Recalibrating Privacy Protections to Promote Patient Engagement.

n engl j med 377;16 nejm.org October 19, 2017 treatment and overestimate its likelihood for success, paving the way for later regret if the outcome is poor. Patients who choose elective procedures while in a hot state and end up with a bad outcome may be at particular risk for regret due to commission bias. Some researchers believe that the relationship of regret to either action or inertia must be viewed in the context of preceding events. Experiments involving sports may be relevant. A team of Dutch researchers led by Marcel Zeelenberg assessed the regret of a coach who decides to change the roster of players just before his team loses a game. The degree of regret depended on whether the team was winning or losing before the roster change. If the team was winning and the coach changed the players, he felt profound regret; but if the team was losing already and he altered the roster and still lost the game, his regret was minimal. In the case of our acquaintance with an arthritic knee, the “team was losing” — he had tried conservative measures without improvement. After an unsuccessful surgery, he did not feel regret. But in the case of the patient with the thyroid nodule, the “team was winning” — the nodule appeared stable — so she was at increased risk for regret when she “changed the roster.” When she shifted to what proved to be an unnecessary surgery rather than staying with the winning strategy of ultrasound surveillance, her team “lost” and her sense of regret was profound. Interestingly, in a review of patient choices regarding hormone replacement therapy, breast cancer surgery, and prostate cancer treatment, regret was greater among patients who changed their original decisions.5 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 baff le us. We should recognize that anticipated regret can leave a patient mired in decisional conflict, unable to choose. For these patients, it is vital to bring anticipated regret to the surface by openly discussing their fears and helping them gain a clear perspective on the risks and benefits of their options in order to move forward. To mitigate the possibility of future experienced regret, we as doctors can try to reduce the emotional temperature and, when feasible, avoid having patients make their decisions while in a hot state. Except in the most urgent circumstances, physicians can set in motion a deliberate process, exploring all treatment options to avert process regret. When patients are heavily influenced by others in making a decision, we can also be alert to the possibility of role regret. Regret is typically viewed as a negative emotion. It is notable that existing patient regret scales have largely failed to assess for a positive impact of regret.1 However, awareness of regret can be positive or functional, a potent force in modifying behavior and enhancing decision making. As physicians, we can help our patients make better decisions by understanding the power of regret in all its forms.