The Last Minutes Shape the Memory. Design How Your Visits End.

Four ways to design the end of a dermatology visit: a clear, clinician-approved recap, the next step in writing, the estimate discussed privately and early, and a goodbye that isn’t rushed.

Patients take the end of a visit home with them. A patient has a shave biopsy on her back. The care is careful and kind. Then the last two minutes go like this: she dresses alone, someone leans in to say “You’re all set,” and at the desk the first thing she hears is a balance due. She walks out unsure when the result will come or who will call. Nobody planned that ending. It just happened. Yet how a procedure ends can change how the whole of it is remembered, and an ending can be designed. Three researchers showed this in a Toronto hospital in the mid-1990s, with 682 colonoscopy patients and one change made only to the final minutes.

The study staff member says: “Your pain right now, zero to ten?”

The patient says: “Maybe a three.”

Measure the moment. In Toronto in 1994 and 1995, patients rated their pain every minute during the procedure, from zero to ten.

The study staff member says: “Now the whole thing. How unpleasant was it?”

The patient says: “About here.”

Then measure the memory. Once sedation had worn off, each patient marked how unpleasant the whole procedure had been on a 10 cm line.

It began with a puzzle about memory. In 1993 experiments with pleasant and unpleasant film clips, Barbara Fredrickson and Daniel Kahneman found that length had only small effects on how people judged a clip afterwards; their judgments looked like “a weighted average of ‘snapshots’.”² In 1996, Donald Redelmeier and Kahneman found a similar pattern in 154 colonoscopy and 133 lithotripsy patients: remembered pain tracked the worst moment and the last three minutes, and long procedures were not remembered as especially bad.³ The pattern is known as the peak-end rule.

A trial in Toronto asked the harder question: if only the ending changes, does the memory change? Between November 1994 and December 1995, Redelmeier, Joel Katz and Kahneman enrolled 682 outpatients having colonoscopy at a Toronto hospital.¹ Each patient was assigned a sealed envelope at the start, and it was opened only at the final stage of the procedure. For patients assigned the modified ending, the tip of the scope was then left resting for up to three minutes before removal, with no suction, no inflation and no added anaesthetic. Patients were never told which group they were in, and staff were asked to keep their behavior unchanged.¹

Only the ending changed, and the memory changed with it. Patients rated their pain from zero to ten every minute. Pain in the final minutes was lower with the modified ending (1.7 versus 2.5), with no significant difference at the start, in the middle or at the worst moment; the procedure ran about 0.8 minutes longer on average.¹ Once sedation had worn off, patients also rated how unpleasant the whole procedure had been, a separate measure from the minute-by-minute pain scores. Those with the gentler ending remembered it as less unpleasant: 4.4 versus 4.9 on a 10 cm line, about 10 percent lower.¹

Length barely registered. Across all 682 patients, how long the procedure lasted hardly tracked how it was remembered, while average pain over the whole procedure tracked it most closely.¹ The ending is the part a team can plan, and when this team changed it, the memory moved with it.

Their advice was gentleness, with the ethics in view. The authors called the trial a proof of concept.¹ They suggested physicians take “special gentleness and care at the end” of an unpleasant procedure on an awake patient, especially one with no previous procedure and no abnormal findings, and they named the ethical tension with patient autonomy themselves.¹ A 2025 ethical analysis argues that prolonging painful procedures to exploit the rule, without telling patients, fails to respect their autonomy and may violate the duty to do no harm.⁵

Service businesses got similar advice. In Harvard Business Review in 2001, Richard Chase and Sriram Dasu set out five principles for service drawn from behavioral science. The first was to end strongly, because the ending is the part customers remember. The second was to deal with the unpleasant experiences early.⁴ For a clinic, the lesson is the shape of the visit, not its length: make the last minutes calmer and clearer, never longer or harder.

Principles of Excellence

• The ending is part of the experience. Changing only the final minutes of a colonoscopy, with no significant change at the start, in the middle or at the worst moment, made the whole procedure remembered as less unpleasant.¹
• Length is not the lever. How long the procedure lasted barely tracked how it was remembered; average pain, the worst moment and the end tracked it more. Pooled studies, as corrected by their authors, put length close to zero too.^{1, 6}
• Measure the memory, not just the moment. Pain every minute, how unpleasant the whole procedure was remembered to be once sedation wore off, and years of return visits: the team measured all three and kept them separate.¹
• Gentler, never longer. The trial’s authors advised being especially gentle and careful as an unpleasant procedure draws to a close. A 2025 analysis argues that stretching a painful procedure without telling patients fails to respect their autonomy.^{1, 5}
• End strongly, and get the hard parts done early. These were Chase and Dasu’s first two service principles: end well, because the ending is what stays with the customer, and deal with the unpleasant experiences early.⁴

4 Exceptional Practices for your Clinic

1. Close the room before the patient stands. In Toronto, only the final minutes changed, and patients remembered the whole procedure as less unpleasant. A better last few minutes can improve what the patient remembers. After a shave biopsy, once the patient is comfortable and ready, and before she stands, the nurse gives a concise recap from the clinician’s approved template: what was done, how to care for the site, when to expect an update and who will call. Questions about the diagnosis or treatment go to the clinician.
2. Put the next step in writing. The Toronto team measured more than pain: they followed patients for years to see who came back for another colonoscopy. The end of today’s visit is also the start of the next one. When the nurse finishes the recap, she hands over the written next step: when to expect an update and who will call, the warning signs to call about and the clinic’s number. If the clinician has planned a follow-up visit, the scheduler gives its date in writing before the patient leaves.
3. Keep the bill out of the last minute. Chase and Dasu advised ending strongly and dealing with the unpleasant experiences early. When the hard moments come first, the last minute is free for the recap and the goodbye. Before an excision, the billing specialist goes over the estimate with the patient privately and early, by phone before the visit or in a private spot at check-in. At checkout, the front desk only confirms what was already agreed and books any follow-up the clinician ordered.
4. Give the goodbye time. The trial’s authors suggested being especially gentle and careful as a procedure finishes, especially for people having one for the first time. The ending is the part a patient carries out the door. When a patient checks out after a first biopsy, the front desk stops typing, turns to face her, confirms when to expect an update and who will call, and asks whether anything is unclear. If the question is clinical, the front desk walks it back to the nurse or the clinician rather than answering it.

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