Peak end rule and its health care implications

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Since the pandemic began in March 2020, global health, finances, and even happiness have hurt healthcare. Humans are hard-wired toward negativity and noticing the negative experience before observing the positive is common. While we are good at identifying problems and placing blame on someone or something else, chronic negativity among healthcare workers can lead to a trickle-down impact on our patients. I often hear colleagues complain about decreasing reimbursements, rising overhead costs, the requirement to spend more time entering data than interacting with patients, and the incursion of time-wasting actions such as prior authorization that don't seem to impact patient care but increase the burden on physicians. Instead, I suggest providing patients a positive experience, especially toward the end of the doctor-patient encounter, referred to as the peak-end rule.

What is the peak-end rule? The Peak-End Rule states that an event is remembered more by what happens at the peak or the end than at any other time during the encounter.

The Israeli psychologist and Nobel Prize winner Daniel Kahneman and his colleagues have shown that how we remember our past experiences is almost entirely determined by two things:

• The average of how the experience felt at its peak (best or worst)
• How the experience felt when it ended

This is known as the peak-end rule, which is how we summarize experiences. We rely on that summary later to remind ourselves of how an experience felt, affecting our decisions about having that experience again. For example, if your eighteenth birthday was filled with laughter but ended with a fistfight, your memory of that event will likely skew to the worst part of the experience and how you felt when the party was over.

How did it start?

Daniel Kahneman reported in a 1993 study titled "When More Pain is Preferred to Less: Adding a Better End".1 They found that human memory seldom accurately records a series of events, thus proving the influence of the peak-end rule on memory processes.

The research study asked participants to endure an uncomfortable experimental condition where individuals were subjected to two versions of the same unpleasant experience. The experiment's first trial asked participants to submerge their hands in 14°C water for 60 seconds. The second version of the trial asked study participants to submerge their other hand in 14°C water for 60 seconds. Participants were also asked to submerge their hands for an additional 30 seconds while the water temperature was raised to 15°C. After these two trials, participants were asked which option of the trial they would choose to repeat. Study subjects were more willing to repeat the second trial despite the prolonged exposure to uncomfortable temperatures. The study concluded that this happened because subjects chose the long trial simply because they liked the memory better than the alternative.

The peak-end rule has been prevalently studied in medical procedures. It suggests that patients prefer to have more lengthy procedures that include a period of decreased discomfort rather than uncomfortable shorter procedures. The peak-end rule states that a painful medical treatment is likely to be less aversive if relief from the pain is gradual rather than abrupt.

A typical example of the peak-end rule and its effects on medical procedures is the patient's assessment of an uncomfortable colonoscopy procedure. Kahneman conducted another study in 1996 to assess patients' appraisals of this reasonably uncomfortable procedure to test responses based on their use of the peak-end rule.2 The study randomly divided colonoscopy patients into two groups. One group of patients underwent a typical colonoscopy procedure. The second group of patients had the colonoscope left in the colon without any movement for an additional three minutes. This extra three minutes created minimal discomfort but did not cause pain for the patients. When participants were asked to recall and evaluate their experiences from the procedures, the study found that patients with more prolonged colonoscopy procedures, i.e., scope left in longer, rated their experience as less painful than those who underwent the typical colonoscopy procedure. Patients who experienced a more extended procedure were also more likely to return for subsequent procedures. The gradual release of discomfort from these more prolonged procedures led to patients evaluating the experience as a positive experience than the other set of patients.

The study found that patients consistently evaluated the discomfort of the procedures based on the pain intensity at the peak or worst moment and at the final moments of the procedure. Regardless of the length of the procedures or the pain intensity experienced, all colonoscopy patients evaluated their procedures through peak events and ending responses.

Another study by Kahneman and Redelmeier further expanded on the discoveries made in their initial 1996 study.3 The study took colonoscopy patients and randomly divided the patients into two groups. One group of the patients underwent a colonoscopy procedure where the scope was left in for an additional three minutes. Still, the scope was not moved, perhaps causing minimal discomfort but not causing pain for the patients. The other group of study participants underwent typical colonoscopy procedures. When participants were asked to recall and evaluate their experiences from the experiment, the experiment found that patients who had more prolonged colonoscopy procedures rated their experience as less painful than those who underwent the typical colonoscopy procedure. Patients who felt prolonged discomfort were also far less likely to return for subsequent procedures. The gradual release of discomfort from these more prolonged procedures led to patients evaluating the experience as a more positive experience than the other set of patients.

An example of an adverse peak-end event might be returning from a lovely vacation. When you arrive at the baggage claim area after a long flight home, your luggage still needs to arrive. You spend an additional half-hour or more at the airline's baggage claim department filling out forms so that the luggage will be delivered to your home later. This negative experience at the end of your vacation can color your entire vacation by having the end of your holiday ending with this negative experience.

Here are a few examples of the peak-end rule that can be adopted by any doctor or practice:

If you have bad news regarding the patient's medical condition or prognosis, offer the negative news first and end with the good news. For example, if you are delivering a prostate cancer diagnosis, state that first and end with news that the condition is treatable or that you are committed that your patient will be kept comfortable and will not experience significant pain or discomfort.

Another pain point that needs to be put before the end of the communication between the doctor and the practice is the financial transaction that historically occurs at the end of the doctor-patient encounter. I suggest that you reverse the payment process, tell the patient about their deductible, co-pays, and anticipated visit cost, and collect the money before the patient is escorted to the exam room. Also, don't encourage the receptionist to ask, "Would you like to take care of your balance today?" The receptionist will usually receive a response that translates to "no." Instead, the receptionist asks, "Will you pay your balance by check or credit card?" This phrasing is more likely to have a better response rate.

Let the last interaction with the patient be something other than the patient making their follow-up appointment. This should be done at the beginning of the appointment or consider having the medical assistant arrange the appointment while the patient is in the exam room. This makes the peak end more positive and allows the receptionist or scheduler to communicate with callers or new patients.

Another peak-end experience is to send the patient a personalized thank you note to arrive the day after they visit the office. Nothing is more satisfying for a patient than receiving a personalized note from the physician thanking them for being a patient. This can also be accomplished by text or email.

I have yet to prove this, but if a doctor is performing a procedure on an awake patient and is seconds away from completing it, he might consider overestimating the time and then, in two or three seconds, remove the instrument. By overestimating the time, patients report less discomfort, thus improving the peak-end rule.

You and your staff can practice the peak-end rule with a gesture or a compliment. The easiest method for your staff is to use the patient's name at the end of their visit to the office. We all like the sound of our own names, and patients will feel special if we use their names before they exit the practice.

Finally, if you have authored a book for laymen or women, give a copy to the patient as they depart from the office. This is an excellent take-home and elevates the peak-end rule.

Bottom Line: The peak-end rule's applicability is genuinely amazing. Imagine how much more successful you would be if you could ensure that your patients, acquaintances, and loved ones left every interaction with you feeling grateful and happy. Make it a priority to apply the peak-end rule and end all your interactions positively. After all, that's what people remember, recall, and savor.

References

1. Psychological Science, 4(6), 401-405
2. Kahneman, D., & Tversky, A. (1984). Choices, values, and frames. American psychologist, 39(4), 341.
3. Redelmeier DA, Kahneman D. Patients' memories of painful medical treatments: real-time and retrospective evaluations of two minimally invasive procedures. Pain. 1996 Jul;66(1):3-8.

Neil Baum is a physician in New Orleans and the author of The Business of Building and Managing a Healthcare Practice, Springer 2023