectation of a successful outcome and the extent to which decision-making is a part of a physician’s job contributes to regret when outcomes are poor.

Additionally, patients’ and societies’ high expectations of physicians contribute to regret when outcomes are not as expected.¹⁰ Perceiving physicians as infallible, especially when faced with medical uncertainty, can provide immediate, temporary relief or psychological comfort to both physicians and patients.¹¹ However, the hierarchical patient-physician relationship places greater decisional pressure on physicians and mitigates the importance of sharing information with the patient on the reality and the degree of medical uncertainty of the patient’s condition. Failure to disclose such information in the event of an adverse outcome not only would compromise patient autonomy and informed consent but would risk greater psychological harm to physicians and create distrust within the patient-physician relationship.¹¹

Experiencing Regret

The experience of regret, especially when left unresolved, can contribute to physicians’ own long-term sequelae of negative experiences that affect both their personal and their professional lives. Hospitalists report experiencing regret in the form of extreme emotional distress, including sadness, anxiety, eating disorders, and increased alcohol use.^2,3,4 Additionally, experiencing regret is associated with higher burnout rates and a desire to leave the profession among hospitalists.^3,4 When physicians experience regret after a patient’s poor medical outcome, the ability to discuss the incident with colleagues or attending physicians and accept responsibility when necessary is associated with constructive changes during clinical practice.^4,5 Conversely, lack of support and institutional judgment for medical errors has been associated with physicians’ emotional distress, and burnout, as well as practice of defensive medicine.^5,12,13 For example, some physicians might be reluctant to suggest the same treatment to another patient or, conversely, might overtreat or over test perhaps as a way to overcompensate for a poor outcome  they deem attributable to their own or another clinician’s earlier poor decision-making.¹⁴ In this way, practicing defensive medicine can have long-term consequences for physicians, patients, and the health care system.¹⁴

Identifying Regret

Given the high stakes associated with regret, such as defensive medicine and burnout, it is imperative for physicians to identify when they are experiencing and negatively coping with feelings of regret. Nevertheless, patient and societal expectations, whereby doctors are typecast as Godlike or superhuman “thinkers” rather than “feelers,” have the potential to cloud physicians’ judgment, keeping them from getting in touch with their own emotions.¹⁰

Physicians have an obligation to engage in honest self-assessment.

In order to fulfill the ethical responsibility of competence and to provide high-quality, safe, and effective patient-centered care, it is imperative that physicians recognize their limitations and refrain from practicing medicine when their physical or mental health impairs their ability to practice safely.¹⁵ When health care professionals neglect to care for themselves and practice while impaired, they risk compromising patient safety, the inherent trust in the patient-physician relationship, and public trust in the practice of medicine.^{6,12,13,15,16} Physicians can use continuous self-awareness and self-observation skills to identify feelings of regret and to remain aware of their well-being and ability to provide quality care at any given time.¹⁷

Coping With Regret

Physicians and other clinicians experiencing physical or psychological effects of regret must engage in effective coping mechanisms in order to maintain their own physical and mental wellness.^{6,12,13,15,16} Physicians cope with regret in different ways that can play a role in their long-term well-being.¹⁸ While it is sometimes difficult to admit when one is not coping well, physicians have an ethical and professional obligation to engage in honest self-assessment about whether their mental or physical wellness is affecting their ability to safely treat patients.¹⁷ In order to fulfill this ethical duty, physicians should make themselves aware of resources and, when appropriate, seek help in addressing their feelings of regret and its physical and psychological consequences. Additionally, physicians and other clinicians should be aware that occupational stressors, such as sleep deprivation, which is common while experiencing regret, can temporarily impair their ability to safely practice medicine.¹⁹ Importantly, physicians should refrain from self-treatment or self-medication.

While one is coping with emotions associated with regret, it is also important to remember one’s responsibility to the patient, especially in the case of a poor health outcome. While experiencing regret might make it easier to avoid having tough conversations with patients about their poor health outcomes, especially when they result from errors, physicians have responsibilities to not abandon their patients.⁹ Open communication and encouraging a patient to express concerns and fears after a poor outcome increases the chances of maintaining trust and allows the physician to either continue providing care or direct the patient to additional care elsewhere.¹¹ While empathic physicians can improve clinical outcomes, empathy and compassion training is rarely included within medical education, and, in one survey, roughly a third of physicians reported a desire for empathy training.²⁰ Uncertainty about how to express empathy makes it challenging for physicians to regulate their emotions during a distressing event and while engaging with a patient after a poor outcome.^18,20 As a result, physicians experience negative emotions, such as sorrow, guilt, frustration, and regret, rather than reacting more constructively through proper emotional regulation.¹⁸

Helping Colleagues Cope With Regret

While physicians strive to improve their patients’ health and alleviate suffering, facing poor patient health outcomes is inevitable due to the imperfect nature of medicine and the reality of human error. However, physicians are often perfectionists by nature and held to exceptionally high standards by society and throughout medical training, which makes coping with a poor medical outcome especially challenging and, without proper coping tools, can increase regret, maladaptive behaviors, distress, and burnout.²¹ This phenomenon is often referred to as “second victim” syndrome and can be detrimental not only to physicians, but to patient care and organizations.²²

Although it can be difficult, it is imperative and ethically indicated to intervene when a colleague is unable to practice medicine safely or is endangering patients.^{6,12,13,15,16,23} It is important to intervene with compassion and to refer or report a physician colleague who continues to practice unsafe medicine despite attempted intervention.²³ In order to foster an environment of support, physicians should strive to eliminate stigma regarding physical and psychological effects of coping with regret. One way to work toward this goal is to advocate for respectful and supportive peer-review policies to identify and assist physicians with a potential impairment.^{6,12,13,15,16,23}

In addition to physicians helping colleagues find support in coping with regret, greater changes within the culture of medicine can be made to support physicians when patients experience poor health outcomes. Effective psychological care provided through organizations for physicians not only benefits individual physicians but, by increasing service accessibility, contributes to the awareness and normalization of the need for and use of such care.²⁴ On its own, however, availability of supportive resources is not enough to reduce the number of clinicians experiencing debilitating side effects of regret. Organizations and individuals should make additional efforts to shift the work culture from blame toward proactively dealing with poor patient outcomes through education. Preparing physicians for realistic rather than perfectionist expectations of patient outcomes can begin during medical education by raising awareness of the emotional challenges of the medical profession and the resources available for seeking support and by teaching resilience, self-regulation skills, and constructive methods of dealing with regret in the event of poor patient health outcomes.²⁵

Conclusion

It is common for physicians to experience feelings of regret in the wake of a patient’s poor medical outcome. Failure to address feelings of regret can contribute to mental and physical health disorders and burnout. Physicians must be aware of their own impairments and care for their own mental and physical health so that they can continue to safely care for their patients. Physicians should cultivate practice environments that promote communication to ensure the delivery of safe and effective care. Additionally, physicians should compassionately intervene when a colleague is experiencing emotional or physical consequences of regret that affect their ability to safely practice medicine.