Learning from regret

• Published in: British journal of surgery Vol. 107; no. 4; pp. 422 - 431
• Main Authors: Boyle, F. M., Allen, J., Rey‐Conde, T., North, J. B.
• Format: Journal Article
• Language: English
• Published: Chichester, UK John Wiley & Sons, Ltd 01.03.2020; Oxford University Press
• Subjects: Communication; Mortality; Patients; Qualitative research; Surgeons; Surgical outcomes
• ISSN: 0007-1323; 1365-2168
• DOI: 10.1002/bjs.11452

Background Death after surgery is infrequent but can be devastating for the surgeon. Surgeons may experience intense emotional reactions after a patient's death, reflecting on their part in the death and the patient's loss of life. Excessive rumination or feelings of regret may have lasting negative consequences, but these reactions may also facilitate learning for future decision‐making. This qualitative study analysed surgeons' reflections on what might have been done differently before a patient's death and explored non‐technical (cognitive and interpersonal) aspects of care as potential targets for improvement. Methods In Australia's Queensland Audit of Surgical Mortality, surgeons reflect on factors surrounding the death of patients in their care and respond to the open‐ended question: in retrospect, would you have done anything differently? Framework analysis was applied to surgeons' responses to identify themes relating to non‐technical aspects of care. Results Responses from 1214 surgeons were analysed. Two main themes were identified. Dilemmas and difficult decisions confirmed the uncertainty, complexity and situational pressures that often precede a surgical death; regret and empathy for patients featured in some responses. In the second main theme, communication matters, surgeons cited better communication, with patients, families, colleagues and at handover, as a source of reflective change to improve decision‐making and reduce regret. Conclusion Surgical decision‐making involves uncertainty, and regret may occur after a patient's death. Enhancing the quality of communication with patients and peers in comprehensive assessment of the surgical patient may mitigate postdecision regret among surgeons. Regret has received little attention in the surgical context. It may be a relatively common emotional response for healthcare professionals when clinical decisions result in adverse outcomes. This study explored 399 surgeons' reflections on what might have been done differently for patients who had died under their care. The focus was on non‐technical aspects of care rather than surgeons' technical skills or medical error. Two preconditions for regret were explored: a sense of personal responsibility and the realization that another decision would have been better. Two main themes emerged from the data: dilemmas and difficult decisions, and communication matters. These themes confirmed that decision‐making is complex and requires situational awareness, and that better communication (with patients, families, colleagues and at handover) could improve patient care. These findings demonstrate the importance of non‐technical skills in surgical practice. Surgical training programmes should incorporate non‐technical skills training. All about better communication