Couda, Woulda, Shoulda

Evidently, there are three (or more) verbal moods:

For facts there is the indicative – “I am writing this blog”

For non-facts, the subjunctive – “I should have written this a month ago” or “I could write this if I have the time.”

And for commands, the imperative – “Write this now”

Phuc Tran in his TED talk speaks about the role these grammatical forms have in our lives and the tension they reflect. We all have dreams, for ourselves, our families and sometimes for our patients that we express with the subjunctive. But as healthcare professionals, we must be grounded in the reality of the indicative. And it is in the grounding that our future yearnings become colored by regret.

“The subjunctive is the most powerful mood, it's like a time-space dream machine that can conjure alternate realities with just the idea of 'could have' or 'should have'. But within this idea of 'should have' is a Pandora's box of hope and regret.”

Last week I spent a day as a defense witness in a malpractice case. The process of informed consent was part of the allegation of ‘negligence’. And I think it may be a good example of Tran’s thesis.

When I discuss care with a patient I begin by describing the benefits, that outcome which I hope the patient and I will achieve. And then I discuss risk, that outcome which I hope the patient and I will avoid. Both are future subjunctives. And in my usual way, I frame both the benefits and risks upon a framework of where I perceive we are today (the disease’s natural history) and further ground myself by discussing my experience, both indicatives. Much later, when the care outcome is known we can look back upon our decisions with satisfaction or in the case, I was testifying upon, regret, a past subjunctive.  

Within behavioral economics, Prospect Theory (for which its author’s Kahneman and Tversky received the Nobel prize in economics) describes how people make these decisions, these informed consents. They argue that decisions are based upon the potential value of loss or gain rather than the outcome itself. As a corollary to their theory, other economists have posited Regret Theory for those times when our expectations are not met. How our regret is based upon our perceived loss, not in comparison to where we are (the indicative), but in comparison to what we might have achieved (the subjunctive). Again, there is tension between the indicative and the subjunctive.

Tran summarizes:

“The subjunctive allows us to be creative, but it also allows us to become mired and regret. And the indicative doesn't really allow us to imagine at all, but it does allow us to talk about ourselves and our experience in real terms, especially if we have the courage to embrace that reality. We take off and put on the lenses of the subjunctive and the indicative every day, and once we recognize the pitfalls of both, the indicative and the subjunctive, we can actively choose a more positive and optimistic look”

While Prospect theory appeals to my need for reasoned analytics and equations, Tran’s thesis has a more intuitive appeal. One of the reasons I chose “the adjacent possibilities” is because the phrase captures the value and tension of the indicative and the subjunctive. It allows us to dream of possibilities while remaining grounded in what we can achieve.

We spend our days alternating between subjunctive and indicative, imperative having been a dying form in healthcare for some time. Perhaps we might take a moment to recognize when we make that grammatical jump if for no other reason than to recognize our mind’s ability to act as a time machine containing past, present and future in a single thought. As surgeons, we have obtained informed consent for over a hundred years. Our medical counterparts are now discovering Shared Decision Making with its nuanced concern for “taking into account the best scientific evidence available, as well as the patient’s values and preferences.” Both are explorations of the adjacent possibility. Our days are filled with decisions, being mindful of our adjacent possibilities allows us to make them moments of informed consent.