Adv in Health Sci Educ (2015) 20:265–282

DOI 10.1007/s10459-014-9516-6

REVIEW

Predictable chaos: a review of the effects of emotions

on attention, memory and decision making

Vicki R. LeBlanc • Meghan M. McConnell • Sandra D. Monteiro

Received: 31 January 2014 / Accepted: 20 May 2014 / Published online: 6 June 2014
 Springer Science+Business Media Dordrecht 2014

Abstract Healthcare practice and education are highly emotional endeavors. While this
is recognized by educators and researchers seeking to develop interventions aimed at
improving wellness in health professionals and at providing them with skills to deal with
emotional interpersonal situations, the field of health professions education has largely
ignored the role that emotions play on cognitive processes. The purpose of this review is to
provide an introduction to the broader field of emotions, with the goal of better under-
standing the integral relationship between emotions and cognitive processes. Individuals, at
any given time, are in an emotional state. This emotional state influences how they per-
ceive the world around them, what they recall from it, as well as the decisions they make.
Rather than treating emotions as undesirable forces that wreak havoc on the rational being,
the field of health professions education could be enriched by a greater understanding of
how these emotions can shape cognitive processes in increasingly predictable ways.

Keywords Emotions
Attention
Memory
Reasoning
Clinical Performance

Introduction

The delivery of health care is an emotional endeavor. Health professionals and trainees are
constantly confronted with emotional events. While some of these events induce extreme

V. R. LeBlanc
Wilson Centre, University Health Network, 200 Elizabeth St, 1ES-565, Toronto,
ON M5G 2C4, Canada

V. R. LeBlanc (&)
Faculty of Dentistry, Department of Medicine, University of Toronto, 200 Elizabeth St, 1ES-565,
Toronto, ON M5G 2C4, Canada
e-mail: vicki.leblanc@utoronto.ca

M. M. McConnell
S. D. Monteiro
Program for Educational Research and Development, McMaster University, Hamilton, ON, Canada

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emotional states such as stress, most are associated with less intense states such as frus-
tration at a perceived lack of professionalism by a colleague, sadness at an undesired
patient prognosis, or happiness and satisfaction as a result of a positive clinical encounter.
In many of these emotion-evoking situations, health professionals and trainees must obtain
and interpret information, make judgments regarding treatment options that have different
benefits and risks, and remember important clinical and patient related information. Cur-
rent research in neuroscience and cognitive sciences indicates that emotions modulate a
variety of cognitive processes, including perception, memory, attention, and reasoning
(Clore and Palmer 2009; Damasio 1994; Kensinger 2009; Lerner and Keltner 2000). As
such, emotion-evoking situations likely affect what information health professionals attend
to, what they remember, as well as the way in which they make decisions in practice. For
example, under extreme stress, health professionals may resort to time- and energy-saving
strategies, such as reliance on heuristics, to make medically relevant decisions. Such
strategies can be adaptive when time is limited and the patient is under extreme distress. It
is unclear, however, how less intense emotional states, such as frustration or enjoyment,
influence attention, memory, and clinical reasoning strategies. Given that health care rarely
occurs in emotionally neutral settings, it is important to understand how health profes-
sionals’ emotional states affect their ability to interpret, make decisions about, and recall
clinical information.
There has been substantial research devoted to the study of how health professionals
and trainees detect clinical features from patient information, how clinical information is
stored and organized in their memory, what information they recall from clinical situ-
ations, and how they reason through clinical cases (Custers 2010; Custers et al. 1996;
Eva 2005; Kok et al. 2012; Norman and Eva 2010; Tanner 2006). However, emotions
are rarely discussed in regards to how health professionals and trainees learn, reason, and
make decisions (McNaughton 2013). Discussions of emotions occur mostly within the
realm of wellness, where investigators and educators are concerned with the impact of
training and practice on the mental health of trainees and health professionals (Dyrbye
et al. 2005; Shanafelt et al. 2012), and with the effects of emotional skills training on
health professionals’ ability to negotiate the interpersonal world of healthcare (Arora
et al. 2010a, b; Austin et al. 2005; Bulmer Smith et al. 2009; Satterfield and Hughes
2007). With a few notable exceptions (Estrada et al. 1994, 1997; Isen et al. 1991;
McConnell and Eva 2012), including growing work on the effects of subjective and
physiological stress on performance and learning (Arora et al. 2010a, b; Cheung and Au
2011; Harvey et al. 2010, 2012; LeBlanc 2009), the roles of emotions on clinical
thinking and reasoning are rarely broached. As discussed in this paper, however, indi-
viduals’ emotional states play an important role in how they perceive and interpret the
world around them, how they make judgments, as well as what they remember from
particular situations. The goal of this paper is to provide a narrative review of how
cognition is affected by emotional states, to discuss the implications of this research for
health professions education and practice, and to suggest potential directions for future
research. The broader domain of emotions research is quite vast, and it would be
unwieldy to attempt a systematic analysis of the effects of emotions on cognitive
function, especially given that different researchers have approached the study of emo-
tions from significantly different theoretical perspectives. As such, the approach taken in
this paper is to highlight leading theories and thoughts on the definition and functions of
emotions, as well as highlight important research that informs our knowledge on the
relationship between emotions and cognitive processes.

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Effects of emotions on cognition 267

Definition of emotions: neurosciences and cognitive perspectives

As an object of study, emotions have been defined in several ways (see Table 1). The
neuroscience approach has focused on the physiological manifestations of emotions,
whereby emotions are defined as physiological or neuronal responses, or ‘‘sensations’’, that
inform the organism about desired or undesired situations (Damasio 1994). A leading
neuroscience account of emotions, the somatic marker hypothesis, posits that emotion-
related signals represent changes in a person’s visceral state (e.g., heart rate, blood pres-
sure, glandular secretions) that serve as somatic markers to indicate a person’s emotional
reaction to a situation. For every response option that is considered in that situation, a
somatic state is generated, and this provides a signal to the organism as to whether the
response is desirable or aversive in terms of attaining one’s goal (Bechara and Damasio
2005). According to this approach, emotional reactions can occur without the subjective
experience of feelings (Naqvi et al. 2006); that is, feelings or conscious thoughts about
specific situations may be associated with emotions, but consciousness is not a requirement
of emotional experiences. To distinguish between conscious and unconscious physiological
manifestations of emotions, consider research on stress. Stress responses can manifest
themselves with conscious feelings of anxiety. They can also manifest themselves in
physiological activation of the brain’s hypothalamic–pituitary–adrenal axis, which releases
the stress hormone cortisol. While anxiety and cortisol responses often occur together,
individuals can have physiological cortisol responses in the absence of subjective feelings
of anxiety (Regehr et al. 2008). Furthermore, the two can have different effects on thought
and behavior (Regehr et al. 2008).
From a cognitive perspective, emotions are understood as the more familiar subjective
experience of feelings or moods—feeling anxious, happy, or frustrated—and they form an
integral part of cognitive function (Izard 2009). As well, cognitive functions can contribute
to the elicitation of emotions. Many models of emotion support this perspective, suggesting
that emotions are not merely triggered by objects and situations in reflexive or habitual
ways (Gendron and Barrett 2009), but arise from an individual’s interpretation of objects
and situations: an emotion emerges when a person’s internal state is understood in some

Table 1 Theoretical perspective on the definition and measure of emotions

Perspectives Definition Measures of Examples in health
emotions professions education

Neurosciences (e.g., Somatic states that Physiological: Böhm et al. (2001)

somatic marker
hypothesis)
Cognitive (e.g., affect-as- Subjective experience of
information theory
provide signals to the Heart rate
organism indicating Hormone levels
whether situations and/ Skin conductance
or responses are etc…
desirable or aversive in Mixed physiological Arora et al. (2010a,
terms of attaining a goal and self-report 2010b)
Harvey et al. (2010,
feeling/mood that 2012)
provide information LeBlanc et al. (2012)
regarding the value and Pottier et al. (2013)
importance of objects, Wetzel et al. (2010)
events or judgments Self-reports scales Cheung and Au (2011)
Isen et al. (1991)
Estrada et al. (1994,
1997)

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way as related to or caused by the situation (Lazarus 1991). For example, the affect-as-
information model (Clore and Storbeck 2006; Schwarz and Clore 2007; Storbeck and Clore
2008) posits that positive, negative, and arousing responses provide physiological and
experiential information, and this information guides individuals’ responses to various
situations. In other words, when confronted with a particular judgment, object, or event,
people often ask themselves ‘How strongly do I feel about it?’ In this way, affective
reactions serve to signal the overall value (e.g., emotional valence: pleasant vs. unpleasant;
desirable vs. undesirable, etc.) and importance (e.g., emotional arousal: urgent vs. not
urgent; important vs. unimportant) of a given judgment, object, or event. For example,
imagine a paramedic treating a critically injured child. In such a case, feelings of anxiety
can indicate that the stakes are high, that there are significant threats to the child’s well-
being, and that time is of essence.

Emotions and cognition: attention, memory and reasoning

It has long been assumed that the emotional groundings of human behavior are separate
from the more rational and superior groundings of thought (Gros 2010). Early perspectives
viewed emotions as part of the limbic system, a discrete network of primitive, less evolved
structures in the brain located between the neo-cortex (the seat of the cognitive and
learning capacities) and the brain stem (responsible for basics life maintenance such as
breathing and blood pressure). The more evolved part of the brain, the neo-cortex, was seen
as responsible for the cognitive functions that distinguish humans from non-human ani-
mals: reasoning, decision-making, anticipation and planning. This conceptualization of
emotions as being localized in the older, more reptilian part of the brain led to the
devaluation of emotions as primitive and antithetical to reason and higher order cognition,
and also promoted the perception of emotions as being separate from cognitive processes.
Emotions were viewed as derailing logic and creating chaos in otherwise rational
individuals.
Several recent advances in neuroscience have challenged the notion that emotions and
cognitive functions are processed separately in the brain. First, research has revealed that
the ‘‘newer’’ and ‘‘reptilian’’ parts of the brain do not differ from each other as much as
originally believed (Damasio 1994). Second, the input from the subcortical emotional
systems into the cognitive systems are stronger than input from the cognitive systems to the
emotional ones, which suggests a primacy for emotional processing over cognitive pro-
cessing (Damasio 1994). Finally, structures believed to be part of the ‘‘emotional’’ limbic
system (e.g., the hippocampus) have been shown to have an active involvement in cog-
nitive processes (e.g., memory), while structures believed to be responsible for cognitive
functions (e.g., prefrontal cortex) have been shown to play an active role in processing
emotional information (Damasio 1994). Emerging from this work is a picture of emotions
as actively involved in many areas of the human brain and tightly interwoven with
structures of memory, attention and decision-making. There is growing recognition that
emotions have a function that is indispensable to human cognitive processes (Bechara et al.
2000). Individuals with damage to parts of the brain that process emotional information
show impaired learning and decision making despite having intact attention, memory and
reasoning capabilities (Pessoa 2008). Thus, without emotions, humans are incapable of
functioning. Emotion and cognition not only interact in the brain, but are often integrated
such that they jointly contribute to behavior (Damasio 1997). As demonstrated by Damasio
(1994), ‘‘when emotion is entirely left out of the reasoning picture … reason turns out to be

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even more flawed than when emotion plays bad tricks on our decisions’’. Emotions thus
appear to coordinate the thoughts and actions of the individual. They trigger sets of
responses- physiological, behavioural, motivational- that enable a person to deal with the
situation encountered (Clore and Palmer 2009; Damasio et al. 1996; Dolan 2002).
Research from cognitive sciences also shows that individuals’ subjective emotions and
feelings can play an important role in shaping cognitive processes, such as attention, per-
ception and memory. Attention and perception are the first stages in information processing,
and as such, factors that influence these will also influence subsequent stages of processing,
including memory and reasoning. Research has shown that people exhibit enhanced percep-
tion for emotionally significant information; for example, people show a more rapid detection
of, and a preference towards, emotionally congruent information such as facial expressions
(Blanchette and Richards 2003; Nabi 2003; Niedenthal and Setterlund 1994; Richards et al.
2002). Furthermore, the interpretation of events tends to reflect individuals’ current emotional
states. For example, anxiety, even when mild, is associated with an increased likelihood of
interpreting ambiguous stimuli (facial expressions, social situations, heard homophones
{‘‘dye’’ vs. ‘‘die’’}) as threatening (Blanchette and Richards 2003; Nabi 2003). In fact, it is
difficult to disengage attention from the emotional qualities of a stimulus, particularly nega-
tively valenced ones (Richards et al. 2002). Extending this idea to a clinical setting, a nurse
who is feeling anxious would be more likely to interpret marginal laboratory readings (e.g.,
hemoglobin of 108) as being more problematic than would a nurse in a neutral or happy mood.
Emotion also plays an important role in memory function. Most readers will be familiar
with the experience of encountering events that were so emotionally charged, they became
indelibly marked in memory, whether they were personal events such as witnessing a loved
one getting injured or historical events such as the Challenger explosion or the events of
September 11th. The literature supports this phenomenon, demonstrating that the emotions
associated with an event can enhance memory for some details of an experience (Ken-
singer 2009). Improved memory also occurs due to enhanced consolidation, the process by
which memories are turned into stable and lasting representations (Kensinger 2009). While
the emotions associated with an event can help make it more memorable through stronger
encoding, emotions during an emotional event have been shown to impair the recall of
previously learned information, such as formulas for drug dosage calculations by para-
medics (LeBlanc 2009).
Together, the body of research reveals that in many cases, signals of emotion are
processed rapidly and automatically in the brain. This early detection of emotion is thought
to have a motivational influence by rapidly signaling the presence or absence of threat, and
cueing changes in cognitive strategies to produce the perceived needed response. In
addition, emotions can influence which information is attended to or retrieved from
memory (Bower and Forgas 2001; Lerner and Keltner 2000; Mather 2007; McConnell and
Shore 2011; Phelps 2006). People selectively retrieve mood-congruent information from
memory and then use that information to make judgments. Finally, emotions can also serve
as information. People rely on their emotions in a heuristic fashion to make judgments
about the world around them (Lerner and Keltner 2000).
While we have gained significant knowledge regarding the interchange of emotion and
cognition, there is still substantially more to learn. Questions remain as to how different
emotions, such as anger, anxiety, happiness or sadness, influence perception, memory,
judgments and reasoning. Dimensional models, such as valence-based theories (e.g., positive
vs. negative emotions) argue that all positive emotions produce effects similar to each other
but distinct from the effects produced by negative emotions. Alternatively, other approaches
argue that different emotions have distinct effects on cognition because emotions vary

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Table 2 Models of emotions

Dimensional models of emotions

Core dimensions account for similarities and differences across different emotional states
Arousal Emotions are characterized based on their
level of arousal. Emotional arousal narrows
and focuses attention by systematically
reducing the range of cues attended to
Valence Emotions are characterized based on whether
they are positive or negative. Positive
emotions broaden a person’s scope of
attention and other cognitive functions
Goal Individuals prioritize emotion-related
relevance information that is relevant to active goals.
Pre-goal emotions have higher motivational
intensity (drive to approach or avoid a
stimuli in the environment) than do post-
goal emotions
Circumplex Emotions are defined based valence (positive
vs. negative) and level of physiological
arousal or activation (high arousal vs. low
arousal). Emotions similar in valence and
arousal will have similar effects on
cognitive processes
Related models/theories:
Cue utilization theory (Cahill and
McGaugh 1995, 1998; Easterbrook 1959)
Related models/theories:
Broaden-and-build theory (Bless 2001;
Fredrickson 2004; Fredrickson and
Branigan 2005; Gasper and Clore 2002)
Related models/theories
Goal relevance models (Kaplan et al. 2012;
Gable and Harmon-Jones 2008, 2010)
Related models/theories
Circumplex models of emotions (Russell
1980; Posner et al. 2005)

Discrete models of emotions

Emotions vary depending on their specific antecedents and physiology

Discrete emotions A person’s interpretation of a situation,
along several dimensions, evokes a
particular emotion. Distinct emotions
organize behavior and physiology in a
predictable fashion to allow the individual
to deal with emotion-evoking events
Related models/theories
Appraisal models of emotions
(Ellsworth and Scherer 2003;
Scherer 1994; Siemer et al. 2007;
Smith and Ellsworth 1985)

depending on their specific antecedents and physiology. In contradiction to the valence theory
then, discrete emotions models suggest that emotions of the same valence (e.g., anger,
anxiety) could have different effects on judgments and other cognitive functions. See Table 2
for a summary of dimensional and discrete models of emotions. Debates between these two
perspectives make the emotion literature somewhat contentious.

Dimension models of emotions

Dimensional approaches attempt to identify core dimensions that account for similarities and
differences across different emotional states, with the most common dimensions being valence,
arousal and goal relevance. These dimensional models of emotion describe affective states as
arising from common overlapping neurophysiological systems (Cahill and McGaugh 1998).

Arousal models: low versus high arousal emotions

Some of the earliest models seeking to explain the effects of emotions on cognition
proposed emotional arousal as the key dimension. A leading model based on the arousal

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dimension is the cue utilization theory by Easterbrook (1959), which states that the effect
of emotional arousal is to narrow and focus attention by systematically reducing the range
of cues attended to. Attention is thus moved away from peripheral or less relevant
information in favor of augmented focus to cues that are central or immediately relevant to
the individual (Bacon 1974; Easterbrook 1959). Emotional arousal, regardless of whether it
is positive or negative, is thought to activate specific parts of the brain, most notably the
amygdala and the hippocampus (Cahill and McGaugh 1998; Hamann 2001). This acti-
vation, in turn, leads to narrowed attention and the selective enhancement of memory for
the central aspects of an event. Clinically, this theory could explain the tunnel vision
sometimes reported during crisis situations, and the accompanying premature closure or
fixation errors. Support for arousal models of emotions comes from studies showing that
individuals who are exposed to emotionally arousing information will show enhanced
memory for central details compared to individuals who are exposed to similar but neutral
information (Cahill and McGaugh 1995, 1998; Hamann 2001). However, arousal-based
models are challenged by research showing that memory can be enhanced for events that
elicit positive or negative emotions without arousal (e.g., sadness) (Kensinger 2004).

Valence models: positive versus negative emotions

Further support for dimensional models of emotions is drawn from studies showing that
positive and negative emotions have different effects on various cognitive skills.
According to the broaden-and-build theory, positive emotions, regardless of their intensity,
broaden a person’s scope of attention and other cognitive functions (Fredrickson 2001,
2004; Fredrickson and Branigan 2005). In support of this theory, positive emotions have
been reported to improve the integration of information in problem solving, decision-
making and cognitive organization. For example, in potentially high-risk situations (e.g.,
gambling and lottery tasks), positive moods tend to produce risk adverse behavior; how-
ever, in low risk tasks, where the likelihood of success is greater, positive emotions are
associated with increased willingness to take risks (Clore and Palmer 2009; Gasper and
Clore 2002; Hockey et al. 2000). Gasper and Clore (2002) found that individuals in a
positive mood tended to think more globally—that is to have a big picture view or see the
forest—whereas individuals in sad moods tend to think more locally, that is to see the
detailed view or the trees. Other researchers have shown that negative moods promote
more analytic processing whereas positive moods promote simple heuristic strategies
(Bless and Fiedler 2006; Bless 2001; Fiedler 2001). Clinically, this could manifest itself as
a physician relying more on pattern recognition in a positive mood than in a neutral or
negative mood.
Emotional valence has also been shown to influence the details that are remembered
from emotional events. Events that engender negative emotions lead to tunnel memory,
with enhanced recall for central details of an event at the expense of peripheral details
(Bernsten 2002; Kensinger and Corkin 2003; Phelps 2006; Reisberg and Heuer 2004). In
contrast, positive events have been associated with an increased recall of peripheral details
and sensory details (Bernsten 2002; Libkumann et al. 2004). The enhanced memory for
emotional details occurs partly because of the attentional effects of emotions described
above; information that elicits emotions is more likely to be attended to, and thus is more
likely to be encoded in memory. The few studies that have looked at the effect of emotions
on clinical reasoning have focused on the valence of emotions. Isen et al. (1991) found that
experimentally induced positive moods led to more rapid diagnostic decisions and greater
integration of clinical information, along with a greater likelihood of continuing to engage

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with the medical problems, in the form of considering alternative diagnoses and treatments.
In other words, students in a positive mood were more thorough in their approach to the
patient. In two other studies by the same group of researchers, participants who were given
a package of candy, and thus assumed to be in a positive mood, demonstrated more
creativity (Estrada et al. 1994) and showed less anchoring biases (overreliance on initially
presented information) (Estrada et al. 1997) than did participants in control groups.

Goal relevance models: pre-goal versus post-goal emotions

A third dimension along which emotions have been classified is goal attainment. The goal
relevance model posits that individuals prioritize information that is relevant to their active
goals. Individuals experience emotions when they perceive a change in the status of their
goals, and this change requires them to modify their beliefs or plans (Kaplan et al. 2012).
Pre-goal emotions (e.g., desire, excitement, fear, anger) are experienced when the attain-
ment or failure of a goal may occur in the future, and goal-directed efforts are ongoing.
Post-goal emotions (e.g., happiness, contentment, sadness, grief) occur when the attain-
ment or failure of a goal has occurred. Pre-goal emotions are thought to have higher
motivational intensity, which is the drive to approach or avoid specific stimuli in the
environment due to the anticipated attainment or failure of their goal. When motivational
intensity is high, individuals attend to and remember information that is relevant to their
active goal, at the expense of information that is less relevant to their goal. Although there
has been limited research in this area, there is some support for the goal relevance model of
emotions. For example, pre-goal desire has been associated with more narrowed attention
than post-goal happiness (Gable and Harmon-Jones 2008). Furthermore, individuals show
a broadening of attention when experiencing positive emotions after winning money in a
game than when experiencing positive emotions in anticipation of winning money (Gable
and Harmon-Jones 2010). According to these models then, health professionals should be
more influenced by their emotional states if they are still pursuing a goal than if the
attainment or failure of that goal has occurred.

Circumplex model: arousal and valence

Although there is some research showing support for the dimensional models described
previously, there is significant research suggesting that one-dimensional models of emo-
tions cannot account for all of the research findings (Kensinger 2004). As a result, a widely
accepted model of emotions is the circumplex model of affect, which postulates that
emotions are defined based on two dimensions; their valence (positive vs. negative) and
their level of physiological arousal or activation (high arousal vs. low arousal) (Friedman
2010; Posner et al. 2005; Russell 1980). Indeed, emotions with similar valence have been
associated with signals from similar neural structures (Colibazzi et al. 2010). Similarly,
highly arousing emotions have been associated with neural structures that are distinct from
the ones associated with valence (Colibazzi et al. 2010). These data suggest that emotions
can be divided into discrete and independent categories of valence and arousal, with
specific neural structures and pathways that subserve these categories (Posner et al. 2005).
Therefore, according to this model of affect, any given emotion is a linear combination of
those two dimensions, which is a variation in degrees of valence and arousal. Any two
emotions with similar valence and arousal levels, such as anxiety and anger (negatively
valenced and high arousal) should have similar effects on cognition and behavior.

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Over the years, there has been a significant accumulation of evidence in support of
dimensional models of emotions. Principal component and multidimensional scaling
analyses based on self-reports have supported the two-dimensional circumplex model of
emotions (Friedman 2010). Furthermore, both valence and arousal have been shown to
have independent influences on memories for autobiographical events (Ford et al. 2012;
Kensinger and Corkin 2004).

Discrete models of emotions: each emotion has specific antecedents and mechanisms

While there is support for dimensional models of emotions, they have also been criticized
as being too simplistic. Researchers argue that one- or two-dimensional representations fail
to capture important aspects of the emotional experience and do not reflect critical dif-
ferences between some emotions (Remington et al. 2000). In response to such criticisms,
researchers have put forward discrete models of emotion, which postulate that distinct
emotions organize behavior and physiology in a predictable fashion to allow the individual
to deal with emotion-evoking events (Barrett 2006). According to appraisal models of
emotion, it is a person’s cognitive interpretation of a situation or physiological sensations
along several dimensions that evokes a particular emotion (Roseman and Evdokas 2004;
Smith and Ellsworth 1985; Siemer et al. 2007). This interpretation, or appraisal, reflects an
evaluation of what the situation implies for a person’ well-being in relation to that person’s
specific needs, goals, resources and abilities. Once the meaning of a situation is assigned,
and a particular appraisal has been evoked, the result is an automated set of emotional
changes that represent the emotional meaning attributed to the situation. Importantly,
discrete emotions can differ in their antecedent appraisals, facial expressions, and physi-
ological, behavioral and cognitive manifestations (Lerner and Keltner 2000). Various
appraisal-based theories of emotions differ in terms of the dimensions or components
involved in the appraisal process, but most include novelty, pleasantness (valence), cer-
tainty or predictability, significance to attaining one’s goal, and agency (caused by self,
other or circumstances) (Ellsworth and Scherer 2003; Scherer 1994; Smith and Ellsworth
1985). Based on the appraisal antecedents, emotions can direct cognition to address spe-
cific problems or opportunities, and thus, can lead to a cognitive disposition to appraise
future events in line with the cognitive appraisal dimensions that triggered the emotion
(Fischhoff et al. 2012). In contradiction to dimensional models then, discrete approaches
argue that emotions of the same valence and arousal can have different effects on judgment
and cognition. For example, fear and anger, while both being negatively valenced high
arousal emotions, differ in terms of certainty and power appraisals. Fear is associated with
appraisals of low certainty and power over a situation, whereas anger is associated with
high certainty and power. In keeping with these appraisals, anger is associated with more
optimistic assessments of the future and lower risk perceptions than is fear (Lerner and
Keltner 2000; Lerner et al. 2003; Raghunathan and Pham 1999). Similar research has
shown that sadness (e.g., negative-low arousal) is associated with more pessimistic
assessments of the future, but less aversion to taking risks (Raghunathan and Pham 1999).
These data suggest that just because emotions overlap in valence and/or arousal, it does not
mean that these emotions will have equivalent effects on individuals. Clinically then, a
physician who encounters a challenging clinical case with a poor prognosis would be more
willing to undertake risky options to treat a patient if her response to the situation is anger
rather than anxiety.

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Recent research on memory of emotional events also supports arguments that dimen-
sional models are not sufficient to account for the effects of emotions. Talarico et al. (2009)
observed that although there is generally a higher proportion of recall of peripheral details
for positive events than negative events, different emotions of the same valence and
arousal differ from each other. Memories of anger-provoking events include a lower
proportion of peripheral details than fear-provoking events, despite both being negative
high arousal emotions. Similarly, individuals recall proportionally more peripheral details
from positive surprise events than happiness-provoking events, despite both being positive
high arousal emotions. Likewise, images that provoke a reaction of disgust are later
recalled better than images that provoke fear (Chapman et al. 2012).
To add to the debate, research on the effects of emotions on memory reveals patterns
that can be explained by both dimensional and discrete models of emotions. Gasper and
Clore (2002) found that participants in a happy mood, but not those in a sad mood, show a
greater effect of reconstructing their memory rather than retrieving what they have
experienced. Participants were shown a drawing of an African shield that bore the title of
‘‘Portrait of a Man’’. One group of participants was asked to study the drawing and then to
draw it from memory. That reproduction was then shown to another group of participants
who were asked to draw it from memory. The second reproduction was viewed by a third
group who then drew it from memory, and so on. For the group of individuals in a happy
mood, the drawings developed into in a drawing of a face of a man. In contrast, the
drawings of the participants in a sad mood were less likely to resemble a face. This
constructive aspect of memory recall was also observed in a clinical setting by LeBlanc
et al. (2012) with anxious participants. Following an anxiety-inducing simulated clinical
scenario, paramedics were more likely to make commission errors in their case report than
following non-anxiety producing scenarios. In other words, they were more likely to report
signs, symptoms or treatments that had not occurred. The majority of the commission
errors were consistent with the expected symptoms of the case, which suggest that when
anxious, paramedics relied more on a reconstructive process of memory, based on their
schema of what would be expected in such a situation. Given the finding that both hap-
piness and anxiety, but not sadness, led to greater reconstructive processes in memory, this
begs the question as to whether the effects were due to specific dimensional aspects of the
emotions (anxiety and happiness are both high arousal emotions) or whether the effects
were due to the different appraisals of each emotion.

Implication for health professions education and future research

The fact that healthcare practice and education are emotional endeavors is well accepted
and recognized. This recognition has extended to movements towards improving mental
health and enhancing the wellness of health professionals and clinicians. However, there
has been little recognition of the fact that trainees’ or health professionals’ emotional state
can have an important effect on how they perceive, interpret and think about their clinical
world. The relatively few studies investigating this topic in health professions have been
focused on the effect of positive emotions or of stress and anxiety. In medical students,
positive emotions have been linked to increased creativity, decreased cognitive biases, and
more thorough approaches to diagnostic reasoning problems (Estrada et al. 1994, 1997;
Isen et al. 1991). In a variety of health professionals, anxiety and stress have been linked
with impaired working memory and immediate recall, subtle alterations in clinical rea-
soning, and impaired technical and clinical performance (Arora et al. 2010a, b; Cheung and

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Au 2011; Harvey et al. 2010, 2012; LeBlanc 2009; Pottier et al. 2013), but also with
increased memory consolidation (DeMaria et al. 2010; Kromann et al. 2011).
Beyond the limited number of studies mentioned above, we have largely ignored the
role of emotions in striving to understand how health professionals develop and acquire the
knowledge and skills required for clinical practice. One reason for this oversight may be
attributed to the strong influence of the default-interventionist model of reasoning in health
professions education research (Monteiro and Norman 2013). This dual processes model
characterizes emotion driven and intuitive responses as rapid, unconscious and non-ana-
lytic. According to this model, the default mode of processing, also know as System 1, is
intuitive and quite error prone, while the interventionist logical and conscious mode, also
known as System 2, is the preferred form of reasoning (Kahneman 2011; De Neys 2010;
Redelmeier 2005). In line with this model, increased reliance on conscious and analytic
thought has been recommended as a strategy to reduce diagnostic errors (Croskerry 2000,
2003a, 2003b, 2009). Recommendations of this nature emphasize the importance of clearly
defined reason and logic over emotions. However, given that emotions and cognition are
intimately linked, this artificial dichotomy of conscious/rational thought and unconscious/
error prone intuitions can have a harmful effect on how physicians perceive their own
decisions, even calling accurate diagnoses into question (Woolley and Kostopoulou 2013).
Intuitions are particularly important to understand since they are unconscious or implicit
solutions to a problem. In over 30 years of research on clinical reasoning, the mechanisms
that support the intuition of the expert physician remain a mystery. Although an intuition is
not an emotion, it is possible that emotions are linked to our ability to assess implicit
solutions (Bolte et al. 2003; Stolper et al. 2011). As such, the study of clinical expertise,
reasoning and learning could greatly benefit from the inclusion of emotion as a moderating
factor. Potentially interesting directions for research include studies to determine whether
the clinical reasoning processes of trainees or health professionals are modified by their
emotional states. For example, are there particular emotional states that engender either
analytical or non-analytical forms of reasoning? Are some emotions associated with
increased susceptibility to cognitive biases such as fixation errors, premature closure or
anchoring? In undertaking this kind of research, it will be important to undertake research
that tests the predictions of dimensional models versus distinct models of emotions.
Although there has been limited research into the effects of emotions on health pro-
fessional’s cognitive processes, the notion that emotions can affect learning is being
increasingly accepted and integrated into education activities. For example, the role of
emotions is discussed in some models of experiential learning, where learning occurs
through having an experience and reflecting around it. For example, transformative
learning is described as a major shift in a person’s perspective that can occur when
fundamental beliefs are challenged (Mezirow 2000; Sandars 2009). Experiential learning
theorists argue that an individual’s emotional reaction to that challenge is instrumental in
the shift in perspective, and thus in the learning (Mezirow 2000). While educators are
advised to support learners in developing an awareness of their emotional reactions and in
processing these emotions such that they lead to the desired transformation in thoughts or
perspectives (e.g., leads to increased understanding of a patient’s suffering rather than
increased self-rumination), approaches based on this perspective treat ‘‘emotion’’ as a
unitary construct. They do not adequately discuss exactly how emotions lead to changes in
thoughts or perspectives. As such, the field of health professions education would benefit
from studies that explore the role of various emotions in experiential learning. For
example, would all negative emotions lead to shifts in perspectives, or would one expect
anger and anxiety to have different effects? Anger, which results from the appraisal that

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someone else is responsible for an undesired situation, could lead to the dismissal and
rejection of the challenge. Similarly, the emotion triggered by a challenge could potentially
influence whether an event is remembered accurately and what details are remembered
from the event. As such, while emotions likely play an important role in providing
important signals to the learner, different emotions may lead to different reactions and
memory from those events. Prior to a wholesale integration of emotions as tools to trigger
or facilitate learning, there is a need for studies investigating the specific effects of various
emotional states on learners’ ability to remember information from an emotional event as
well as their ability to transfer that new information to new problems.
In one form of experiential learning, simulation-based education, there is growing
discussion regarding the importance of integrating emotional elements, particularly neg-
ative high arousal ones, into the activities in order to enhance learning (Bath and Lawrence
2012; DeMaria and Levine 2013; MacDougall et al. 2013). Some support for this comes
from literature on enhanced memory consolidation and learning following stressful events
(DeMaria et al. 2010; Kromann et al. 2011; LeBlanc 2009). However, it is important to
note that while memory forms an important part of learning, it is one of many components.
Learning, the application of previously learned information or solution to a current situ-
ation or problem, also requires transfer of knowledge, cognitive flexibility and associative
learning. For example, consider ‘‘pimping’’, a pedagogical technique common in health-
care education settings, whereby senior clinicians ask their junior colleagues a series of
challenging questions in a public format. These pimping experiences induce a variety of
emotions including humiliation, embarrassment, excitement, and anxiety, and educators
have theorized that these emotional states promote learning during the pimping experience
(Brancati 1989; Wear et al. 2005). However, we do not yet have a complete understanding
of if, why or when pimping works. Does the impact of pimping on memory depend on
whether trainees experience positive versus negative emotions or arousing versus non-
arousing states? Does pimping promote or impede the transfer of knowledge and skills to
new clinical cases? It remains unclear how various emotions can, or cannot, be used to
enhance learning and transfer of knowledge to new clinical situations. As such, it may be
premature to seek to deliberately use emotions as teaching or learning aids. Without a
better understanding of the role of emotions, how they shape clinical reasoning, thinking
and learning, deliberately manipulating emotions for the purposes of learning could have
important ethical implications. At the current moment, the only clear implication of this
work is for a greater recognition and acceptance of the ubiquitous nature of emotions. They
are everywhere all the time.
Finally, growing from the work on emotions and mental health are discussions around
the importance of emotional intelligence and emotional regulation (Hayes et al. 2010;
Richards and Gross 2000). While these are potentially important concepts for the field of
health care practice and education, caution is warranted. Both the concepts of emotional
intelligence and emotional regulation have been critiqued because of the various defini-
tions of each and the various forms in which they have been measured. While emotional
intelligence is argued as essential for perceiving, interpreting information, and interacting
with others in emotional situations, the evidence supporting this is equivocal (Arora et al.
2010a, b; Cherry et al. 2014; Humphrey-Murto et al. 2014). More research is needed to
determine whether individuals who are high in emotional intelligence show different
effects of emotions on their cognitive abilities, and whether they demonstrate a greater
ability to perform in emotional situations. Furthermore, emotional regulation can refer to
both emotional suppression and cognitive reappraisal. Suppression refers to the conscious
inhibition of an emotional reaction once an emotion is being experienced. Cognitive

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Effects of emotions on cognition 277

reappraisal, in contrast, is the decrease or increase of emotional associations of a situation

by changing its meaning or relevance (Hayes et al. 2010; Richards and Gross 2000).
Cognitive reappraisal has been found to be a more adaptive strategy for regulating emo-
tions, in that it leads to greater reduction in undesired emotions and better memory per-
formance than does suppression (Goldin et al. 2008). There is some evidence that active
suppression of emotions can degrade memory (Richards and Gross 2006, 2000; Bonanno
et al. 2004). Being being asked to suppress facial expressions, or keep a straight face, leads
to impaired recall of events seen on a surgical video (Richards and Gross 2006).
The concepts of emotional intelligence and emotional regulation also bring with them
the assumption that some emotions are undesirable, which seems unlikely given the
ubiquitous nature of affect. More research is needed on the effects of emotions, as well as
the effects of modifying these emotions, on how clinical information is attended to,
recalled and used to make management decisions. For example, imagine a situation where
a clinician has to consider several treatment options for a patient. One presents fewer risks
to the patient, but will not be a fully satisfactory way of resolving the patient’s problem.
The other presents greater risks to the patient, but if it works, will lead to a more satis-
factory resolution of the patients’ presenting clinical problems. In such a situation, the
literature on emotions suggests that a happy or anxious clinician would select the less risky
option (Constans and Mathews 1993; Maner et al. 2007) while the sad or angry clinician
would be more likely to select the riskier option (Lerner and Tiedens 2006; Mittal and Ross
1998). If the optimal choice between the two options is ambiguous, then one would be hard
pressed to draw conclusions as to what would be the more desirable emotional state of the
clinician in such a situation. As another example, positive moods are generally viewed as
being more desirable. However, given research that shows that people in a positive
emotion are more likely to attend to irrelevant information (Biss and Hasher 2011;
McConnell and Shore 2011), it is possible that clinicians and trainees may be more
susceptible to distractions in situations that require focused attention. A greater under-
standing of the impact of various emotions could provide invaluable guidance to educa-
tional interventions focused on emotional awareness and regulation, as well as institutional
and systems based approaches to optimize patient care during emotional situations.

Conclusion

Health professionals and trainees, at any given time, are in an emotional state. The fact that
healthcare practice and education are emotional endeavors is well accepted and recog-
nized. This recognition has extended to movements towards improving mental health and
enhancing the wellness of health professionals and clinicians. However, there has been
little recognition of the fact that emotional states influence how health professionals and
trainees perceive the world around them, what they recall from it, as well as the decisions
they make. Questions remain as to how different emotions, such as anger, anxiety, hap-
piness or sadness, influence perception, memory, judgments and reasoning in the health-
care setting. In the broader domain of emotions research, dimensional approaches attempt
to identify core dimensions that account for similarities and differences across different
emotional states, with the most common dimensions being valence, arousal and goal
relevance. Alternatively, other approaches argue that different emotions have distinct
effects on cognition because emotions vary depending on their specific antecedents and
physiology. The field of health professions education could be enriched by research that
builds on current models of emotions in order to gain a greater understanding of how

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278 V. R. LeBlanc et al.

emotions can shape the cognitive processes of health care professionals and trainees in
increasingly predictable ways.

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