There are two types of memory, the cognitive and the emotional, and the latter is more enduring. Maya Angelou characterized the distinction between these two types of memory most eloquently and succinctly when she said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” She was ahead of her time, because neurocognitive research has objectified with science what Ms. Angelou captured so elegantly in her prose. Emotional events are processed in the sensory systems and then transmitted to the medial-temporal lobe and the amygdale for the formation of an emotional memory. When the memory is cued and retrieved from the amygdale, it triggers an emotional response. Emotional experiences leave strong traces in the brain. Memories about emotional situations are stored in both the conscious and unconscious memory, which is part of the reason emotional memories are so enduring.1 Studies of patients with severe anterograde amnesia following circumscribed bilateral hippocampal brain damage showed enduring memories of emotion despite the absence of conscious memories.2 This has a demonstrably practical application in patients with dementia, who we now know have feelings of happiness and sadness long after they have forgotten what caused the emotion.3
The distinction is important because patients judge the quality of their medical care based on emotions. The patient satisfaction disconnect arises from the fact that physicians live in their cognitive memory, while patients live in their emotional memory. Being cognitive and objective is a critical skill a physician must bring to the bedside every day; the reason we don’t allow physicians to treat family members is that their ability to remain objective will be impaired. I realized that my emotion, my passion, and my empathy for the dying would impair my judgment when I started medical school, and I launched myself on a conscious and systematic discipline to keep those feelings out of my mind during patient care. The effort worked and, for the most part, I have been able to remain objective and unemotional as I care for my patients. Recently, however, I realized that my focus on objectivity negatively impacts patient experience. As a result, I have expanded my view: While I must stay objective and detached with my thinking, I must be emotionally engaged to provide a great patient experience.
I can remain objective and detached in my clinical judgment as I engage and connect emotionally during my patient encounters. This delicate balancing act has taken years of trial and error, however. I recently cared for a woman in her 60s who had fallen and broke her hip. Everyone was pleased that a top orthopedic surgeon was on call and able to give her the first-rate care she needed to begin walking again. The surgery went smoothly, and she was transferred to the medical/surgical ward, where things took a turn for the worse. She had a lot of anxiety in addition to her osteoporosis. Objectively, she was doing great, and we had a big success on our hands; however, she remained anxious, and she peppered the surgeon with fears that, while unfounded, were very real in her mind. The surgeon brushed them off, saying that her fears were not real and that he didn’t need to address them; his response made her emotional state spiral out of control. Her nurse notified me of the situation, and I came to her bedside. She was very agitated. I sat down at a low level and just started listening. She got all of her anxieties out in words. I held her hand, looked her in the eye, and assured her that I would be there for her and that things were going to be alright. Subsequently, she wrote letters of gratitude and proclaimed to any medical staff who would listen what a talented and great doctor I was. I did not have the skill to fix her broken hip; if it had been left to me alone, she would still be bed-bound. But I did have the human skills to connect with her and fix her agitated mind. If we remember the enduring power of the emotional memory, we can create great patient experiences.
The importance of these experiences was illustrated to me at the 2014 Dignity Health Patient Experience Summit, a powerful event featuring motivational speakers and leaders from across the country. The most powerful speakers, however, were patients. These patients had received terrible diagnoses that committed them to a prolonged interaction with the healthcare system. They were scared of what their diagnoses would mean for their future, they were subjected to uncomfortable procedures in which they struggled to maintain their dignity, and they repeatedly met the indifference of healthcare providers and clerical people who were only there to do a job. They related how the lack of caring and empathy made fears and anxiety much worse. But each of them had a story about that one person, that one care provider, who took the time to reassure them, to show that they cared, and to ensure that the patient did not feel alone. In most of these stories, the stand-out care providers took the time to hold their hands and reassure the patients. They took the time to connect with the patient’s emotional memory in a positive way, and that simple gesture of empathy had a powerful and lasting impact on the patient.
Invariably, the care provider at the heart of the patients’ stories was a nurse. Nurses have the reputation for being angels of mercy because they do the simple, empathetic gestures that let a patient know they are being cared for. These feelings endure in the patients’ memories long after the treatment is over. Doctors can, and should, be that type of care provider. It requires us to recognize that patients are scared and anxious, even though they may do their best not to show it. We, as physicians, often don’t see their anxiety, and we are so focused on the cognitive memory that we don’t address the anxiety and fear that is just under the surface. But taking just a few minutes to acknowledge their emotions, to explore them, and to reassure the patient that we are there for them has a lasting impact. In my group, we talk about the “human-business-human” encounter with patients. We begin all interactions with a human interaction (“Hello, I am Dr. McIlraith…”), conduct the business we came to provide (“Now I am going to examine you…”), and end with a human interaction (“What else can I do for you today?”). Patients expect physical contact with us during the “business” part of that interaction. I find that respectful, reassuring, and appropriate physical contact during the final “human” portion of that interaction helps solidify my patients’ experience. It helps make them feel that they have been cared for, particularly if the visit includes bad news.
Much of the recent focus on patient satisfaction has been driven by financial incentives. In 2013, CMS began penalizing hospitals 1.25% for poor HCAHPS scores as a part of the Affordable Care Act. In 2014, the maximum penalty increased to 2%, and to 3% in 2015. Hospitals have notoriously high overhead costs and slim profit margins, so these penalties can have a profound impact on the financial viability of an institution. But, while hospitals across the country have taken notice (see related article in this edition of The Hospitalist), I find doctors are more motivated by the well-being of their patients than are their hospital administrators. Satisfied patients are more compliant with treatment plans and have better outcomes.4,5 Hospitalists spend a lot of effort making sure their heart failure patients are on an ACE inhibitor, and their heart attack patients are discharged on aspirin, beta blockers, and statins so that they will have a good outcome following treatment for their acute illness. The same outcome-driven, evidence-based practice of medicine relates to patient satisfaction, however. Success in HCAHPS is as important as core measures when it comes to patient outcomes. And if I can’t convince you patient satisfaction is important because of the good it does for hospitals and patients, think about yourself for a minute. Satisfied patients are much less likely to sue their physicians.6 Practicing quality, evidence-based medicine will keep you out of peer review; however, satisfied patients will keep you out of the courtroom.
I frequently hear the comment that “we can do great on patient satisfaction, but then it gets busy, and patient satisfaction goes out the window.” My own experience contradicts this maxim, however. It is not how much time you spend with your patient but, rather, what you do with the time you have. One of the most powerful things we can do is listen. I used to make the mistake that I only wanted to hear the information I needed to figure out my patients’ problems so I could start treating them; however, I have come to learn that being heard is, in itself, therapy for my patients. It is often quoted that physicians interrupt their patients within 18 seconds of starting the interview.7 A lot of physicians dispense with attentive listening when they are under time pressure, when they should instead dispense with lengthy discourses on the patient treatment plan. It is important to educate our patients on their illness and treatment, I admit. I find a lot of hospitalists want to impart their knowledge and their treatment rationale to their patients; however, they frequently give patients and families much more information than they can hold in their cognitive memory. And time pressures are not the only anxieties hospitalists carry with them to the bedside. Our increasingly metric-driven profession means that we not only have to worry about morning discharges, interdisciplinary rounds, length of stay, and so on, but we also have to consider patient experience. It is not easy to hide all the stress we are under when we come to the bedside of a patient, but we have to. The easiest way to do that is to take a deep breath, sit next to the patient, ask an open-ended question, and then say nothing until the patient is done speaking. Active listening with good eye contact and encouragement to continue solidifies the patient’s experience of being heard. There are extreme cases when a patient is in a manic phase and won’t ever stop speaking; bend the rules a bit in those circumstances. However, the above rule works very effectively in the majority of physician-patient interactions. Being heard leaves an enduring emotional memory with our patients.
Hospital medicine often looks to other industries for inspiration on how we can improve. The airline industry is often held up as an example of how we can model patient safety, for instance, but these comparisons oversimplify the challenges we face. The same is true with patient satisfaction. In the business world, adages like “The customer is always right” are central to customer satisfaction, yet completely irrelevant to HM practice. Patients and families frequently have inappropriate and unrealistic expectations of their hospitalist physicians. We cannot, and should not, tell the patient addicted to narcotics that they can have as much IV Dilaudid as they would like. We cannot fix the patient with end-stage cancer, heart failure, or dementia. This is where we have to part ways with comparisons to principles that guide other industries if we are going to find a way forward with patient experience in hospital medicine. Because we have to set limits for patients, we often have to give our patients and families bad news, and because we have to tell them things they don’t like to hear, like “You can’t have any salt in your diet,” or “You must quit drinking alcohol,” we must develop our own principles on patient experience and satisfaction. Otherwise our options are either delivering inappropriate medical care or abandoning the pursuit of patient satisfaction all together. This is when we must remember that emotional memories are more enduring. We can’t always give our patients what they want, and we can’t always tell them what they want to hear, but we can always show them that we care. When we show our patients that we care in a palpable way, we leave them with the feeling that they have been cared for regardless of their condition, and the positive memory will endure despite the negative information we may have to convey. Maybe they won’t cut down on their salt or quit drinking alcohol, but they will never forget that their hospitalist physician cared.
And if they remember that the physician cared, it is much more likely that they will cut down on the salt or quit drinking alcohol when they go home. To paraphrase Maya Angelou, “I can’t always tell my patients what they want to hear, I can’t always tell them that their lifestyle is appropriate, but I can always show them that I care.”
Dr. McIlraith is chairman of the department of hospital medicine of Mercy Medical Group in Sacramento, Calif.
- LeDoux JE. Emotional memory. Scholarpedia. Accessed August 2, 2015.
- Feinstein JS, Duff MC, D Tranel D. Sustained experience of emotion after loss of memory in patients with amnesia. Proc Natl Acad Sci. 2010:107(17):7674-7679.
- Guzmán-Vélez E, Feinstein JS, Tranel D. Feelings without memory in Alzheimer disease. Cogn Behav Neurol. 2014;27(3):117-129.
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. March 2001. Accessed August 2, 2015.
- Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239.
- Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient statisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133.
- Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692-696.