Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [33]
Although these experiments involved investing, they provide insight into medical decisions. Cognitive psychologists like Terry Connolly of the University of Arizona have confirmed the observation that when a person actively chooses a treatment and the outcome is poor, he or she can feel a deeper sense of self-blame and persistent regret. Both Lisa and Carl chose active intervention.
Later work by Dutch researchers led by Marcel Zeelenberg suggested that regret associated with active intervention could be modified by preceding events. The researchers studied this by looking at sports. They asked people to assess the regret of a coach who decides to change the roster of players on a team just before the team loses a game. The level of regret varied depending on whether the team was winning or losing before he altered the roster. If the team was winning and the coach changed the players, people expected that he would experience profound regret; but if the team was losing before, and he changed the roster and then lost the game, his regret would be minimal.
The Dutch sports studies may be relevant to Lisa and Carl. Lisa’s cortisone injections were working well, and she could enjoy walking with little pain for hours in Paris. This is analogous to the sports team winning. So when she “changed roster”—that is, when she shifted to an extensive surgery rather than staying with the winning strategy of the injection—her team “lost” and her sense of regret was profound. Carl, on the other hand, was on the “losing team,” his misery index high and prolonged. Physical therapy was not alleviating his pain and immobility, so when his operation did not succeed either, he did not feel much regret. This is one possible contributor to why Lisa but not Carl experienced regret.
Of course, Lisa’s winning strategy may or may not have been a good long-term option. A third cortisone shot might not have been effective. Following the sports analogy, the score then changed and the team began to lose. At that point, shifting strategy would be expected to result in less regret, even if at the end of the “game” her team lost, meaning the operation was not a success.
In considering clinical choices, cognitive psychologists have described what is termed “omission bias.” Some people prefer not to actively choose a treatment because they fear the greater regret they will experience from committing to a treatment if there is a bad outcome, especially a side effect. This anticipation of regret may lead some patients to avoid (“omit”) rather than take (“commit to”) a treatment.
This “omission bias” has been invoked to explain the low rate of vaccination for illnesses like influenza, typically 35 to 45 percent of adults. While people are feeling good, they anticipate the regret they would experience if they got sick from the injection. Even though the risks of side effects from the vaccine are low and typically very mild, many people prefer to omit the vaccination and take the risk of later developing influenza, which generally has more severe effects on the body. Not surprisingly, those who later catch a bad flu then regret that they omitted the vaccination and may blame themselves for being shortsighted.
Terry Connolly and his team of researchers at the University of Arizona found that when there is a negative outcome after treatment, the target of regret may be the decision process preceding the choice. This was the case with Lisa after her failed surgery. She repeatedly trawled over the events, the sequence of conversations with doctors and family and friends, as well as the shifts in her own mind-set, looking for what she could have changed.
Connolly distinguishes between “normal” and “nonstandard” decision processes. The latter deviate from an individual’s usual logic, behavior, or preferences. Lisa had had the experience of her lupus, where she followed her naturalism orientation, spending months in bed