“Had I known then what I know now…”
That sentence is not a reflection of patient indecision. It’s a system failure.
We’ve historically defined success in clinical terms we control: complication rates, readmissions, technical execution, aesthetic outcome. Those matter, but they’re incomplete. A technically excellent operation that leaves a patient misaligned with their own priorities is not a success. It’s a mismatch between what was delivered and what actually mattered.
If you accept that, the implication is straightforward: informed choice is not a prelude to care. It is the intervention. This is the principle I built Breast Advocate® around, the standard we’ve worked to embed at PRMA, and the one I’m now working to scale across the ARSA platform.
Regret is a clinical metric.
We don’t routinely measure regret, but we should. It’s one of the most honest outcome signals available.
Regret emerges when expectations, values, and lived experience diverge. That divergence is rarely about surgical technique. It’s about decision quality upstream: what the patient understood, what was framed, what was omitted, what was assumed.
When a patient says “I didn’t realize this would mean multiple stages,” or “I didn’t know sensation might not return,” that’s not a communication gap in isolation. It’s a failure of the clinical system to ensure the decision itself was fully informed and aligned.
We are not just responsible for how we operate. We are responsible for how patients choose.
The 99% problem.
Roughly 99% of a patient’s decision-making happens outside the clinic. Not because patients are uninformed or disengaged. Face time with physicians is shrinking, and the factors that shape decisions, including childcare, work schedules, support after surgery, recovery burden, body image, and intimacy, play out in everyday life, far from the exam room.
The consultation should ideally not carry the full weight of an informed decision. It should confirm one. When it’s asked to do both, it risks failing at both.
Building the decision infrastructure that lives outside the clinical encounter is one of the clearest opportunities in how we design care. The tools exist. The evidence exists. What’s required is the commitment to treat it as a clinical priority rather than leaving it to chance.
What shared decision-making actually requires.
The industry still talks about shared decision-making as a cultural aspiration. Something physicians should do better. Something that requires more empathy, more time, more relationship.
That framing is insufficient and unfair. Physicians are operating under time constraints that are real and only increasing. A genuine shared decision-making visit takes time most clinical schedules don’t allow. Asking physicians to solve a system problem through individual effort is not a strategy. It places an unreasonable expectation on clinicians who are already stretched, and it leaves patients without the support they need.
Culture without system doesn’t scale. Good intentions don’t produce consistent outcomes.
Shared decision-making needs to be designed. A patient who understands their full range of choices is a patient using their autonomy to make a real decision. It needs to account for values, not just clinical variables, and it ideally needs to start before the consultation, not during it.
A piece I wrote for Doximity Op-Med in 2017 on shared decision-making in breast reconstruction made the case that what patients understand before surgery shapes their experience of the outcome as much as the technical result itself. The decision quality matters as much as the decision.
Why Breast Advocate exists.
When I looked at what was available for patients navigating breast cancer surgery and reconstruction, the gap was clear. Information existed. Decision support did not.
Breast Advocate®, the flagship product of Toliman Health™, was built to close that gap. It’s a structured, personalized tool that walks patients through every option before they sit down with a surgeon. Built by board-certified specialists and grounded in evidence-based published research and patient experiences, it helps patients compare options, understand what each choice may mean for them, and prepare for a more informed conversation with their care team. It helps patients clarify their values, understand trade-offs, and arrive at the consultation ready to participate rather than to receive. It also serves as a resource throughout the care journey, including a peer community for ongoing support.
The goal is not to replace the physician or surgical consultation. It’s to help make it a different kind of conversation.
The operational argument.
Health systems and physician groups that treat shared decision-making as a cultural aspiration will never deploy it consistently. The ones that treat it as infrastructure will.
That means measuring it. Building it into care pathways. Holding it to the same standard we apply to infection prevention or time-out protocols. It’s scalable, measurable, and technology-enabled. It reduces regret, improves alignment, and changes what the consultation can accomplish.
Shared decision-making is infrastructure, not philosophy.
The practices and platforms that build it that way will outperform on every outcome metric that matters, clinical and operational.
Related reading: What to Ask Before Saying Yes to Breast Reconstruction →
Lymphedema After Breast Cancer: The Treatment Exists. The System Doesn’t Scale It Yet. →