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Medical students' reflections on professional behavior: cognitive style as a predictor of content and level of integrative complexity

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Medical students' reflections on professional behavior: cognitive style as a predictor of content and level of integrative complexity

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Content MEDICAL STUDENTS’ REFLECTIONS ON PROFESSIONAL BEHAVIOR:

COGNITIVE STYLE AS A PREDICTOR OF CONTENT AND LEVEL OF

INTEGRATIVE COMPLEXITY

by

Moreen E. Logan

A Dissertation Presented to the
FACULTY OF THE ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

December 2008

Copyright 2008 Moreen E. Logan

ii
Dedication
This dissertation is dedicated to my parents, Emory and Trudy Logan. They have
always been supportive of me no matter what I choose to do in life. I sincerely appreciate
their unconditional love, imparted knowledge and wisdom, and generosity year after year.
Most of all, I have them to thank for giving me a true appreciation of hard work and
continuous encouragement in attaining my goals.

iii
Acknowledgements
I would like to acknowledge my parents, family, and friends for their endless
support and belief in my ability throughout this doctoral program journey.
I am very grateful for the unwavering support, time, and contributions of my
dissertation chair, Dr. Rodney K. Goodyear, and committee members, Dr. Maura
Sullivan, and Dr. Julie Nyquist, whose guidance and expertise made this achievement
possible. I want to thank my dissertation group colleagues, especially Jo-Ann Yun, for
her consistent collaboration and motivation, and Tiffany Kane, Micah Cohen, Alaisen
Reed, Matt Nelson, and Veronica Ortega. It is with sincere appreciation that I
acknowledge my colleagues in the USC-KSOM Introduction to Clinical Medicine
program, Susanne Brody, Elti Ramirez, Dr. Pamela Schaff, Becky Taylor, and Dr.
Theresa Woehrle, for their continuous support, manuscript editing, and tolerance of
recurring deadline crises.
Last, but not least, I’d like to acknowledge my fellow USC-KSOM medical
student educators, especially Dr. Madeleine Bruning and Dr. Janet Trial, who were
always willing to share their knowledge and expertise with me, and pressed me to
succeed.

iv
Table of Contents
Dedication....................................................................................................................ii

Acknowledgements.....................................................................................................iii

List of Tables .............................................................................................................. vi

List of Figures............................................................................................................vii

Abstract.....................................................................................................................viii

Chapter One: Conceptual and Empirical Foundations for the Study........................... 1
Purpose of the Study .............................................................................................. 6
Definition of Terms................................................................................................ 7
Review of the Literature ........................................................................................ 8
Standards on Professionalism in Medicine and in Medical Education............ 9
Professionalism and Reflection in Medical Education .................................. 15
An Overview of Reflective Practice .............................................................. 23
Integrative Complexity .................................................................................. 29
Cognitive Style............................................................................................... 31
Research Questions............................................................................................... 34

Chapter Two: Method................................................................................................ 36
Participants...........................................................................................................36
Raters...................................................................................................................36
Measures..............................................................................................................36
Open-ended Survey........................................................................................ 37
Myers-Briggs Type Indicator (MBTI) Form M Questionnaire ..................... 38
Framework for Evaluating Participant Level of Reflections ......................... 40
Linguistic Inquiry and Word Count (LIWC)................................................. 41
Procedures............................................................................................................ 42
Data Analyses ...................................................................................................... 43

Chapter Three: Results............................................................................................... 45
Research Question One........................................................................................ 45
Theme Event Examples ....................................................................................... 46
Research Question Two ....................................................................................... 47
Research Question Three ..................................................................................... 48
Post hoc Analyses ................................................................................................ 51

Chapter Four: Discussion........................................................................................... 54
Conclusions.......................................................................................................... 54
Conclusion One.............................................................................................. 54

v
Conclusion Two............................................................................................. 57
Conclusion Three........................................................................................... 59
Conclusion Four............................................................................................. 61
Summary of Conclusions........................................................................................... 62
Limitations ................................................................................................................. 64
Delimitations.............................................................................................................. 65
Recommendations for Future Research..................................................................... 65
Implications for Medical Education Practitioners ..................................................... 66
Admission Procedures ......................................................................................... 67
Faculty Development Programs........................................................................... 67
Reflective Practice Teaching and Assessment..................................................... 68

Bibliography .............................................................................................................. 70

Appendix A................................................................................................................ 78
Appendix B ................................................................................................................ 81
Appendix C ................................................................................................................ 83
Appendix D................................................................................................................ 86
Appendix E ................................................................................................................ 88

vi
List of Tables
Table 1: Number of Reflections Based on Themes ................................................... 45

Table 2: Reflections Ranked by Level of Integrative Complexity ............................ 48

Table 3: Reflection LIC Score by MBTI Personality Type....................................... 48

Table 4: ANOVA Results of MBTI Preferences ....................................................... 49

Table 5: LIC Score Distribution by MBTI Preferences............................................. 50

Table 6: LIC Score Distribution by Keirsey Temperament Type.............................. 50

Table 7: Distribution of LIC Score by Word Count .................................................. 52

Table 8: Distribution of LIC Score by LIWC Dictionary Captured Words .............. 52

Table 9: Distribution of Themes by LIC Score ......................................................... 59

vii
List of Figures
Figure 1: Kolb’s Experiential Learning Model (1984).............................................. 27

Figure 2: Atkins and Murphy Model of Reflection (1993)........................................ 28

Figure 3: Atherton, 1990, after Mezirow (2005) ....................................................... 29

Figure 4: NF Temperament Type Distribution by LIC Score.................................... 51

Figure 5: Distribution of LIC Score by Word Count................................................. 52

viii
Abstract
This mixed methods, exploratory study examined the content and characteristic
levels of integrative complexity of 45 first year medical students’ written reflections upon
a personal challenge/dilemma they had encountered in the clinical or classroom setting.
As well, cognitive style was examined as a possible predictor of integrative complexity.
All incoming medical students at the University of Southern California’s Keck School of
Medicine (USC-KSOM) take the Myers-Briggs Type Indicator; as well, each first year
student is asked to provide written reflections on their experiences. Through a purposeful
random sample strategy, reflections of 45 students were examined; they were selected so
that three students represented each of the 16 Myers-Briggs personality types. Two
doctoral students reviewed the reflections and identified four themes: Personal
Interaction, Encounter with a Patient, Interaction with a Peer, and Interaction with an
Educator. A team of four doctoral students, which included the two who identified the
themes, and one professor, assigned a level of integrative complexity (LIC) score to each
reflection through consensus, using Hatton and Smith’s (1995) framework. The typical
score was relatively low, with a M of U2.16U (possible range: 1 - 4). In fact, the reflections
of only three students were assigned a LIC score of Level Four.
No combination of MBTI preferences predicted medical students’ LIC scores.
However there was an interesting relationship between the LIC scores of those 11
medical students whose Keirsey temperament type were NF Idealists and their pattern of
LIC scores. Specifically, nine had a LIC score of Level Two. Also, in post hoc analyses,
it was found that the number of words in a particular reflection was an excellent predictor

ix
of the LIC score. Limitations and delimitations of the study, recommendations for future
research, and implications for medical education practitioners (faculty and
administrators) were also discussed.

1
Chapter One: Conceptual and Empirical Foundations for the Study
In recent years, medical education literature has focused on the need for formal
evaluation of professionalism in medical students during all years of training (Cohen,
2006; Fryer-Edwards, Pinsky, & Robins, 2006; Papadakis, Loeser, Healy, 2001). In
addition, major initiatives to teach and evaluate professionalism as a core competency in
Accreditation Council for Graduate Medical Education (ACGME) accredited residency
programs and in medical schools in the United States have been generated (Coulehan,
2005). There has also been retrospective research that correlates disciplinary action of
physicians by state medical boards to prior documented unprofessional behavior in
medical school (Papadakis, et al., 2005; Papadakis, Hodgson, Teherani, & Kohatsu,
2004). It has also been noted by Kirk and Blank (2005) that professionalism is a difficult
competency to measure and requires formal teaching, especially in the “service of
healing” (p. 2710). Medical schools now have various forms of evaluation that allow for
assessment of student “professional” behavior, both by student self-assessment and
faculty assessment. However, there is a need for medical school faculty to formally
measure or gain an understanding of student perception of professionalism attributes in
the clinical or classroom setting that has an effect on their learning and development in
becoming a physician.
Professionalism is an essential component of medical education and while many
schools are including the necessary requirements in their courses it is hard to measure and
a difficult concept to grasp as learning objective. Practices such as self-reflection have
been used in some courses to measure different types of performance which include

2
professionalism. Patient narratives, and parallel charting described by Charon (2001a,
2001b) have also been used in Introduction to Clinical Medicine and professionalism
courses as well as in the focused topics of ethics and narrative medicine in required
clinical clerkships/rotations. Epstein (1999) describes “mindful practice,” noting that
mindfulness is a logical extension of the concept of reflective practice which is integral to
the professional competence of physicians (Epstein, 1999). Epstein also concluded that
new formats that can assess professionalism are promising; one of which is reflection
(Epstein, 2002).
Reflective practice can be valuable in medical education because it can uncover
aspects of teaching and learning that we are unaware of (i.e., students who are personally
struggling in the clinical or classroom setting with their peers or faculty, students who
don’t recognize their behavior as a lapse in professionalism, etc.) Recognition that these
situations exist through reflective practices will allow medical educators to better teach
the necessary components of professionalism and remediate medical student behavior.
Reflective practice has received a great deal of attention in the professional
literature, including medical education. Dewey (1933) began the modern conversation on
reflection with his seminal work entitled “How We Think: A Restatement of the Relation
of Reflective Thinking to the Educative Process.” Kuiper and Pesut (2004) concur that
reflective thinking began with Dewey’s definition of reflection and that it “can be defined
as careful consideration and examination of issues of concern related to an experience”
(p. 384). While Dewey focused on education broadly, Schön (1983, 1987) revitalized the
conversation on reflection and turned the focus to the practitioner. Schön described this

3
professional as a “reflective practitioner,” where reflection has been identified as an
elusive and intriguing component of practice. Practitioners meet the standard of a
profession as they engage in the “swampy lowlands” of practice where outcomes of
practice are not prescribed (Schön, 1983, 1987).
The importance of reflection has also been discussed by theorists in a variety of
fields, including critical theory (Friere, 1993; Chui, 2006) as “conscientization” as well as
with student development in higher education (Baxter Magolda, 2001; Kegan, 1982;
King & Kitchener, 1994). As a result of the work of Schön and others, multiple
professions have taken to defining reflection in the context of their practice. This has
been particularly true in two professions, nursing and teacher education. In the nursing
profession there has been discussion of learning how to be reflective (Plack & Greenberg,
2005), the role of reflection in self-regulation (Kuiper, 2005; Kuiper & Pesut, 2004), and
the stages of reflection (Atkins & Murphy, 1993). Teacher education also has explored
reflection in practice through the causes (Brookfield, 1987, 1990; Kuit, Reay, &
Freeman, 2001), the process (Kolb, 1984), and the teaching of reflection in preparatory
programs (Hatton & Smith, 1995; Van Manen, 1995).
Despite the quantity of literature and the attention by professional educators,
reflectivity is a broad concept for which there is no universally understood definition.
Many have attempted to define reflection, although there is no agreed upon definition
(Kuit, et al., 2001; Mezirow, 1981; Pee, Woodman, Fry, & Davenport, 2002; Schön,
1991). Those who have attempted to define reflection include Dewey (1933) who brings
forth the notion of reflection in the context of how students learn. This definition

4
describes an individual coming into contact with a troubling situation where previous
experience will not help to solve the problem. This causes a feeling of discontinuity for
the individual where they begin to reflect on the situation. Schön (1991) called this the
experience of surprise. Boyd and Fales (1983) define it as a feeling of “inner discomfort”
and it is also called a “critical incident” in some professions (Kuit, et al., 2001).
For the purpose of this study, reflection will be understood to be caused by an
event, which is for example:
 a critical incident (Branch, 2005; Brookfield, 1990; Flanagan, 1954; Kuit et al.,
2001),
 an ill-structured issue (King & Kirchener, 1994),
 a trigger event (Brookfield, 1990), or
 a problematic situation (Schön, 1983).
To be considered reflection, the event that causes reflection should lead to a change in
thinking for the practitioner. This phenomenon has been given several names, assumption
change (Boyd & Fales, 1983; Brookfield, 1990; King & Kirchener, 1994), reframing
(Schön, 1983), a new perspective (Atkins & Murphy, 1993), and propositional knowing
(Chui, 2006).
Perhaps because of the quantity of research on the reflective process or outcomes
of critical reflection in several professions it lacks a universal definition. Reflection has
been described in the medical education literature in terms of student portfolios and
assessing professionalism (Fryer-Edwards, Pinsky, & Robins, 2006), and journal writing
(Plack & Greenberg, 2005). However more discussion and research is required,

5
especially on the causes of critical reflection in medical students which can influence
future behavior, particularly their professional behavior. Through studying the
phenomenon, a definition of critical reflection can be gleaned and medical educators can
then decide how to incorporate the process in the curriculum; which is essential to
becoming a professional who engages in lifelong learning.
This study is important to medical education in general and specifically for pre-
clinical medical education. Medical students are a unique group of novice professionals
due to the process of personal and professional development in which reflective practice
is essential and it is a skill that must also be taught. Reflective practice is also a self-
supervision skill and one that is required for all healthcare professionals to practice
effectively and safely, especially physicians (Hilton & Southgate, 2007). Medical student
educators are motivated to shape the values, attitudes, and feelings that underlie medical
students’ professional behavior (Cruess, R., Cruess S., & Johnston, 1999). I have often
thought about what medical educators could do differently in the clinical skills training of
medical students that would allow the development of lifelong behaviors of
professionalism, which in turn may have an effect on patient outcomes. What have
remained unexplored in medical education are student reflections of professional
behaviors in the clinical and/or classroom setting and an examination of the level of
integrative complexity in their reflections. In addition, the relationship between first year
medical students Myers-Briggs Type Indicator (MBTI) personality type and Keirsey
temperament type, as measures of cognitive style, and their level of reflection may also
reveal what motivates medical students to choose one action over another when dealing

6
with patients and their health care colleagues now and in the future. Reflection-on-action
has been found to be a vital component of decision-making processes that caused
learning to occur which improved future decision-making (Ferry, 1995).
Current trends in medical education do focus on providing students’ opportunities
to develop reflection skills and professional behaviors (Cohen, 2006). We assume that
critical reflection is a skill that can be taught and while in medical training people
internalize the process as well as learning specific skills along the way. Through studying
medical students reflections on a personal challenge/dilemma medical educators may
learn how best to educate students and themselves about the need for critical reflection
throughout their personal and professional lives. To outline the contributions to medical
education, this study may:
 provide faculty with key information regarding characteristics of learners
 monitor student reflections for issues related to professionalism
 assist students to become aware of their own abilities to reflect-on-action
 structure school curricula to teach critical reflection skills to students
Purpose of the Study
The purpose of this exploratory descriptive study is threefold: (1) to examine first
year medical students’ surveys of a personal challenge/dilemma in the clinical and/or
classroom setting (reflections of professional behaviors) for thematic content; (2) to
determine the level of integrative complexity of first year medical students’ reflections;
and (3) to compare Myers-Briggs personality type (MBTI) and Keirsey temperament type
(KTT), as measures of cognitive style, to the level of integrative complexity in medical

7
student reflections of professional behaviors. My hope is that longitudinal research can
eventually be done in order to predict to what extent medical students are able to reflect
on professional behaviors which in turn may influence their learning and future
professional behavior and practice.
Definition of Terms
For the purpose of this study, the following are the definition of terms used:
Cognitive Style: Of, relating to, or being conscious mental activity, the way in which
individuals think, remember, learn, or use language (Merriam-Webster, 1995).
Critical Reflection: Demonstration of awareness that actions and events are not only
located in, and explicable by, reference to multiple perspectives but are located in, and
influenced by multiple historical and socio-political contexts (Hatton & Smith, 1995).
Hidden Curriculum: The set of influences that function at the level of organizational
structure and culture including, for example, implicit rules to survive the institution such
as customs, rituals, and taken for granted aspects (Lempp & Seale, 2004).
Integrative Complexity: A state cognitive style variable characterized by differentiation
(the recognition of different dimensions within, or perspectives on, a given stimulus) and
integration (the recognition of trade-offs, syntheses, and higher order concepts relating
the differentiated units) (Suedfeld & Bluck, 1993).
Reflection-in-action: Reflection that practitioners use during moments of pause while in
the midst of action (Schön, 1983, 1987).
Reflection-on-action: Reflection of past actions taken by practitioners (Schön, 1983,
1987).

8
Review of the Literature
Literature that describes the practice of medicine as a profession and its
component of professionalism curricula is relevant to this study. In addition, literature
that contributes to an increased understanding of reflection, the process of reflection, and
how reflective practice has been utilized in professional programs/curricula is relevant to
this study. The literature reviewed is organized into four major sections. The first section
provides standards on professionalism in the medical profession and in medical
education, courses in medical schools related to professionalism teaching, assessment,
and evaluation, and reflection as a tool in the practice of medicine. The second section
provides an overview of reflection and its various definitions in higher and professional
education literature and the themes that have emerged from the different theorists. The
third section provides background on the construct of integrative complexity. The final
section provides background on the construct of cognitive style and the use of the MBTI
and KTT as measures of cognitive style, both of which will be used as measures in this
study.
The literature addressing the topic of professionalism and reflection in the
medical profession and in medical education is the basis on which this section is
organized. First, standards on professionalism in the medical profession and in medical
education are provided. Second, courses in medical schools related to professionalism
teaching, assessment, and evaluation are reviewed.

9
Standards on Professionalism in Medicine and in Medical Education
The American Medical Association (AMA) (2001) adopted the “Principles of
Medical Ethics” as their standards of conduct which define the essentials of honorable
behavior for the physician (American Medical Association, 2001). They were developed
primarily for the benefit of the patient and the principle of medical ethics regarding
professionalism specifically states “a physician shall uphold the standards of
professionalism, be honest in all professional interactions, and strive to report physicians
deficient in character or competence, or engaging in fraud or deception, to appropriate
entities” (AMA, 2001, p. 1). The AMA (1998) also remarks in regard to patient
confidentiality practices that “the AMA’s ethical guidelines are not binding by law,
although courts have used ethical obligations as the basis for imposing legal obligations.
Moreover, “maintaining patient confidentiality is a legal duty as well as an ethical duty”
(American Medical Association, 1998, p. 1). It is important to note here that some
elements of professional conduct can also be defined as legal duties as well as ethical
duties.
According to Papadakis and colleagues (2004) physicians who were students at
the University of California at San Francisco from 1990–2000 that had received
comments regarding unprofessional behavior were more than twice as likely to be
disciplined by the Medical Board of California when they became practitioners. They
also noted that in previous studies the “majority of actions taken against physicians are
for deficiencies in professional behavior rather than incompetence” (Papdakis, Hodgson,
Teherani, & Kohatsu, 2004, p. 249).

10
Teherani and colleagues (2005) completed yet another retrospective study which
expanded on their previous research to identify the domains of unprofessional behavior in
medical students that are most problematic. Three domains were identified: (1) poor
reliability and responsibility; (2) lack of self-improvement and adaptability; and (3) poor
initiative and motivation. Practitioners who had experienced difficulty in any of these
domains while in medical school were more likely to be disciplined by a state medical
board, especially within the behaviors of the first and third domains. Several studies have
now identified lack of reliability and responsibility as a critical domain of unprofessional
behavior (Arnold, 2002; Hemmer, Hawkins, Jackson, Pangaro, 2000; Teherani, Hodgson,
Banach, & Papadakis, 2005). The authors suggest that medical educators with the
knowledge of these domains should focus on “methods to train faculty to consistently
evaluate behaviors and assess outcomes accordingly” (Teherani, Hodgson, Banach, &
Papadakis, 2005, p. S19).
The Liaison Committee on Medical Education (LCME) is the accreditation body
for all programs leading to the Medical Doctor (M.D.) degree in the United States. It is
jointly sponsored by the Association of American Medical Colleges and the American
Medical Association. Accreditation is important for several reasons: (1) it signifies that
national standards for structure, function, and performance are met by a medical schools
education program; (2) it is required for schools to receive federal grants for medical
education and to participate in federal loan programs; (3) students and graduates from
LCME accredited schools are eligible to take the United States Medical Licensing Exam
(USMLE); (4) graduates are eligible to enter residencies approved by the Accreditation

11
Council on Graduate Medical Education (ACGME); and (5) graduating from an LCME-
accredited U. S. school and passing the USMLE are prerequisites for licensure in most
states (Liaison Committee on Medical Education, 2005a, p. 1). In the “Medical Student”
admissions/selection section of the standards for the Educational Program for the M.D.
Degree, the LCME (2005b) notes that “medical schools must select students who possess
intelligence, integrity, and personal and emotional characteristics necessary for them to
become effective physicians” (LCME, 2005b, p. 4). The ACGME was established in
1981 and is the body responsible for accreditation of U. S. medical residency programs.
Its member organizations are the American Board of Medical Specialties, American
Hospital Association, American Medical Association, Association of American Medical
Colleges, and the Association of Medical Specialty Societies. The ACGME defines the
purpose of graduate medical education: “to provide an organized educational program
with guidance and supervision of the resident, facilitating the resident’s ethical,
professional, and personal development while ensuring safe and appropriate care for
patients” (Accreditation Council for Graduate Medical Education, 2003, p. 2). In regard
to the competency of professionalism, the ACGME requires that:
The sponsoring institution must ensure that each ACGME-accredited
program defines, in accordance with its Program Requirements, the
specific knowledge, skills, attitudes, and educational experiences required
in order for their residents to demonstrate the following: Professionalism,
as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse
patient population. In addition, the Sponsoring Institution must ensure that
residents develop a personal program of learning to foster continued
professional growth with guidance from the teaching staff. (p. 9-10)

The American Board of Internal Medicine (ABIM) (2001) is the organization
responsible for certifying physicians committed to careers in internal medicine or the

12
medicine subspecialties. The Board defines, promotes, and assesses all of the components
with the domain of competence for an internist that includes: medical knowledge; clinical
judgment; and clinical skills, including proficiency in performing certain procedures and
the professional attitudes and behavior “which are the foundation for a success as a
physician” (American Board of Internal Medicine, 2001, p. 5). In 1990, in response to
“concerns that changes in the health care environment produce stress that can negatively
affect the behavior of physicians” (ABIM, 2001, p. 5) the ABIM developed Project
Professionalism. The ABIM notes that:
Professionalism in medicine requires the physician to serve the interests of
the patient above his or her self-interest. Professionalism aspires to
altruism, accountability, excellence, duty, service, honor, integrity and
respect for others. The elements of professionalism required of candidates
seeking certification and recertification from the ABIM encompass: A
commitment to the highest standards of excellence in the practice of
medicine and in the generation and dissemination of knowledge.
A commitment to sustain the interests and welfare of patients. A
commitment to be responsive to the health needs of society. (p. 5)

Coulehan (2005) states that these terms of professionalism defined by the ABIM
refer to different but intrinsically related aspects of human functioning and that “conduct
arises from aims, which, in turn, are conditioned by qualities” (p. 893). However,
Coulehan further states that “for young physicians to become more humane and effective
healers, they must demonstrate professional conduct, which they are unlikely to do unless
their education also explicitly nourishes motivation and virtue” (Coulehan, 2005, p. 893).
Unfortunately, the tacit learning (hidden curriculum) of “objectivity, detachment, self-
interest, and distrust” (Coulehan, 2005, p. 894) that takes place in the hospital and clinic
environment can weaken the explicit curriculum.

13
The USC-KSOM Code of Professional Behavior (Appendix A), found in the
USC-KSOM (2007a) student handbook section seven: honor system, formerly known as
the “honor code,” historically focused only on academic integrity that a student could be
held in violation of and may be reported to the Student Ethics Committee. The Code of
Professional Behavior requires students to reflect the high standards of moral character
demanded by the medical profession by subscribing to similar elements of the ABIMs
Project Professionalism. The USC-KSOM (2007b) student handbook section seven:
honor system, Professional Behavior Expectations (Appendix B), elaborates on the
responsibilities of USC-KSOM students noting the possibility of probation and possible
further disciplinary action or dismissal from the KSOM for any violation. In turn,
medical students have the right to expect the same professional behavior of their faculty,
medical residents, instructors, and mentors.
This issue is also addressed by the American Medical Association (n.d.) which
has a policy on the teacher-learner relationship in medical education that recommends:
…that each medical education institution have a widely disseminated
policy that 1) sets forth the expected standards of behavior of the teacher
and the learner; 2) delineates procedures for dealing with breaches of that
standard, including: a) avenues for complaints; b) procedures for
investigation; c) protection and confidentiality; d) sanctions; and 3)
outlines a mechanism for prevention and education. (p.1)

The AMA notes the “Code of Behavior” in the policy that “the teacher learner-
relationship should be based on mutual trust, respect, and responsibility…that it should
be carried out in a professional manner, in a learning environment that places strong
focus on education, high quality patient care, and ethical conduct” (American Medical
Association, n.d., p. 1)

14
Haidet and Stein (2005) discuss the student-teacher relationship in the formation
of physicians and that professions seek to reproduce themselves through traditions and
values. Unfortunately students must somehow learn the knowledge, skills, values,
attitudes and behaviors needed to survive in the hierarchy of medical training where
medical students reside at the bottom (Haidet & Stein, 2005). In the midst of the culture
and situated learning it is imperative that medical educators are held to the same code of
professional behavior and expectations developed for medical students.
The University of Southern California Keck School of Medicine (USC-KSOM)
(2007c) “Essential Characteristics and Abilities Required for Completion of the M.D.
Degree” document, clearly delineated in the student handbook, under behavioral and
social attributes, states that:
A candidate must possess the emotional health, maturity and self-
discipline required for full use of one’s intellectual and judgmental ability
and for successful participation in, and completion of, the course of study
leading to the M.D. degree. These include but are not limited to
attendance, integrity, honesty, conscientiousness in work, teamwork, and
other attributes described in ICM and PPM. The candidate must accept
responsibility for learning, exercise good judgment, and promptly
complete all responsibilities necessary for sensitive and effective
relationships with patients and others. Candidates must be capable of
interactions with patients and health care personnel in a caring and
professional manner. The candidate must also be able to tolerate
physically taxing workloads, to function effectively under stress, to adapt
to changing environments, and to display flexibility. (p. 2)

Students must sign this form in agreement that they are able to meet these requirements
upon admission to the USC-KSOM. Students that apply to medical school are highly
motivated and have a general understanding of the road ahead of them however it is the
responsibility of the institution to make these requirements explicit in the curriculum.

15
Professionalism is not explicitly included in the content of the standards for the
Educational Program for the M.D. Degree however the LCME (2005b) notes “a medical
school must teach medical ethics and human values, and require its students to exhibit
scrupulous ethical principles in caring for patients, and in relating to patients’ families
and to others involved in patient care” (p. 3). More specifically the LCME (2005b) states:
“Scrupulous ethical principles” imply characteristics like honesty,
integrity, maintenance of confidentiality, and respect for patients, patients’
families, other students, and other health professionals. The school’s
educational objectives may identify additional dimensions of ethical
behavior to be exhibited in patient care settings. (p. 13)

Professionalism and Reflection in Medical Education
The Keck School of Medicine at the University of Southern California (USC-
KSOM), ninth Four–Year Educational Program Objective (2007d) “Professionalism” is
described as:
Act with altruism, honor, and integrity in professional and personal life.
Demonstrate caring and compassion for patients, and for members of the
health care team. Respect patients’ rights and wishes. Act in a respectful
manner toward faculty, colleagues and staff. Act responsibly in his/her
professional and personal life. Model good leadership in interactions with
others, and foster the development of others. (p. 1)
In addition, the tenth Four–Year Educational Program Objective (2007d)
“Lifelong Learning” is described as:
Pursue excellence in scholarship, assuming responsibility for addressing
gaps in his/her knowledge and experience. Demonstrate the skills of self-
education and lifelong learning to actively setting clear learning goals,
pursuing them, and applying the knowledge gained to the practice of
his/her profession. (p. 1)

16
This objective requires students to demonstrate habits, skills, and competence in
reflection and self-directed learning by initiating steps to rectify gaps in knowledge,
skills, and attitudes, and by evaluation of others.
Medical students are evaluated by faculty on these USC-KSOM educational
program objectives, along with eight others, throughout the four years of medical
school, as noted in the University of Southern California, Keck School of Medicine
(2007e) student handbook in the evaluation process and promotion requirements
section. In Years I/II written narrative evaluations of student performance are
required for Introduction to Clinical Medicine (ICM), Professionalism and the
Practice of Medicine (PPM), and in all Year III/IV clinical clerkships, which include
performance related to professionalism. In addition, it is important to note that there
are “synopsis” sections of these narrative evaluations that are prepared for use in the
Medical Student Performance Evaluation (MSPE), which accompanies applications
for medical residency and may have an impact on acceptance to a particular residency
(University of Southern California, Keck School of Medicine, 2007e).
For 39 years at USC the medical school has been in compliance with the LCME
standard cited in the previous section, by providing the Introduction to Clinical Medicine
(ICM) course, which has stated program goals and educational objectives that assist
medical students in meeting all of the USC-KSOM ten Educational Program Objectives.
Historically, ICM has always included teaching and evaluation of the professional
attributes of medical student behavior. There is one physician instructor (USC-KSOM
faculty or voluntary faculty) per group of six students who teach the course and most

17
ICM groups utilize the LAC+USC Medical Center and USC University Hospital for their
weekly sessions in the Year I-II continuum. Some ICM instructors do have students’
complete periodic narrative self-evaluations or patient narrative assignments (parallel
charts), as described by Charon (2001a) however none are required for completion of the
course.
ICM is a required interdisciplinary course that spans the first two years of medical
school, which is designed to emphasize the patient-centered orientation of the medical
school curriculum. The physician-patient encounter is the primary vehicle for teaching
and learning; medical students are introduced to patients and are involved in patient care
activities from their first day in the course. The program is planned not only to help the
student understand disease and begin to develop clinical competence in medical
interviewing and physical examination skills, but also to understand patients and their
experiences of illness. The student is expected to gain an understanding of himself/herself
as a developing physician in relation to the patient. The focus is on a unified concept of
disease, which emphasizes all levels of reaction and adaptation to noxious influences
from the molecular to the psychological and social. Students must understand that they
are a vital part of the diagnostic and therapeutic process and that the effect they have on
their patients and the effect their patients have on them is more important than any
historical fact or laboratory test or physical finding or psychosocial circumstance.
Furthermore, small group learning over a prolonged period of time with a
clinician instructor is a critical way to help the student through the process of becoming a
physician. In ICM the dehumanizing effect of the student-to-physician process can be

18
modified and an approach to medicine which stresses the importance of the patient rather
than the disease can be fostered. The overarching goal of ICM is to graduate clinicians
whose interest in patient-centered medicine stimulates them to be problem-solvers rather
than detectives, to continue learning throughout their lifetime and to practice the kind of
medicine which enables them to achieve personal satisfaction in their profession. Yet, it
must be noted that there are no formal reflection tasks or assignments required in the
ICM course.
In 2000, the four-year curriculum at the KSOM-USC was revised while taking
into consideration that in the 30 years since it was established there have been (1)
enormous increases in medical research and an explosion of medical knowledge, (2)
increasing specialization in medicine, (3) new emphasis on molecular medicine, genetics,
medical informatics, ethics, evidence-based medicine, and (4) revolutionary changes in
financing and delivery of health care (Abbott, Schechter, & Elliott, 2000). The new
curriculum was implemented in fall 2001 and as noted in the introduction,
professionalism is the ninth of ten USC-KSOM educational program objectives. In order
to fully assist medical students in meeting the professionalism objective, as well as many
of the other educational program objectives, a required course, Professionalism and the
Practice of Medicine (PPM) was introduced as part of the new curriculum. It takes place
approximately 12 times per academic year in the Year I-II continuum. There are two
faculty mentors per group of 24 students who teach the course in a multidisciplinary lab
(MDL) where other small group sessions are taught. One mentor is a clinical faculty
member, i.e., physician, and one mentor is a doctoral prepared faculty member. At this

19
time PPM mentors do not continue to meet with their respective groups of medical
students in Years III-IV due to time and logistics of the clerkship rotation framework.
However, the faculty and administration recognize the need for continued mentoring in
the clinical years.
The University of Southern California, Keck School of Medicine (2007f), PPM
course goals in Year I assist medical students’ in meeting six of the ten USC-KSOM
educational program objectives, which includes the objectives of professionalism and
lifelong learning, and the goals are:
Creating a community and a social context to provide identity and
facilitate learning; provide professional role models for students to
emulate in the areas of communication, social and community context of
health care, ethical judgment, self-awareness, self-care and personal
growth, professionalism, and life-long learning; prepare students to work
collaboratively and increase their small group skills to improve
participation in ICM, gross anatomy, MDL groups, and large group
sessions; provide students with an opportunity to build professional
identity and make specialty choices; encourage students in their learning,
reflection, peer and self-evaluation; provide opportunities for student to
gain skills and demonstrate competence in the areas of communication,
social and community context of health care, ethical judgment, self-
awareness, self-care and personal growth, professionalism, and lifelong
learning. (p. 1)

The University of Southern California, Keck School of Medicine (2007g), PPM
course goals in Year II also assist medical students’ in meeting six of the ten USC-
KSOM educational program objectives, which includes the objective of professionalism,
and the additional goals are:
Maintaining a community and a social context to provide identity and
facilitate learning; encourage students to continue to work collaboratively
and increase their small group skills to improve participation in all small
group settings; encourage student to demonstrate self-initiative and
leadership skills when leading and presenting to the group; encourage

20
greater professional maturity as demonstrated through behavior in PPM;
prepare students for transition to the third year. (p. 1)

Medical students are expected to be on time and attend all PPM sessions as well
as be prepared for each session to ensure success of the group activity. They are also
expected to participate and reflect on their professional growth and the professional
growth of their peers. In Year I they are to lead at least one session with their small group
of 24 students and in Year II they are to lead at least three sessions in their small group.
Medical students are also required to keep a portfolio of all of their PPM assignments that
they use at the time of evaluation with their mentor and to keep for reflection (University
of Southern California, Keck School of Medicine, 2007h).
The evaluation and feedback system for the USC-KSOM PPM course is clearly
stated in the Years I and II PPM student and faculty manuals and it includes self-
reflection and self-assessment, peer-assessment and feedback, and faculty feedback and
evaluation. However, the self-reflection forms that are completed on the thematic focus
sessions, e.g., Professionalism, Empathy, Cultural Competence, ask that students:
(1) summarize the main learning points for them personally, including one clinical
experience from ICM; (2) state their personal areas of weakness in relation to the focus;
and (3) state their plan for how to continue to progress in each of those areas. Currently,
students do not receive formal training in reflective practice in the PPM or ICM courses
and the self-reflection forms do not necessarily require “critical reflection.” Furthermore,
it is not known if students have had previous formal training in reflection. One of the
current PPM mentors noted that in completing the self-reflection forms some students
only report what was taught on the area of focus and provide very little personal

21
reflection which necessitates feedback by the faculty mentors (M. Sullivan, personal
communication, January 28, 2008). Reflection, for some, does not come naturally
therefore it is essential to have facilitation on the process (Plack & Greenberg, 2005).
Year I medical students have not been taught the skill of reflection, let alone critical
reflection, although they are required to do so in the PPM course.
In 2005, the Association of American Medical Colleges (AAMC) selected the
USC-KSOM as one of a few medical schools in the United States to pilot test an
instrument to specifically evaluate medical students’ professional behavior. The
instrument includes the following areas which are further subdivided: honesty/integrity;
responsibility/reliability/accountability; respect for others (e.g., colleagues, faculty,
hospital and administrative staff); altruism; empathy; commitment to excellence; and
respect for patients (Appendix C). In the 2005–2006 academic year the USC-KSOM
faculty implemented the use of the evaluation instrument at mid-year and at end-of-year
in the ICM and PPM courses in the Year I/II continuum, and at the end of each six week
rotation in the Family Medicine, Internal Medicine, Pediatrics, and Psychiatry Year III
required clerkships. While the evaluation ratings were not incorporated into students’
formal evaluations during the pilot year, students with professionalism deficiencies were
to be referred to the Office of Student Affairs and/or the appropriate student performance
committee. This initiative in medical schools is consistent with the ACGME focus on
professionalism as one of its six outcome competencies. Dr. Peter J. Katsufrakis, the
former USC-KSOM Associate Dean of Student Affairs, noted that using the evaluation in
medical schools “presents an opportunity to advance our profession’s focus on and

22
understanding of student professionalism” (P. Katsufrakis, personal communication,
December 14, 2005). However, the professionalism evaluation instrument may not be
able to adequately extrapolate the intrinsic and extrinsic reason(s) for a student’s behavior
in a given clinical situation therefore another form of assessment is needed in the
curriculum.
USC-KSOM faculty found the experience of using this instrument to supplement
other student evaluations valuable in stimulating a conversation with students. Year I and
II students also participated in the process by completing the forms on themselves in the
PPM course and utilized them in their final ICM evaluation sessions with their faculty.
Many ICM faculty found the students to be very forthcoming about their behavior and at
times more appropriately critical than the faculty. It is important to note that in the pilot
year some faculty evaluators felt uncomfortable making this very type of qualitative or
subjective assessment of students’ professionalism behavior. Faculty were made aware
that at this point the professionalism assessment form would be used for teaching and
monitoring professionalism behavior but that it would not be used to determine final
grades. The Educational Performance Committee approved that the professionalism
assessment form be used in all courses that participated in the pilot phase, and
involvement was extended to the remaining required Year III-IV clerkships. Current
electronic formats which collect student evaluation data, including the professionalism
assessment, have been developed to track individual students’ longitudinal performance.
Faculty have been specifically trained around the use of the scale to standardize their
responses. However, a paradigm shift is required for faculty to gain an understanding that

23
professionalism is a required competency of medical students and for themselves as a
practitioner. In order for faculty to formally use the professionalism assessment form as a
formal academic evaluation of medical students in the future additional training will be
necessary as well as a comprehensive understanding of the required competency of
professionalism for all practitioners. Charon (2001a) declares that “the effective practice
of medicine requires narrative competence” (p. 1897). This competence enables the
physician to practice medicine with…reflection and professionalism. Reflection is a
useful tool for professional behaviors to be assessed. In a seminal article by Inui (2003)
“A Flag in the Wind: Educating for Professionalism in Medicine,” Dr. Inui notes that
professional formation is “rooted” in daily activities, and the need for reflection is one of
these daily activities (Inui, 2003).
An Overview of Reflective Practice
We assume that critical reflection is a skill that can be taught to a novice
professional and utilized as an experienced professional in the future. To begin the
discussion of reflective practice, it is first important to explore the various definitions of
the term. As previously stated, there is no agreed upon definition of reflections and
reflective practice (Atkins & Murphy, 1993; Mezirow, 1991; Pee, Woodman, Fry, &
Davenport, 2002; Plack & Greenberg, 2005). The concept of reflection can be traced in
the past century to the work of Immanuel Kant regarding perception and reflection as
well as that of Dewey (1933). Dewey explored both inquiry and reflection with a focus
on “problematic situations” (Neufeldt, Karno, & Nelson, 1996). Schön (1983, 1991)
similarly describes situations that are in need of reflection as being framed as problems.

24
King and Kitchener (1994) refer to a similar idea with the catalyst for reflection being
“ill-structured” issues.
Types of Reflection. Schön (1983, 1987) delineates between two types of
reflection, “reflection-in-action” and “reflection-on-action.” The former describes the
type of reflection that practitioners use during moments of pause while in the midst of
action. In contrast, “reflection-on-action” refers to the reflection of past actions taken by
practitioners. It is this type of reflection that is most in line with the definitions of Dewey
(1933). Killion and Todnem (1991) extend Schön’s types of reflection describing
“reflection-for-action,” where practitioners begin to anticipate problematic situations
before they occur. King and Kitchener (1994) describe a model of “reflective judgment”
whereby individuals’ recognize that they differ greatly in their “epistemic assumptions”
and that these differences manifest themselves in the decision-making of individuals with
regard to ill-structured problems.
Process of Reflection. The process of reflection has also been the topic of many
explorations in the literature and within these differences in models of reflection, and
there is also disagreement about the stages, skills, and methodological issues in studying
reflection (Atkins & Murphy, 1993). Some argue that reflection is an internal process that
individuals use to make sense of their experience perspective or assumption change
(Boyd & Fales, 1983; King & Kitchener, 1994; Mezirow, 1991; Plack & Greenberg,
2005; Schön, 1983). Others that describe the process of reflection through an explanatory
model have defined specific phases and transitions between phases that occur (Atkins &
Murphy, 1993; Boud & Walker, 1998; Kolb, 1984; Kuiper & Pesut, 2004). Stages of

25
reflection have also been described (Atkins & Murphy, 1993; Boud, Keogh, & Walker,
1985; Boyd & Fales, 1983; Mezirow, 1981; Schön, 1991; Van Manen, 1977), as well as
the skills involved in reflection (Boud et al., 1985; Schön, 1991).
Schön (1983) also describes reflection through the lens of a reflective practitioner
where “they listen and reframe the problem. It is this ensemble of problem framing, on-
the-spot experiment, detection of consequences and implications, back-talk and response
to back-talk, that constitutes a reflective conversation with the material of a situation–the
design like artistry of professional practice” (1987, p. 158). Schön (1987) further
describes the process of reflection in the metaphor of a “ladder” where to move up is to
move from being involved in an activity to–reflection on that activity, and to move down
is to move from a state of reflection to an action that causes further reflection.
Plack and Greenberg (2005) believe that reflection can be learned. Also, learning
from reflection gives meaning to the process, and it is both cognitive and affective (Boud
& Walker, 1998). Reflection requires a practitioner to seek alternative ways of practicing
whereby learning occurs by being open to criticism and change (Driscoll & Teh, 2001.)
Overlapping Constructs. Reflection is also contrasted with other overlapping
constructs for example: (1) self-regulated learning is using a set of behaviors that are used
to guide, monitor, and direct one’s thinking in order to succeed, which is also a form of
lifelong learning (Kuiper, 2005; Kuiper & Pesut, 2004); (2) critical thinking is the ability
to recognize assumptions, beliefs and values that underlie decision-making processes as
one solves problems or anticipates outcomes while justifying their actions (Plack and
Greenberg, 2005); (3) experiential learning is the process of evaluating experiences that

26
are shaped by one’s culture which can be transformative (Brookfield, 1995; Fryer-
Edwards, Pinsky, & Robins, 2006; Kolb, 1984), and (4) metacognition, which is any
knowledge or cognitive process that refers to, monitors, or controls cognition, i.e.,
thinking about thinking (Kuiper & Pesut, 2004).
Context and Domain of Reflection. These have also been explored in a number of
ways and they are particularly relevant to the practice of medicine, nursing, psychology,
and other professions in which practitioners are responsible for the care of patients. In
these professions development of a professional identity includes professional values,
beliefs and attitudes which requires self-critique and reflection that inform the
practitioner’s clinical decision-making process (Plack & Greenberg, 2005). The work of
Schön (1983, 1987) describes reflection as primarily constructivist, situated in the
experience of the practitioner, and that there are no “real truths” but only those
constructed by the practitioner. Schön (1983) describes that reflective practice is a shift
from positivism (where the only authentic knowledge is scientific knowledge) or what he
calls “technical rationality” as a necessity for professions, even if the positivism is still
relied upon in science driven professions.
Models of Reflection. Argyris and Schön (1974) in their description of single loop
and double loop learning describe reflection as an ongoing process where one is
constantly questioning their own assumptions and the status quo to improve, learn, and
change for the greater good. Kolb (1984) defines reflection in the context of his
“Experiential Learning Model” where knowledge is created through a transformative

27
experience (Kuit et al., 2001, Figure 1). In this model the learning cycle can be started at
any stage but then the stages are followed in a more linear sequence.
Figure 1
Kolb's Experiential Learning Model (1984)

Atkins and Murphy (1993) view reflection as a non-linear three-step process, first
a trigger event occurs that causes awareness of uncomfortable feelings and/or thoughts
(positive or negative); second, a critical analysis of the feelings and thoughts and the
experience itself occurs; and third, there is a development of new perspectives as a result
of the critical analysis (Atkins & Murphy, 1993, 1994, see Figure 2).

28
Figure 2
Atkins and Murphy's model of reflection (1994)

Mezirow (1998) noted that reflection is a simple awareness of an object, event or
state, including awareness of perception, thought, feeling, disposition, intention, action,
or of one’s habits of doing these things. He describes a model of reflection with seven
distinct levels ranging from reflectivity which represents awareness of thought and
feelings to theoretical reflectivity which represents a change of perspectives (Mezirow,
1998). In 1990, Atherton revised Mezirow’s model to represent action model which can
be viewed in Figure 3 (Atherton, 1990).

29
Figure 3
Atherton, 1990, after Mezirow (2005)

The next section of the literature review provides background on the construct of
integrative complexity, which will be used as a measure in this study.
Integrative Complexity
The most regarded definition of integrative complexity is that of Suedfeld and
Bluck (1993) who define it as “a state cognitive style variable characterized by
differentiation (the recognition of different dimensions within, or perspectives on, a given
stimulus) and integration (the recognition of trade-offs, syntheses, and higher order
concepts relating the differentiated units)” (p. 124). More simply stated it is a measure of
an individual’s intellectual style in processing information, solving problems, or making
decisions. In examining written reflections, the authors heed a limitation warning of
assessing integrative complexity in that an individual may just be projecting a desired
image of themselves. Hence the examiner cannot conclude that a shift in cognitive
processing has actually taken place.

30
Pee and colleagues (2002) conducted a qualitative study to assess the
effectiveness of reflection in teaching dental therapy students. They noted the
requirement of “evidence” on at least three levels: to determine actual use of reflective
techniques; to establish that use of reflection over time increases one’s ability to reflect;
and to assess what effect the increased ability to reflect has on one’s learning and
professional practice (Pee, Woodman, Fry, & Davenport, 2002). Other authors describe a
similar framework wherein four types of writing are used to characterize student writing
as “reflection” which have also been used in teacher training. The four types are
described as: (1) “descriptive” which is only a reporting of the events; (2) “descriptive
reflection” that includes reasons for the events (subjective); (3) “dialogic reflection”
which displays thinking of why the reasons or alternative reasons contributed to the
event; and lastly (4) “critical reflection” which describes the whole event including
setting, roles of participants, responsibility, decisions to be made, etc. (Hatton & Smith,
1995; Kaplan, Rupley, Sparks, & Holcomb, 2007). In 1995, Hatton & Smith conducted a
study wherein a literature review was done on reflection and the previous described
framework was proposed for defining reflection in teacher education (Hatton & Smith,
1995). This framework can also be employed in examining reflections for the cognitive
variable of integrative complexity which will be discussed in turn.
The final section of the literature review provides background on cognitive style
and the MBTI personality type and the Keirsey dual variable temperament disposition, as
measures of cognitive style, both of which will be measures used in this study.

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Cognitive Style
Cognitive style is defined in the Merriam-Webster (1995) dictionary as the way in
which individuals think, remember, learn, or use language, i.e., any mental activity
(Merriam-Webster, 1995). In explaining the cognitive variable, Cacioppo, Petty, and Kao
(1984) note that the “need for cognition is an individual’s tendency to engage in and
enjoy effortful cognitive endeavors” (p. 306). Furthermore, this is predictive of the way
in which individuals deal with tasks and social information (Cacioppo, Petty, & Kao,
1984). In addition, cognitive style, as a variable, measures the strength of one’s
preference for the manner in which individuals process information. One’s preferences
can change over time depending on personal growth. The Myers-Briggs Type Indicator
(MBTI) is a self-report questionnaire developed in 1958 by Katherine Cook Briggs and
her daughter, Isabel Briggs Myers which identifies 16 distinctive personality types that
result from the preferences scored from interactions in the four dichotomies implicit in
Carl G. Jung’s theory of psychological types which can serve as a measure of cognitive
style (Keirsey, 1998). The MBTI four preference variables include: 1) Extroversion (E)
or Introversion (I), 2) Sensing (S) or Intuition (N), 3) Thinking (T) or Feeling (F), and 4)
Judging (J) or Perceiving (P). Those who don’t have a clear preference in one or more of
the categories may be more flexible and/or adaptable but are less likely to have strong
abilities in those categories. However the 16 MBTI types are “dynamic energy systems
with interacting processes” rather than static types (Briggs Myers, 1998, p. 7).
The current MBTI is the most widely used instrument for understanding normal
personality differences and it explains basic patterns in human functioning. At the USC-

32
KSOM first year medical students complete a MBTI Form M following session seven in
the PPM course, which is two months into their first year of medical school. During
session seven the attributes of medical professionalism and student’s responsibilities in
developing the attributes, as well as the Keck School of Medicine Code of Professional
Behavior are discussed in small groups of 24 students and two faculty mentors. The
following week the PPM session focus is on effective teamwork and successful groups
where the small groups of students discuss their individual preference types in relation to
the members of the group. In addition, the PPM faculty mentors reveal their own MBTI
preferences to facilitate a better process of group teaching and learning leading to
effective teamwork in the classroom which can transfer to the clinical setting wherein
effective teamwork is vital. Knowing and understanding a medical student’s Myers-
Briggs type is important for medical educators for several reasons: 1) it enables medical
students and faculty to gain an understanding of each student’s behavior, skills, and
attitudes; 2) it can facilitate positive group interactions by medical students recognizing
their strengths and weaknesses as a group; and 3) it assists medical students in becoming
self-aware, which is necessary for the reflective practice to occur—the most important
reason to include it as a variable in this study.
Subsequently, Keirsey (1998) divided the Myers-Briggs sixteen types into four
groups: (1) the SP Artisans, (2) the SJ Guardians, (3) the NF Idealists, and (4) the NT
Rationals. He states that there are two sides to one’s personality, one is temperament
defined as one’s inclinations (innate or inherent) and the other is character defined as a
disposition (exactly configured or definitively systemic) or temperament disposition. The

33
importance of these four types in cognition is that some people are oriented by intuition
and others are oriented by sensory perception which ultimately determines “our thoughts
and the words that reflect them keep us oriented to reality by telling us who we and our
companions are, and what we and they are to do” (Keirsey, 1998, p. 27). These
temperament types can be used as a variable in predicting reflection ability.
The review of the literature reveals that critical reflection is an essential
skill for practitioners and their professional growth and that it can be taught and learned.
It also reveals that standards, policies, and regulations for professionalism in the practice
of medicine are being scrutinized more than ever therefore, the emphasis of
professionalism in medical education is critical to the future of physicians and their
practice. If upon admission to medical school students sign a form in agreement that they
are able to meet the essential characteristics and abilities required for completion of the
M.D. degree, that includes robust behavioral and social attributes, and during the first
month of medical school participate in a “White Coat” ceremony where they are
presented with the traditional short white coat and recite the Hippocratic Oath, which
symbolizes their initiation into the medical profession, one would believe they have truly
chosen to become a medical professional. However, as research has shown, it is not
always the case that individuals are prepared for the responsibilities and that medical
school brings in to their lives. Medical educators, physicians, and future physicians need
to recognize that critical reflection is a required skill in becoming a professional.
Teaching, assessment, remediation, and evaluation of reflection skills in professionalism
and ICM courses should be top priorities for medical schools in 2008 and beyond.

34
As previously noted, context is fundamental in addressing the needs of the
practitioner, whether it is in dentistry, medicine, nursing, physical therapy, psychology,
teacher education, or social work. An institution, its professionals, and the setting must
cultivate a culture of change for reflective teaching and learning practices to exist and
thrive. However, it is the process of institutionalizing reflective practice in medicine that
presents the greatest obstacle in the teaching and learning of these skills.
Research Questions
This study used the information gained from the literature review as foundational
knowledge to understand the mandates on professionalism in medical education, the
importance of professional behaviors throughout medical training, and the process and
development of reflection skills for current and future practice as a physician. In order to
thematically describe professional behaviors, first year medical students were asked to
reflect upon a personal challenge/dilemma in the clinical and/or classroom setting; and
subsequently, the level of integrative complexity in their reflections was assigned. MBTI
preferences and Keirsey temperament types were also compared to the assigned level of
integrative complexity. The three research questions that guided this study are:
1. When first year medical students are asked to reflect upon a personal
challenge/dilemma in the clinical or classroom setting, what type of
professional behaviors do they report?
2. What are the characteristic levels of integrative complexity in first year
medical students’ reflections on a personal challenge/dilemma regarding
professional behaviors?

35
3. To what extent do the four preferences of the MBTI personality type, and
Keirsey temperament type, predict the level of integrative complexity in first
year medical students’ reflections?
Chapter Two describes the methods and analytical strategies that were used to
address the preceding research questions that guided this study.

36
Chapter Two: Method
This chapter describes the methods used in this study. Specifically, it will describe
the study’s participants, raters, measures and procedures.
Participants
A sample of 45 (22 female; 23 male) was drawn from 168 first year medical
students with a mean age of 25.8 (SD = 3.46; range 23 – 37). They described their race or
ethnicity as White/Caucasian (30, 67%); Unspecified (6, 13.3%); Hispanic/Mexican-
American (4, 8.8%); American Indian/Alaskan Native (1, 2.2%); Asian Indian (1, 2.2%);
Asian Korean (1, 2.2%); Black/African American (1, 2.2%); Pacific Islander/Hawaiian
(1, 2.2%).
Raters
Raters were four USC Rossier School of Education doctoral students, three
female, one, Caucasian (dissertation author), one, African-American, and one, Asian-
American; one male Caucasian; and one male Caucasian professor. The raters ranged in
age from 27 – 60. All students were engaged in mixed-methods dissertation research, had
completed two doctoral level inquiry courses, and had participated in mock rating
sessions with the professor which utilized data gathered when piloting the critical
reflection survey.
Measures
This study used four measures: (1) an open-ended survey employing a critical
reflection method, which captured data that was used in the analyses of content for
themes of professional behaviors and level of integrative complexity assignment, (2) the

37
Myers-Briggs Type Indicator (MBTI) personality type and Keirsey Temperament Type
(KTT) as measures of cognitive style, (3)consensus scoring of reflections for level of
integrative complexity, and (4) Pennebaker’s Linguistic Inquiry and Word Count 2007
(LIWC) to measure the use of content and style words. Each measure will be discussed in
turn.
Open-ended survey
The stimulus for this study consisted of 11 questions that were developed as an
iterative process in working with the team of four doctoral students and one professor.
The final version of those questions were, in order, (also see Appendix C):
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA
lab; MDL; lecture hall) setting that has occurred since you started medical school,
in which your own behavior or reactions directly affected the event that resulted
in your feeling confused, upset, or left you wondering.

2. How long ago (in days; months) did this experience occur?

3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the
event.

4. What internal factors (i.e., your personality traits; emotions; values; biases)
influenced your response to the event?

5. What external factors (i.e., setting; other people; time of the event; etc.)
influenced your response to the event?

6. If faced with a similar experience while in medical school, how do you think you
would react differently?

7. What conclusions have you reached based on your subsequent thinking about this
experience?

8. What questions or concerns does the experience raise for you to explore in your
future practice as a physician?

9. Have you ever received formal training in the use of critical reflection?

38
a. Yes
b. No
10. If yes, in what course or program?

11. Is English your primary language?
a. Yes
b. No

Myers-Briggs Type Indicator (MBTI) Form M Questionnaire
The MBTI Form M is a self-scorable 93-item instrument which identifies 16
distinctive personality types which result from preferences scored from interactions in the
four dichotomies implicit in Jung’s theory of psychological types. There have been
hundreds of studies over the past 40 years which have proven the instrument to be both
valid and reliable. The Form M instrument was introduced in 1998, which has many
similarities to the MBTI that was originally developed in 1958. The revisions of the
instrument have ensured that the “…measurement of type keeps up with and takes
advantage of the latest advances in psychometrics and test development” (Briggs Myers,
McCaulley, Quenk, & Hammer, 1998, p. 17). The MBTI Form M is available for
purchase at ( HUhttp://www.cpp.com/detail/detailprod.asp?pc=157UH).
The MBTI personality type (cognitive style) includes four preferences: (1)
Extroversion (E) or Introversion (I), (2) Sensing (S) or Intuition (N), (3) Thinking (T) or
Feeling (F), and (4) Judging (J) or Perceiving (P).
 The E or I is one’s preference for how energy is received (E indicates a focus on
the outer world whereas I indicates a focus on one’s inner world).

39
 The S or N is one’s preference for how information is processed (S indicates a
focus on basic information whereas N indicates a focus on interpreting
information and adding meaning).
 The T or F is one’s preference for how decisions are made (T indicates a focus on
looking at logic and consistency whereas F indicates a focus on looking a people
and special circumstances).
 The J or P is one’s preference for how one chooses to live their life (J indicates a
focus on getting things decided whereas P indicates a focus on staying open to
new information and options) (Briggs Myers, McCaulley, Quenk, & Hammer,
1998).
The MBTI types identified for each medical student were provided by the PPM
Co-Director and entered into a UMicrosoft Word U table by the ICM program assistant.
The KTT was derived from each student’s MBTI and used as another measure of
cognitive style. Keirsey (1998) notes that “people are different from each other, and that
no amount of getting after them is going to change them. Nor is there any reason to
change them, because the differences are probably good” (Keirsey, 1998, p.1). In the late
1950’s he began “typewatching” as a result of Isabel Myers work on personality types.
He partitioned the Myers-Briggs types into four groups, each of them representing a dual
variable temperament disposition, which include: the SPs, the SJs, the NFs, and the NTs.
These temperament types are based on the skilled actions of people, what is observable,
and therefore what can be defined more objectively. Each temperament has two
complementary types and one opposite type in the use of concrete or abstract words, and

40
utilitarian or cooperative tools. The use of words and tools are the two dimensions of
personality upon which Keirsey based his type definitions.
 SP Artisans are concrete utilitarians
 SJ Guardians are concrete cooperators
 NF Idealists are abstract cooperators
 NT Rationals are abstract utilitarians (Keirsey, 1998)
Framework for Evaluating Participant Level of Reflections (Hatton & Smith,
1995)
Evaluations of the level of integrative complexity (One to Four) of student
reflections were made using the “Criteria for the Recognition of Evidence for Different
Types of Reflective Writing” framework, developed in 1995 by Hatton and Smith. The
scores range from level One, where there was evidence of no reflection whatsoever, to
level Four, where critical reflection had indeed occurred. The four categories which were
treated as level of integrative complexity (LIC) scores for the purpose of this study are as
follows:
– Descriptive Writing (Level One)
- Not reflective.
- Description of events that occurred/report of literature.
- No attempt to provide reasons/justification for events.

– Descriptive Reflection (Level Two)
- Reflective, not only a description of events but some attempt to provide
reason justification for events or actions but in a reportive or descriptive
way. For example, “I chose this problem-solving activity because I
believe that students should b active rather than passive learners.”
- Recognition of alternate viewpoints in the research and literature which
are reported. For example, Tyler (1949), because of the assumptions on
which his approach rests suggests that the curriculum process should begin

41
with objectives. Yinger (1979), on the other hand argues that the “task” is
the starting point.
- Two forms:-
(a) Reflection based generally on one perspective/factor as rationale.
(b) Reflection is based on the recognition of multiple factors and
perspectives.

– Dialogic Reflection (Level Three)
- Demonstrates a “stepping back” from the events/actions leading to a
different level of mulling about, discourse with self and exploring the
experience, events, and actions using qualities of judgements and possible
alternatives for explaining and hypothesizing. Such reflection is analytical
or/and integrative of factors and perspectives and may recognize
inconsistencies in attempting to provide rationales and critique, for
example, “While I had planed to use mainly written text materials I
became aware very quickly that a number of students did not respond to
these. Thinking about this now there may have been several reasons for
this. A number of students, while reasonably proficient in English, even
though they had been NESB learners, may still have lacked some
confidence in handling the level of language in the text. Alternatively, a
number of students may have been visual and tactile learners. In any case I
found that I had to employ more concrete activities in my teaching.” Two
forms, as in (a) and (b) above.

– Critical Reflection (Level Four)
- Demonstrates an awareness that actions and events are not only located
in, and explicable by, reference to multiple perspectives but are located in,
and influenced by multiple historical and socio-political contexts. For
example, “What must be recognized, however, is that the issues of student
management experienced with this class can only be understood within the
wider structural locations of power relationships established between
teachers and students in schools as social institution based upon the
principle of control” (Smith, 1992.)

Linguistic Inquiry and Word Count (LIWC)

Pennebaker and Francis first developed the LIWC in 1993 as part of an
exploratory study of language and disclosure. However, the LIWC2007 computer
software program has an expanded dictionary and modern software design that can
analyze individual or multiple language files quickly and efficiently. It is able to calculate

42
the degree to which people use different categories of words across a wide array of texts
(Pennebaker, Chung, Ireland, & Booth, 2007). The LIWC2007 was used in post hoc
analyses of the student reflections.
Procedures
An open-ended survey (reflection on a personal challenge/dilemma), was
administered electronically, during the 2007–2008 academic year, to all first year medical
students (N=168) in the Professionalism in the Practice of Medicine (PPM) required
course at the University of Southern California, Keck School of Medicine (USC-KSOM).
From there, a purposeful random sample (n =48) was selected to represent three each of
the 16 MBTI types, determined from data described below. However, only 45 of the 48
students had completed their reflections and so were used in this study. These students all
had completed the first semester of PPM as well as Introduction to Clinical Medicine
(ICM) where a reflection task is appropriate and practical. The 45 medical students, and
their associated MBTI personality types, were coded by number for anonymity by the
PPM Course Co-Director and tracked in a UMicrosoft Excel U spreadsheet.
The MBTI Form M was administered to the entire first year class of medical
students as part of the PPM course at the USC-KSOM during September of the 2007–
2008 academic year (N=168) therefore existing data was utilized. Each student’s Myers-
Briggs four preference personality type, as a measure of cognitive style, served as the
independent variable (IV) in a one-way analysis of variance with the LIC serving as the
dependent variable (DV) in medical student reflections of professional behaviors. In

43
addition, each student’s Keirsey dual variable temperament type also served as an IV in a
one-way analysis of variance with LIC (DV).
Data Analyses
Descriptive Theme Development. After the Critical Reflection on Professionalism
Behaviors survey was closed, the ICM program assistant downloaded the responses from
the myMedWeb system and generated a UMicrosoft Word U file. The word file was
photocopied for two of the four doctoral student raters to review for theme development.
The two raters independently read each event and generated a list of themes they found
present. Theme generation was limited to one theme per event. In order to reduce bias,
the two raters met to review their independent theme lists and those themes that were
common were placed on a master list. The two raters agreed upon the master list
containing four over-arching themes which emerged from a total of 45 individual events.
These themes answered research question number one.
Descriptive Evaluation of Participants Level of Reflection. To answer research
question number two, four doctoral students and one professor employed the Hatton and
Smith (1995) coding schema in reviewing the medical student reflections to determine
the level of integrative complexity in two group meeting sessions. Each rater
independently read an individual event and assigned a level of integrative complexity
score (One to Four). Subsequently, a discussion occurred amongst the raters to agree
upon a final level of integrative complexity score for each reflection (through consensus)
in succession.

44
Descriptive Statistics. All data were entered into SPSS statistical programming
version 15.0 for UMicrosoft Windows U. One-way analysis of variance was performed
between all variables in order to investigate the relationship between MBTI preferences
and KTT, as a measures of cognitive style (IV) and medical student reflections LIC
scores (DV). ANOVA results answered research question number three.
In post hoc analyses, the medical students’ written reflections were entered, one at
a time, into the LIWC2007 computer program to measure word count and percentage of
words captured by the LIWC dictionary. These measures were also compared to the LIC
score and KTT.

45
Chapter Three: Results

This chapter presents the study’s results. Each section begins with the research
question that was used to guide the study, and then presents the obtained results. The
chapter concludes with post hoc analyses results of the data.
Research Question One
When first year medical students are asked to reflect upon a personal
challenge/dilemma in the clinical or classroom setting, what type of professional
behaviors do they report?
The raters identified four themes in the 45 personal challenge/dilemma
reflections. Table 1 reports the number of reflections assigned to each.
Table 1
Number of Reflections Based on Themes

Personal
Interaction
Encounter
with Patient
Interaction
with Peer
Interaction with
Educator
Number of
Reflections

15

14

12

3

The first theme, personal interaction within the medical school clinical or
classroom setting had the greatest number of events (n = 15). The other events were
reported to have occurred as follows: 14 events concerned an encounter with a real or
standardized patient; 12 events concerned an interaction with a peer; and three events
concerned an interaction with an educator. There was also one student who stated in the
reflection that “there has been no such incidents” and answered “n/a” for all of the
remaining questions.

46
Theme Event Examples
The following examples each represent one of the four themes that emerged from
the medical student reflections.
Personal interaction within the medical school classroom or clinical setting.
During the beginning of the school year we received orientation about all the
aspects of the medical school that were basic to our knowledge of how things
worked here at Keck-USC. We were given a lecture by a studies skills professor,
which made me feel as if I could handle the material in medical, yet I still felt
uncertain about my abilities. Toward the end of orientation week, we were asked
if we knew what Keck-USC Medical School expected of us by a show of hands, I
didn’t raise my hand. Even though I didn’t raise my hand and I had mixed,
confused feelings about how to handle the curriculum, I didn’t seek help and as a
result I failed Core I. [I thought] I should be strong and figure things out myself
because only the weak sought help… [In the future] I will remember that it takes
strength and wisdom to be able to seek help when it is needed.

Encounter with a Patient (Real or Standardized). During my ICM rotations
through LAC-USC last semester, I came across a patient who was suffering from
chronic alcoholism, depression and suicidal thoughts…I asked him for permission
to take his history and he mumbled that it was fine. Suddenly, when I began
asking him certain questions he glared at me and began to become hostile.
Eventually, after overcoming my initial shock at the situation, I felt more
comfortable and was able to empathize with him. I understood where his feelings
of frustration came from: disappointing his family and himself, being ordered
around by doctors and social workers and most importantly, not being able to let
go of the grasp alcohol held on his life…As almost having been transformed, he
began telling me all of his fears and frustrations. At the end of the interview I
gave him some encouraging words and thanked him for his time, and he looked at
me square in the eyes and said, thank you for listening and having that talk with
me…I think next time I experience this, I will have a better understanding of the
situation and not be as surprised. I readily understand now why many patients,
especially those that are easy to stereotype, are frustrated with their medical
care…In this instance specifically, the patient confided in me that he was sick of
being told what to do and how to do it. He asserted that it was his life, and it was
time for him to take control of it. Later in thought I wondered how much more
effective his treatment would have been if his health care team included him in a
team plan rather than having ordered him repeatedly what he had to do.

Interaction with a Peer. GA [gross anatomy] lab was difficult in the beginning.
Our group didn’t share responsibilities well. Everyone wanted to dissect. Nobody
wanted to read the lab guide because then it became hard to get a turn with a

47
scalpel. Some people came to lab unprepared. I made it a goal for myself to try
and facilitate a better dynamic by the time we dissected the heart. I came up with
a rotation of jobs and emailed the group. I was nervous about it, because I had
been stomaching a lot of frustration and I didn’t want to appear critical in an
unconstructive way. However, the group was receptive to my ideas. Our heart
dissection was a highlight of my year. We all took turns teaching each other
different section of the dissection and everyone had their turn to dissect. It was
also very productive and I did not have to study the heart much after our
dissection. Overcoming our group problems in GA lab brought our group closer,
and helped us learn how to be more productive together…I am drawn to
teamwork environments which is one reason that I think a lot about emergency
medicine. But teamwork can be as challenging as it is rewarding. This experience
makes me realize that the group dynamics can be just as challenging as other
aspects of patient care.

Interaction with an Educator. During a patient interview at which our ICM
instructor and all 6 of our group members were present, I became very frustrated
with the way that our instructor was treating both the patient and the student
conducting the interview. I felt that our instructor was being rude and
disrespectful to the patient by speaking about him to us as though he wasn’t there.
Additionally, I thought our instructors’ comments were extremely inappropriate,
since he directly suggested that the patient was an alcoholic, when this was not
the case. The student had started to establish a good rapport with the patient up
until to this point, but after this outburst from our instructor, the patient was
clearly uncomfortable with continuing the interview, and it took some time for the
student to regain his trust…I was frustrated and felt compelled to do something
about what I thought was completely inappropriate behavior. [However,] I knew
it was inappropriate to intervene at the moment that the instructor was making his
comments, since it was in the hospital, in front of a patient…[In the future] I need
to control my frustrations better, and that it will be beneficial to develop the
courage to deal with problems head on. [In addition] I question my ability to
criticize authority figures when criticism is deserved.

Research Question Two
What are the characteristic levels of integrative complexity in first year medical
students’ reflections on a personal challenge/dilemma regarding professional behaviors?
The medical student reflections were coded as follows: 13 at level One, 15 at
level Two, 14 at level Three, and three at level Four (see Table 2.) Appendix E presents

48
all of the reflections, ordered by LIC score One to Four, with the first reflection in each
category representing the best example.
Table 2
Reflections Ranked by Level of Integrative Complexity

Level One Level Two Level Three Level Four
Number of
Reflections

13 (28.9%)

15 (33.3%)

14 (31.1%)

3 (6.7%)

Research Question Three
To what extent do the four preferences of the MBTI personality type, and Keirsey
temperament type, predict the level of integrative complexity in first year medical
students’ reflections?
All 45 reflections assigned a LIC score had a corresponding MBTI personality
type. Table 3 summarizes these results: for each of the 16 possible MBTI personality
types, the LIC scores are indicated.
Table 3
Reflection LIC Score by MBTI Personality Type

MBTI
Level
One
Level
Two
Level
Three
Level
Four

Total

M
ISTJ 0 1 2 0 3 2.67
ISFJ 1 0 1 1 3 3.67
INFJ 0 2 1 0 3 2.33
INTJ 0 1 1 0 2 2.50
ISTP 2 0 1 0 3 1.67
ISFP 0 0 2 0 2 3.00
INFP 1 2 0 0 3 1.67
INTP 1 1 1 0 3 2.00
Introvert Total 5 7 9 1 22 2.27

49
Table 3, Continued
Reflection LIC Score by MBTI Personality Type

The possible MBTI personality type means ranged between 1.67 and 3.67, as
summarized in the right column of Table 3.
Table 4
ANOVA Results of MBTI Preferences

MBTI Preferences M SD N F p d
Extraversion vs. Introversion .68 .41 .25
Extraversion 2.04.98 23
Introversion 2.27.88 22
Sensing vs. Intuition .21 .65 .14
Sensing 2.091.0222
Intuition 2.22.85 23
Thinking vs. Feeling .03 .86 .05
Thinking 2.13.97 23
Feeling 2.18.91 22
Judging vs. Perceiving .08 .78 .47
Judging 2.38.97 21
Perceiving 1.96 .86 24

Next, the data were aggregated according to the four preferences of the MBTI
personality type and one-way ANOVAs were run for each. The results are summarized in
Table 4. None of the comparisons was statistically significant. As an additional look at
the results, effect sizes (Cohen’s d) were calculated using a free program available at

MBTI
Level
One
Level
Two
Level
Three
Level
Four

Total

M
ESTP 1 1 1 0 3 2.00
ESFP 2 0 1 0 3 1.67
ENFP 0 3 0 0 3 2.00
ENTP 2 0 1 0 3 1.67
ESTJ 2 0 0 0 2 1.00
ESFJ 1 1 1 0 3 2.00
ENFJ 0 2 0 1 3 2.00
ENTJ 0 1 1 1 3 3.00
Extrovert Total 8 8 5 2 23 2.04
Total 13 15 14 3 45 2.16

50
( HUwww.work-learning.com/effect_sizes.htm UH). Small effect sizes were obtained for the first
three preferences, though the fourth preference (Judging vs. Perceiving; .47) yielded a
medium sized effect using Cohen’s (>=.40 and <.75) suggested cutoffs.
Table 5 reports the distribution of the medical student’s reflection LIC score by
the four preferences of the MBTI personality type.
Table 5
Level of Integrative Complexity Score Distribution by MBTI Preferences

Table 6 reports the distribution of the medical student’s reflection LIC score by
the Keirsey temperament type.
Table 6
LIC Score Distribution by Keirsey Temperament Type

Level of Integrative Complexity Score
One Two Three Four
MBTI Preferences N % N % N % N %
Extraversion vs.
Introversion
Extraversion 8 34.78 8 34.78 5 21.74 2 8.70
Introversion 5 22.73 7 31.82 9 40.91 1 4.55
Sensing vs. Intuition
Sensing 9 40.91 3 13.64 9 40.91 1 4.55
Intuition 4 17.39 1252.17 5 21.74 2 8.70
Thinking vs. Feeling
Thinking 8 34.78 5 21.74 9 39.13 1 4.35
Feeling 5 22.73 1045.45 5 22.73 2 9.09
Judging vs. Perceiving
Judging 4 19.05 8 38.10 6 28.57 3 14.29
Perceiving 9 37.50 7 29.167 8 33.33 0 0.00
Level of Integrative Complexity Score
One Two Three Four Total
Keirsey Type N N N N N M SD
SJ 4 2 4 1 11 2.18 1.35
SP 5 1 5 0 11 2.00 1.23
NF 1 9 0 1 11 2.09 .98
NT 3 3 5 1 12 2.33 .85

51
The NF Idealist temperament type is abstract in their communication, i.e. word
usage, and cooperative in implementing their goals, i.e., tool usage, both of which have
an effect on a student’s depth of reflection. This KTT had the greatest number of level
Two LIC scores, representing descriptive reflection, and the greatest number of any one
particular level as depicted in Figure 4.
Figure 4
NF Temperament Type Distribution by LIC Score

NF 9% 82% 0% 9%

Post hoc Analyses
Each medical student reflection was entered into the LIWC2007 computer
program to measure word count, the percent of words captured by the LIWC dictionary,
and to identify the various emotional, cognitive, and structural words used. Table 7
reports the distribution of the LIC score by the word count, showing that the mean
number of words used in the reflection increased with each successively higher LIC
score.

0
20
40
60
80
100
1 2 3 4
LIC Score
Percent

52
Table 7
Distribution of LIC Score by Word Count

These results are depicted visually in Figure 5.

Figure 5
Distribution of LIC Score by Word Count

Table 8 reports the distribution of the LIC score by the percent of words captured
by the LIWC dictionary.
Table 8
Distribution of LIC Score by LIWC Dictionary Captured Words

LIC Score N M SD Mdn
One 13 80.69 14.44 84.10
Two 15 85.34 4.39 86.40
Three 14 87.43 6.44 88.30
Four 3 89.60 0.44 89.40
Total 45 84.93 9.17 86.50
LIC Score N M SD Mdn
One 13 264.38 175.65 176
Two 15 414.87 144.10 425
Three 14 559.00 172.20 475
Four 3 698.00 161.09 789
Total 45 435.11 208.11 438
0
100
200
300
400
500
600
700
800
1 2 3 4
LIC Score
Word Count

53
A medical student’s prior formal training in the use of critical reflection and
having English as their first language were included in the personal challenge/dilemma
survey. They were not used in these analyses, but will be discussed in the next chapter.

54
Chapter Four: Discussion
This chapter is organized into three sections. The first presents the conclusions to
be drawn from the study and discussed the relationship between them and the existing
literature. Second, the limitations and delimitations will be presented. Lastly,
recommendations for future research and implications for medical education practitioners
(faculty and administrators) will be offered.
Conclusions
This study provided valuable insight on the type and quality of professional
behaviors reflected upon by first year medical students during a professionalism course.
Four conclusions were reached:
Conclusion One
Four distinct themes were identified in the medical students’ reflections
concerning a personal challenge/dilemma they had experienced in the first year of
medical school. These themes were: (1) a personal interaction within the medical school
clinical or classroom setting which had the greatest number of events (n = 15), (2) an
encounter with a real or standardized patient, (n = 14), (3) an interaction with a peer (n =
12), and (4) an interaction with an educator (n = 3). It is interesting that three of the
themes were nearly evenly distributed which leads me to believe that all of them are of
equal perceived salience to these students. There was also one student who stated in their
reflection “there has been no such incidents” and answered “n/a” for all of the remaining
questions therefore was not assigned to a theme.

55
Students who reflected upon a personal interaction theme were most often
distressed due to their own or peers inadequacies/abilities, procrastination in studying,
indecision, discouragement with their current intended choice of medical specialty,
immaturity in dealing with their peers, dislike of medical school course material, and
religious or cultural differences from their peers, faculty, or patients.
The encounter with a patient theme, in which all but one student reflected upon
real patients even though they did have the option of reflecting about a standardized
patient (SP) encounter. Often students report how contrived the encounter with SPs are in
ICM and I was pleasantly surprised that only one of them chose to do so in this reflection
and they were critical of their own behavior/performance. All of these reflections were at
least descriptive reflection, but most were dialogic reflection with two of them
representing critical reflection. Most were frustrated, shocked, in disbelief, or angry at
either positive or negative patient behavior, or in regard to the healthcare the patient’s
were receiving at LAC+USC Medical Center. A couple of students were critical of their
own behavior in the patient encounter.
The interaction with a peer theme was assigned to reflections wherein students
were upset by peers exhibiting inappropriate or disrespectful behavior amongst peers or
faculty in ICM, PPM and/or gross anatomy; or they were left wondering why their peers
had particular attitudes towards the topic of PPM sessions.
While only three students reflected upon an interaction with an educator,
unfortunately all concerned negative educator’s (ICM Instructor’s) behavior, which is
very disconcerting and an unexpected finding of this study. One student described being

56
“…annoyed by my ICM [instructor] constantly interrupting… during my patient
interview…comments not constructive… …in front of my peers.” The student resolved
the reflection in stating “…sometimes I dread having to take crap from superiors for the
next ten years…[However] I can learn the differences from my experiences and be sure
not to reciprocate or do the same when I am the opposite position.” This reflection
revealed what motivates medical students to choose one action over another when dealing
with patients and their health care colleagues now and in the future, i.e., using the skill of
reflection-on-action.
Another student, who had the same ICM instructor, reflected that “during another
student’s patient interview…with the other five students observing…I was frustrated
with…our [ICM] instructor [who] was being rude and disrespectful to the patient by
speaking about him to us as though he wasn’t there.” After the event the student
“…declined to partake in the conversation…when discussing the case …and felt it was
immature to have just acted displeased…[rather than] do something about the
inappropriate behavior.” In resolving the event the student concluded with “I question my
ability to criticize authority figures when criticism is deserved.” While this is descriptive
reflection I believe that the student was unable to dialogue or critically reflect about the
entire event due to the nature of the ICM instructor’s actions. This actually thwarted the
student’s ability to take any action or reflect beyond criticizing himself rather than
recognizing all of the factors. An event such as this could be defined as a critical incident,
one which gives meaning, unfortunately negative, to a student as they learn medicine
(Branch, 2005).

57
The reflections in this theme describe what medical educators refer to as the
“hidden curriculum” which will also be discussed in a subsequent section of this chapter.
These behaviors are not taught explicitly but none the less are gained via tacit learning
(Coulehan, 2005) through the actions of a student’s role-model, e.g., ICM instructor,
which can be very destructive. There is no doubt that faculty are being scrutinized by
medical students and other healthcare colleagues, however in the hierarchy that exists in
the medical training culture deference is given to those in authority, even if they are poor
teachers (Haidet & Smith, 2005).
Conclusion Two
Qualitative research offers educators a unique perspective regarding medical
students’ process of reflection and subsequently the level of integrative complexity (LIC)
in the reflection. Only three (6.7%) reflections were at the highest LIC (level Four) –
(Critical Reflection), a level that demonstrated awareness of the event that occurred and
referenced to multiple historical and socio-political contexts. Given the competitiveness
of entry into medical school, with the best and the brightest students being selected for
admission, these students clearly are intellectually capable of high quality reflection, but
this was not the case in this study. However, these skills need to be taught and practiced
before they can be incorporated into routine behavior and subsequently assessed.
The remaining medical student reflections LIC scores were more evenly
distributed at levels Three (Dialogic Reflection), which demonstrated a “stepping back”
from the event and actions leading to a different level of exploring the event using
qualities of judgments and alternative explaining, (n = 14; 31.1%); Two (Descriptive

58
Reflection), reflective, not only in description but some attempts were provided to reason
the justification for the events (n = 15; 33.3%); and One (Descriptive Writing), not
reflective and had little reasons or justifications for the event, (n = 13; 28.9%).
Only three medical students reported having had previous formal training in
critical reflection and interestingly their LIC scores were Four, Four, and Two. Therefore
it possible to conclude that the majority of first year medical students’ might not have the
skills necessary to complete a reflection in the first place or have the motivation to
reflect, both of which are necessary in the practice of medicine therefore these skills must
be learned in medical school. A medical student’s motivation to just complete the
assignment by writing about the behavior of others rather than to engage in the hard work
of critical reflection may have also occurred. In addition, students may find it personally
uncomfortable to disclose information about themselves and others or in revealing more
than can be dealt with by either the student or faculty in the context of a professionalism
course (Boud & Walker, 1998).
The confound between the reflection length and an assigned level Three or Four
LIC score showed that these reflections explained the experience in depth and greater
detail, with the exception of those reflections that were not about themselves but rather
about other people’s involvement in the experience. Conversely, the reflection length and
an assigned level One or Two LIC score showed little reflection whatsoever about the
experience or the medical student’s involvement in it.
In addition, there was a distinct distribution of the four themes found in the
reflections by LIC score which are summarized in Table 9.

59
Table 9
Distribution of Themes by LIC Score

Theme Level One Level Two Level Three Level Four
Personal
Interaction

6

6

3

0
Encounter with
Patient

0

4

8

2
Interaction with
Peer

5

4

3

0
Interaction with
Educator

1

1

0

1

Those medical students who limited their reflection to a personal interaction
and/or an interaction with a peer in the clinical or classroom setting generally received a
LIC score of One, in which they only reported the event that occurred with no attempt to
provide a reasons for their involvement with the events, or Two, where the event that
occurred was describe with some attempt to provide reasons for their actions. Conversely,
medical students who reflected upon an encounter with a patient received a LIC score of
Three, in which they described their feelings during the patient encounter, what the
patient revealed to them, and their understanding of the patient’s illness or situation, or
Four, in which they included the components of a level Three, but went a step beyond by
attempting to explain or understand the impact on healthcare, the patient’s future or
society as a whole (Hatton & Smith, 1995).
Conclusion Three
This is the first study in which first year medical students MBTI preferences and
Keirsey temperament type (KTT) as measures of cognitive style, were examined as
predictors of the LIC in their reflections. The results of this study show that MBTI
preferences as a whole cannot be used to predict first year medical students’ reflection

60
LIC scores with any significance. It is also important to note that medical students’ MBTI
preferences, as a measure of cognitive style, may also change as a natural part of
maturation and/or medical training.
The medical students KTTs were nearly evenly distributed amongst the 45
students with 11 SJs, 11 SPs, 11 NFs, and 12 NTs, which represent approximately 27%
of the 168 medical students in the class of 2011. If we were to use this sample as a
predictor for the entire class there would be an even distribution which could provide
valuable information about medical students’ ability to reflect. Clearly these types are not
predicting either their interest in medical school or the admission decisions being made.
Moreover, these scores seem not to predict level of reflection quality.
There was however an interesting relationship between the KTTs and the LIC
scores, particularly with the NF Idealists who are defined by Keirsey (1998) as abstract
cooperators, abstract in their communication, i.e. word usage, and cooperative in
implementing their goals, i.e., tool usage, both of which have an effect on a student’s
depth of reflection. There was a rather uneven distribution of LIC scores amongst the
medical students with an NF KTT (M = 2.09; SD = .98). Eleven of the 45 students in this
study are NF KTT and 82% of them received a LIC score of Two, 9% received a Four,
9% received a One, and none of them received a Three. Therefore, it is possible to predict
that medical students with an NF KTT would receive a LIC score of Two, where they are
capable of “descriptive reflection” i.e., a description of events with some attempt to
provide reasons for their actions. However, the caveat of a having had a small sample

61
(n = 45) is that the results are only suggestive at this point. It is also important to note that
the KTT, as a measure of cognitive style, may also change as a natural part of maturation
and/or medical training.
It is interesting to note that the one student who stated in their reflection “there
has been no such incidents” and answered “n/a” for all of the remaining questions is an
ESTJ, and an SJ Guardian. This finding seems out of character for an ESTJ personality
type and especially, the SJ Guardian temperament type. It is possible that the
extroversion preference dominates the overall behavior of the student which would not
allow for focus on their inner world of ideas and experiences. A typical SJ Guardian, also
termed a Concrete Cooperator by Keirsey (1998), uses concrete words which could be
thought of as less reflective. The student did comply with completing the required
reflection however SJs do not usually ignore the rules to get the job done or speed things
up (Keirsey, 1998).
Conclusion Four
In post hoc analyses, the LIWC2007 computer software program was used to
examine the medical students’ use of content and style words in their reflections and
subsequently, a comparison to their LIC score and KTT. In general, the LIWC analyses
showed that a higher word count is associated with a higher LIC score which validates
the confound between the reflection length and an assigned level Three or Four LIC score
which showed that these reflections explained the experience in depth and greater detail,
with the exception of those reflections that were not about themselves but rather about
other people’s involvement in the experience. The three level Four medical student

62
reflections had a word count, percent of words captured by the LIWC dictionary, and
assigned theme, respectively, of 789 (90%), interaction with a patient (real); 512 (89%),
interaction with an educator; and 793 (89%), interaction with a patient (real).
The LIWC also showed that a lower word count is associated with a lower LIC
score which conversely, validates the confound between the reflection length and an
assigned level One or Two LIC score which showed little reflection whatsoever about the
experience or the medical student’s involvement in it (see Table 7).
Lastly, in terms of specific word choice, there was one student who used a swear
word (see Appendix E, reflection #80) in a required written reflection in a
professionalism course. This was a low incidence behavior, but shocking to me as a
medical educator.
Summary of Conclusions
In summary, the most important finding is that medical schools need to actively
teach and assess reflection skills, which can be easily done within the context of a
professionalism or ICM course. Professional behaviors are clearly stated in the
educational objectives of the USC-KSOM and the goals/objectives of their PPM and ICM
courses however it is reasonable to speculate that faculty, instructors, and/or mentors are
not meeting those objectives themselves and may be inhibiting student learning of the
stated professional behaviors.
As stated in the results chapter, a medical student’s prior formal training in the
use of critical reflection and having English as their first language were included in the
personal challenge/dilemma survey, however they were not used in the analyses of this

63
study. Only three medical students reported having prior formal training in the use of
critical reflection and interestingly their MBTI preferences/Keirsey temperament types
were: ENTJ/NT Idealist (“several class activities and retreats I have been involved with
for leadership training”), ENFP/NF Rational (“high school peer support counseling
program; college minority peer counseling program”), ENFJ/NF Rational (“…asked to
critically assess master’s program writing and defend his statement orally”); and their
LIC scores were, respectively: Four, Four, and Two. Therefore, it is reasonable to
speculate that the prior training had some effect on these students ability to complete the
personal challenge/dilemma reflection, noting that two of these three reflections received
a LIC score of Four, especially given that only three of 45 medical students in the study
received a LIC score of Four. The third student reported only having been “asked to
critically assess” therefore it is highly possible that no training was received which
validates the reflection LIC score of Two.
Only five medical students reported that English was not their first language and
their MBTI preferences/Keirsey temperament types, and reflection themes were: ISTJ/SJ,
interaction with a peer (articulate and well-written), ENFJ/NF, interaction with peer
(articulate and well-written), ENTJ/NT, personal dilemma—religious issues (some
difficulties with English grammar and tense), ENTP/NT, interaction with a peer (some
difficulties with English grammar), ENFP/NF, personal dilemma—minority issues
(articulate and well-written); and their LIC scores were, respectively: Two, Two, Two,
One, and Two. For some of these students it is possible that a deficiency in their English
language skills had an effect on their ability to actually “write and/or compose” the

64
reflection. However, it is more likely that the theme of their reflection rendered the lower
LIC score. As stated previously, those students who limited their reflection to a personal
interaction and/or an interaction with a peer in the clinical or classroom setting only
received a LIC score of One or Two, which is represents descriptive writing or
descriptive reflection, not dialogic or critical reflection.
Limitations
There are a few methodological limitations that must be considered when
discussing the findings in this study. First, the participants in this study were limited to
first year medical students at USC-KSOM; therefore selection bias may have affected the
results in some way. As well, all participants were attending USC-KSOM and so may
have had unique experiences that would affect the type and quality of their reflection.
Second, the range of maturity in this sample of students could be considerable
secondary to gender, age, ethnicity, and life experience or lack thereof, all of which were
not used as variables in this study.
Third, this study used self-reported, retrospective data. Several factors can cause
people to be inefficient and inaccurate processors of information about their past.
Sometimes people forget important aspects or nuances of their past, or they misremember
(Nisbett & Wilson, 1977). Additionally, they may reinvent the past to suit their current
needs and circumstances. People also tend to remember more positive than negative
emotions. Medical students in this study were asked to reflect upon a personal
challenge/dilemma that had occurred since they started medical school (~six months) and
it is possible that memory errors may have occurred.

65
Delimitations
There were few delimitations present in this study. This study was not designed to
measure changes or improvements in cognitive style (MBTI preferences and Keirsey
temperament type). Only the cognitive style variables that could be measured reliably
were used in this study. Although this study was conducted at only one institution the
conclusions may be generalizeable to students at other medical schools.
Recommendations for Future Research
The previous conclusions have led to the following four recommendations for
future research. First, it would be ideal to have the USC-KSOM, class of 2011, which
includes the participants in this study, to further reflect on a personal challenge/dilemma
in the Year II PPM course, Year III and Year IV required clerkships to collect
longitudinal data regarding professional behaviors. This data could also be used for
comparison between first, second, third, and fourth year medical students’ reflection
content of professional behaviors and level of integrative complexity noted in the
reflections.
Second, there are additional research questions in regard to critical reflection in
the area of professionalism. For example, it would be interesting and valuable to
recognize and understand the particular types of professional behavior that medical
students perceive to elicit critical reflection and furthermore cause them to change their
future behavior, i.e., actual reflection-on-action. It would also be of value to evaluate the
themes of professional behavior noted in medical students’ reflections and their
relationship to the core concepts/elements of a PPM course in the first two years of

66
medical school. Medical educators could then determine that the teaching of these core
concepts may actually have a lasting impact on medical students’ professional behaviors
now and as a practicing physician. In addition, comparisons between the themes and any
disciplinary actions taken against students during medical school would be of value.
Lastly, another area for future research is of faculty/medical residents’ reflections
of their own professional behavior, which may be instrumental in changing not only their
own but others, most importantly medical students, current and future behavior through
tacit learning (Coulehan, 2005) and role-modeling (Haidet & Stein, 2005). At USC-
KSOM faculty currently assess students’ professional behavior, and students complete a
professionalism self-assessment in ICM, PPM, and the required Year III clerkships.
Given that in this study, first year medical students, albeit only three of 45, reflected upon
faculty behavior that was upsetting to them, interactions with and professional behavior
of faculty who teach in any of the fours years of medical school should be formally
assessed. In the near future I would expect that medical students’ will request/insist that
faculty/medical resident behavior assessed be given that the teacher-student relationship
is so very critical to medical students learning, especially in the process of role-modeling
and affecting change in the hidden curriculum.
Implications for Medical Education Practitioners
The previous conclusions produced valuable information that can be used by
medical education practitioners to enhance learning and maximize positive outcomes for
medical students.

67
Admission Procedures
Currently, the process of selection for admission relies on students total Medical
College Admission Test (MCAT) score that combines verbal, physical science, biological
science; undergraduate GPA; graduate GPA (if applicable); a written personal statement;
and an interview with admission committee member. An MCAT writing sample score is
also provided for each student but it is not presently utilized. The actual MCAT writing
samples could be examined and assigned a LIC score using the Hatton and Smith (1995)
framework for reflective writing used in this study, and/or the writing sample scores
could be scaled and used as data for a student’s ability to reflect, either of these variables
could then be utilized in the final determination of the applicant’s admission to medical
school. In addition, the admissions committee could examine each applicant’s written
personal statement for a LIC score, which would provide insight into the essential skill of
reflection in medical training and future practice as a physician. With that said, the
process would be labor intensive but could initially be completed on a small sample for
the purpose of evaluating the efficacy of the process.
Faculty Development Programs
First, I must address the previously noted reflection excerpts assigned the theme
of interaction with an educator which makes me painfully aware of some students’
perception of inappropriate behavior exhibited by their ICM instructors. When clinical
educators in the first two years discuss the hidden curriculum they usually discuss the
inappropriate behaviors or poor role-modeling of the “house officers,” i.e., medical
residents, and/or “attendings,” i.e., physicians who oversee medical residents and

68
students, which can have a negative impact upon third and fourth year students learning
and the process of professionalization (Lempp & Seale, 2004). It is now clear to me that
in ICM our instructors are capable of contributing to the hidden curriculum in clinical or
classroom teaching settings in the first two years of medical school. However, in order to
avoid the dehumanization and disillusionment of the ideals and practices that are taught
in ICM and PPM courses in the first two years of medical school, the hidden curriculum
must be addressed in Years III/IV (clinical years), as well as in ICM given the result in
this study (Hickson, Pichert, Webb, & Gabbe, 2007).
Reflective Practice Teaching and Assessment
A longitudinal perspective of student professionalism behaviors using critical
reflection as the assessment of those behaviors is necessary as it will make faculty and
administration aware of the need for remediation in the first two years of medical school.
In addition, for continuous learning to take place reflection should be continued in all of
the required clerkships in Years III/IV but within the appropriate context, which
according to Boud & Walker (1998) “…is perhaps the single most important influence on
reflection and learning. It can permit or inhibit working with learners’ experience”
(p. 196). While some of the clerkships do have students participate in some reflective
activities, e.g., narrative medicine writing in Family Medicine, there are many more
opportunities for longitudinal teaching and learning in the clinical years, especially in the
domain of professionalism (Schaff, 2006). This study’s results make us aware that first
year medical students are unable to perform “critical reflection” in a professionalism
course. It may be that they dislike writing reflections in the PPM and in any course for

69
that matter. The Hatton and Smith (1995) framework could prove useful in assessing all
self-reflection assignments given to medical students. However, it is important that a
teaching component of reflective writing be incorporated into several medical school
courses in order for students to incorporate such skills into their daily practice.

70
Bibliography

Abbott, A. V., Schechter, J., & Elliott, D. E. (2000). University of southern california
keck school of medicine. Academic Medicine, 75(9), S32-S34.

Accreditation Council for Graduate Medical Education (2003). Institutional
requirements. Retrieved May 25, 2006, from
HUhttp://www.acgme.org/acwebsite/irc/irc_IRCpr703.pdf U

American Board of Internal Medicine (2001). Project professionalism. Retrieved June
19, 2006, from HUhttp://www.abim.org/pdf/publications/professionalism.pdf U

American Medical Association (n.d.). H-295.955 Teacher-Learner relationship in
medical education. Retrieved June 19, 2006, from HUhttp://www.ama-
assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-
295.955.HTM U

American Medical Association (1998). Patient confidentiality. Retrieved May 25, 2006,
from HUhttp://www.ama-assn.org/ama/pub/category/print/4610.html U

American Medical Association (2001). Principles of medical ethics. Retrieved May 25,
2006, from HUhttp://www.ama-assn.org/ama/pub/category/print/2512.html U
Argyris, C. & Schön, D. (1974). Theory in practice: Increasing professional
effectiveness. New York: Addison-Wesley.
Arnold, L. (2002). Assessing professional behavior: yesterday, today, and tomorrow.
Academic Medicine, 77(6), 502–515.
Atherton, J. S. (2005). Learning and teaching: Critical reflection. Retrieved, January 18,
2008, HUhttp://www.learningandteaching.info/learning/critical1.htm U
Atkins, S. & Murphy, K. (1993). Reflection: a review of the literature. Journal of
Advanced Nursing, 18(8), 1188-1192.
Atkins, S. & Murphy, K. (1994). Reflective practice. Nursing Standard, 8(39), 49-56.
Baxter Magolda, M. B. (2001). Making their own way: Narratives for transforming
higher education to promote self-authorship. Sterling: Stylus.
Branch, W.T., Jr. (2005). Use of critical incident reports in medical education: a
perspective. Journal of General Internal Medicine, 20(11), 1063-67.

71
Boud, D. & Walker, D. (1998). Promoting reflection in professional courses: The
challenge of context. Studies in Higher Education, 23(2), 191-206.
Boud, D., Keogh, R., & Walker, D. (1985). Promoting reflection in learning: A model. In
D. Boud, R. Keogh, & D. Walker (Eds.). Reflection: Turning experience into
learning (pp. 18-40). London: Kogan Page.
Boyd, E. & Fales, A. (1983). Reflecting learning: key to learning from experience.
Journal of Humanistic Psychology, 23, 99-117.
Brookfield, S. (1990). The skillful teacher. San Francisco: Jossey-Bass.
Brookfield, S. (1995). Adult learning: An overview. In A. Tuinjman (Ed.), International
Encyclopedia of Education. Oxford: Pergamon Press. Retrieved August 20, 2008
from HUhttp://www.ettc.net/tech/adultlearning/Adult%20Learning.pdf U
Cacioppo, J. T., Petty, R. E., & Kao, C. F. (1984). The efficient assessment of need for
cognition. Journal of Personality Assessment, 48(3), 306-307.
Charon, R. (2001a). Narrative medicine: A model for empathy, reflection, profession, and
trust. Journal of the American Medical Association, 286(15), 1897-1902.
Charon, R. (2001b). Narrative medicine: Form, function, and ethics. Annals of Internal
Medicine, 134(1), 83-87.
Chui, L. F. (2006). Critical reflection: More than nuts and bolts. Action Research, 4(2),
183-203. Retrieved January 31, 2007 from
HUhttp://arj.sagepub.com/cgi/content/abstract/4/2/183 U
Cohen, J. J. (2006). Foreword. In D. Stern, (Ed.), Measuring medical professionalism
(pp. v-viii). New York: Oxford University Press, Inc.
Coulehan, J. (2005). Today’s professionalism: Engaging the mind but not the heart.
Academic Medicine, 80(10), 892-898.
Coutinho, S. A. (2006). The relationship between the need for cognition, metacognition,
and intellectual task performance. Educational Research and Reviews, 1(5), 162-
164.
Cruess, R., Cruess, S. & Johnston, S. E. (1999). Renewing professionalism: An
opportunity for medicine. Academic Medicine, 74(8), 878-884.

Dewey, J. (1933). How we think: A restatement of the relation of reflective thinking to
thinking to the educative process. Boston: D. C. Heath and Company.

72
Driscoll, J. & Teh, B. (2001). The potential of reflective practice to develop individual
orthopaedic nurse practitioners and their practice. Journal of Orthopaedic
Nursing, 5(2), 95-103.
Epstein, R. (1999). Mindful practice. Journal of American Medical Association, 282(9),
833-839.
Epstein, R. (2002). Defining and assessing professional competence. Journal of American
Medical Association, 287(2), 226-235.
Ferry, N. M. (1995, November). The use of reflection-in-action by adult educators: An
inquiry into Schön's epistemology of practice. Paper presented at the meeting of
the Annual Meeting of the American Association for Adult and Continuing
Education, Kansas City, MO.
Flanagan, J. C. (1954). The critical incident technique. Psychological Bulletin, 51, 327-
358.
Freire, P. (1993). Pedagogy of the oppressed. New York: The Continuum International
Publishing Group Inc.
Fryer-Edwards, K., Pinsky, L. E., & Robins, L. (2006). The use of portfolios to assess
professionalism. In D. Stern, (Ed.), Measuring medical professionalism (pp. 213-
233). New York: Oxford University Press, Inc.
Haidet, P. & Stein, H. F. (2005). The role of the student-teacher relationship in the
formation of physicians: The hidden curriculum as process. Journal of General
Internal Medicine, 21, S16-S20.

Hatton, N. & Smith, D. (1995). Reflection in teacher education: Towards definition and
implementation. Teaching and Teacher Education, 11, 33-49.

Hemmer, P. A., Hawkins, R., Jackson, J. L., & Pangaro, L. N. (2000). Assessing how
well three evaluation methods detect deficiencies in medical students'
professionalism in two settings of an internal medicine clerkship. Academic
Medicine, 75(2), 167–173.

Hickson, G. B., Pichert, J. W., Webb, L. E., & Gabbe, S. G. (2007). A complementary
approach to promoting professionalism: Identifying, measuring, and addressing
unprofessional behaviors. Academic Medicine, 82(11), 1040-1048.

Hilton, S. & Southgate, L. (2007). Professionalism in medical education. Teaching and
Teacher Education, 23, 265-279.

73
Inui, T. S. (2003). A flag in the wind: Educating for professionalism in medicine.
Association of American Medical Colleges.
Kaplan, D. S., Rupley, W. H., Sparks, J., & Holcomb, A. (2007). Comparing traditional
journal writing with journal writing shared over e-mail list serves as tools for
facilitating reflective thinking: A study of preservice teachers. Journal of Literacy
Research, 39(3), 357-387.
Kegan, R. (1982). The evolving self: Problem and process in human development.
Cambridge: Harvard University Press.
Keirsey, D. (1998). Please understand me II: Temperament, character, intelligence. Del
Mar: Prometheus Nemesis Book Company.
Killion, J. P. & Todnem, G. R. (1991). A process for personal theory building.
Educational Leadership, 48(6), 14-16.
King, P. M., & Baxter Magolda, M. B. (1996). A developmental perspective on learning.
Journal of College Student Development, 37(2), 163-173.

King, P. M. & Kitchener, K. S. (1994). Developing reflective judgment: Understanding
and promoting intellectual growth and critical thinking in adolescents and adults.
San Francisco: Jossey-Bass.
King, P. M. & Kitchener, K. S. (2004). Reflective judgement: theory and research on the
development of epistemic assumptions through adulthood. In M.E. Wilson & L.
Wolf-Wendel, (Eds.), ASHE reader on college student development theory (pp. 5-
22). Boston, MA: Pearson Custom Publishing.
Kirk, L. M. & Blank, L. L. (2005). Professional behavior – A learner’s permit for
licensure. The New England Journal of Medicine, 353(25), 2709-2711.

Kolb, D. A. (1984). Experiential Learning: Experience as the Source of Learning &
Development. Upper Saddle River: Prentice-Hall.
Kuhn, D. (1999). A developmental model of critical thinking. Educational Researcher,
28, 16-25, 46.
Kuhn, D. (2000). Metacognitive development. Current Directions in Psychological
Science, 9, 178-181.
Kuiper, R. A. (2005). Self-regulated learning during a clinical preceptorship: The
reflections of senior baccalaureate nursing students. Nursing Education
Perspectives, 26(6), 351-356.

74
Kuiper, R. A. & Pesut, D. J. (2004). Promoting cognitive and metacognitive reflective
reasoning skills in nursing practice: self-regulated learning theory. Journal of
Advanced Nursing, 45, 381-391.
Kuit, J. A., Reay, G., & Freeman, R. (2001). Experiences of reflective teaching. Active
Learning in Higher Education, 2, 128-142.
Lempp, H. & Seale, C. (2004). The hidden curriculum in undergraduate medical
education: Qualitative study of medical students’ perceptions of teaching. British
Medical Journal, 329, 770-773.

Liaison Committee on Medical Education (2005a). Frequently asked questions. Retrieved
May 25, 2006, from HUhttp://www.lcme.org U

Liaison Committee on Medical Education (2005b). Functions and structure of a medical
school: Standards for accreditation of medical education programs leading to the
M.D. degree. Retrieved May 23, 2006, from HUhttp://www.lcme.org U

Merriam-Webster (1995). Merriam Webster’s Desk Dictionary. Springfield: Merriam-
Webster, Incorporated.

Mezirow, J. (1981). A critical theory of adult learning and education. Adult Education
Quarterly, 32(1), 3-24.

Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco:
Jossey-Bass.
Mezirow, J. (1998). On critical reflection. Adult Education Quarterly, 48(3), 185-198.
Myers, I. B. (1998). Introduction to type. Mountain View: CPP, Inc.
Myers, I. B., McCaulley, M. H., Quenko, N. L., & Hammer, A. L. (1998). MBTI manual:
A guide to the development and use of myers briggs type indicator (3rd ed.). Palo
Alto: Consulting Psychologists Press, Inc.
Neufeldt, S. A., Karno, M. P., & Nelson, M. L. (1996). A qualitative study of experts'
conceptualisation of supervisee reflectivity. Journal of Counseling Psychology,
43, 3-9.
Nisbett, R. E., & Wilson, T. D. (1977). Telling more than we know: Verbal reports
on mental processes. Psychological Review, 84, 231-259.

75
Papadakis, M. A., Loeser, H., & Healy, K. (2001). Early detection and evaluation of
professionalism deficiencies in medical students: One school’s approach.
Academic Medicine, 76(11), 1100-1106.

Papadakis, M. A., Hodgson, C. S., Teherani, A., & Kohatsu, N. D. (2004).
Unprofessional behavior in medical school is associated with subsequent
disciplinary action by a state medical board. Academic Medicine, 79(3), 244-249.

Papadakis, M. A., Teherani, A., Banach, M. A., Knettler, T. R., Rattner, S. L., & Stern,
D., et al. (2005). Disciplinary action by medial boards and prior behavior in
medical school. The New England Journal of Medicine, 353, 2672-2682.
Pee, B., Woodman, T., Fry, H., & Davenport, E. S. (2002). Appraising and assessing
reflection in students' writing on a structured worksheet. Medical Education, 36
(6), 575-585.
Pennebaker, J. W., Chung, C. K., Ireland, M., Gonzales, A., & Booth, R. J. (2007).
Retrieved August 8, 2008, from HU http://liwc.net/liwcdescription.php
Plack, M. M. & Greenberg, L. (2005). The reflective practitioner: Reaching for
excellence in practice. Pediatrics, 116, 1546-1542.
Schaff, P. (2006). Donning the white coat: The narrative threads of professional
development. Journal for Learning through the Arts: A Research Journal on Arts
Integration in Schools and Communities, 2(1), Article 5. Retrieved February 7,
2008, from HUhttp://repositories.cdlib.org/clta/lta/vol2/iss1/art5 U

Schön, D. (1983). The reflective practitioner: How professionals think in action. USA:
Basic Books.

Schön, D. (1987). Educating the reflective practitioner. San Francisco: Jossey-Bass.

Schön, D. A. (1991). The reflective turn: Case studies in and on educational practice,
New York: Teachers Press, Columbia University.

Suedfeld, P. & Bluck, S. (1993). Changes in integrative complexity accompanying
significant life events: Historical evidence. Journal of Personality and Social
Psychology, 64(1), 124-130.

Teherani, A., Hodgson, C. S., Banach, M. & Papadakis, M. A. (2005). Domains of
unprofessional behavior during medical school associated with future disciplinary
action by a state medical board. Academic Medicine, 80(10 suppl), S17-S20.

76
University of Southern California, Keck School of Medicine (2007a). Student handbook:
Section 7: Honor system, code of professional behavior, 80-81. Retrieved
January, 28, 2008, from
HUhttp://www.usc.edu/schools/medicine/student_resource/assets/student_hb_2007.p
df U

University of Southern California, Keck School of Medicine (2007b). Student handbook:
Section 7: Honor system, professional behavior expectations, 87. Retrieved
January, 28, 2008, from
HUhttp://www.usc.edu/schools/medicine/student_resource/assets/student_hb_2007.p
df U

University of Southern California, Keck School of Medicine (2007c). Student handbook:
Section 1: School policies, essential characteristics and abilities required for
completion of the M.D. degree at the Keck School of Medicine, 5. Retrieved
January, 28, 2008, from
HUhttp://www.usc.edu/schools/medicine/student_resource/assets/student_hb_2007.p
df U

University of Southern California, Keck School of Medicine (2007d). Educational
Program objectives keck school of medicine. Retrieved January 28, 2008, from
HU http://curriculum.usc.edu/keck/keck_objectives-epc_approved_7-11-07.pdf

University of Southern California, Keck School of Medicine (2007e). Student handbook:
Section 3: Evaluation process and promotion requirements, 52. Retrieved January
28, 2008, from
HUhttp://www.usc.edu/schools/medicine/student_resource/assets/student_hb_2007.p
df U

University of Southern California, Keck School of Medicine (2007f). Professionalism
and the practice of medicine: Course goals – year I. Retrieved June 28, 2008,
from HU http://medweb.usc.edu/site/ppm1/07_08/yr1_ppm_course_goals.pdf

University of Southern California, Keck School of Medicine (2007g). Professionalism
and the practice of medicine: Course goals – year II. Retrieved January 28, 2008,
from HUhttp://medweb.usc.edu/site/ppm2/07_08/yr2_course_goals_07_08.pdf U

University of Southern California, Keck School of Medicine (2007h). Professionalism
and the practice of medicine: Expectations – year I. Retrieved January 28, 2008
from HUhttp://medweb.usc.edu/site/ppm1/07_08/yr1_ppm_expectations.pdf
Van Manen, M. (1977). Linking ways of knowing to ways of being practical. Curriculum
Inquiry, 6(3).

77
Van Manen, M. (1995). On the epistemology of reflective practice. Teachers and
teaching: Theory and practice, 1(1), 33-50.
Westberg, J. & Jason, H. (2001). Fostering reflection and providing feedback: Helping
others learn from experience. New York: Springer Publishing Company.
Williams, B. (2005). Case based learning a review of the literature: Is there scope for this
educational paradigm in prehospital education? Emergency Medicine Journal, 22,
577-581.

78
Appendix A

CODE OF PROFESSIONAL BEHAVIOR

The students of the Keck School of Medicine of the University of Southern California, in
order that our activities reflect the high standards of moral character demanded by the
medical profession, do subscribe to the following CODE OF PROFESSIONAL
BEHAVIOR:

UHonesty and Integrity U:
• We will conduct ourselves with the highest degree of integrity and honesty in all our
academic endeavors including examinations, papers, procedures, and activities given
by or associated with the Keck School of Medicine or the medical profession.
• We will truthfully conduct our research and report our research findings, and will not
represent others’ work or ideas as our own.
• We will not seek, by action or implication, oral or otherwise, to create an incorrect
impression of our abilities or to create an unfair advantage over our colleagues during
evaluations and other procedures.
• We will not tolerate or support unethical behavior in our colleagues and will report
such behavior when it occurs through established procedures as detailed in the
Student Handbook.

UResponsibility, Reliability, and Accountability U:
• We accept our professional responsibility to respect the time and effort of others
including our patients and will be punctual with required activities and assignments.
• We hold ourselves accountable to policies and procedures of the school and its
associated clinical sites including, but not limited to, evaluations, charting, and
documentation requirements.
• We recognize our own personal limitations and will seek help when needed. We will
not assume responsibilities beyond our capabilities.
• We will represent the Keck School of Medicine appropriately in all relevant settings.

URespect for others (students, colleagues, faculty, staff, patients) U:
• We will treat others with respect and honor their dignity, both in their presence and
with the health care team.
• We will not discriminate nor tolerate discrimination based on race, ethnicity,
language, religion, gender, sexual orientation, age, disability, disease, or
socioeconomic status.
• We will respect the confidentiality of our patients at all times.
• We will treat all members of the health care team with respect and consideration and
will work in collaboration with others to achieve satisfactory outcomes.
• We will demonstrate respect for our patients and colleagues by maintaining an
appearance that is appropriate to learning and patient care.

79
Specific violations of the KSOM Code of Professional Behavior include but are not
limited to the following examples. It is not just the letter, but also the spirit of the Code of
Professional Behavior that is to be upheld by students.

• Giving or receiving aid in examinations; writing or preparing reports or presentations
that a reasonable person would conclude are to be done without collaboration.
• Presenting the work of someone else as one’s own.
• Plagiarism, including using prepared reports from the Internet or “cutting and
pasting” without referencing original works.
• Falsely reporting attendance at a required activity when the activity was not attended.
• Falsifying data in research or knowingly participating in research activities that are
reporting false data.
• Falsely reporting physical examination findings, laboratory data, or patient history
information.
• Forging a physician’s signature, even if told to do so by the physician. This includes,
but is not limited to: prescriptions, physician’s orders, forms for restricted
medications, and discharge summaries.
• Performing a procedure without specific authorization and/or supervision by the
student’s supervising physician.
• Conducting clinical responsibilities while impaired by drugs or alcohol.

In addition:
• Students must abide by all University of Southern California policies as described in
the University Catalogue and the SCAMPUS student guide book (section 11.00 –
11.55, Behavior Violating University Standards).
Attendance at the Keck School of Medicine of the University of Southern California
constitutes de facto acceptance of the CODE OF PROFESSIONAL BEHAVIOR and its
concepts, the Honor System, and its procedures.

HONOR SYSTEM

Medical ethics is a difficult subject to describe, much less to judge. Because of the
relationship of physicians to the public at large, there exist strong feelings towards
physicians’ attitudes and behavior by society. Traditionally, the physician has been
ultimately held accountable to society. The individual doctor’s actions are reviewed and
endorsed by colleagues who attempt to settle in their minds whether or not the adjudged
has fulfilled the basic tenets and an essentially unwritten code on the ethical care of
patients.

Professional behavior encompasses integrity, respect, courtesy, and compassion, in a
pattern of moral and ethical interaction with patients, peers, faculty, and staff. It requires
confidentiality and responsibility regarding patient information and group discussions,
and demands an understanding of and esteem for oneself, patients, peers, faculty, and
staff.

80

The Student Ethics Committee (SEC) at USC operates in this framework. Anticipating
that the student will soon find himself/herself involved in this tradition, an attempt is
made to prepare him/her to understand and respect this obligation. To do so, s/he must
certainly respect and have confidence in himself/herself. The SEC is a body which is
elected by the students and asked to interpret and describe for them what is ethical
behavior, and in certain instances, to judge whether a certain student has met those
criteria. The SEC itself can only direct. (The final responsibility is, of course, a private
one. Attendance at USC constitutes a de facto acceptance of this Code of Professional
Behavior.)

81
Appendix B
PROFESSIONAL BEHAVIOR EXPECTATIONS

Although all students are expected to behave professionally without supervision, these
expectations have been written to elaborate upon the responsibilities of all students at
Keck School of Medicine. A violation of any of these expectations by a student on
Professional Behavior Probation may constitute the sole reason for further disciplinary
action or dismissal from the Keck School of Medicine.

1. The student must be punctual for and attend all required ICM sessions,
Professionalism and the Practice of Medicine (PPM) sessions, lectures, rounds,
clinics, conferences, and all clerkship activities.
2. The student must be present for call, and participate in all team activities.
3. Absence from any of the above activities requires a written note cleared through the
Office of Student Affairs, as well as the completion of an absence request/notification
form.
4. The student must introduce and represent himself or herself as a student physician at
all times. Therefore, a student will not wear a long white coat or a badge
misidentifying his or her level of training.
5. The student must follow the LAC+ USC professional dress code in all clinical
settings.
6. The student must follow all signatures by designating their current standing, e.g., MS
III or MS IV.
7. The student may sign (or indicate electronically) only his or her own name and/or
signature to indicate his or her presence at a workshop, conference, or other activity
with a sign-in sheet or required electronic sign-in or evaluation form. Signing in
another student's or physician's name, or having another individual sign your name
or otherwise indicate your presence will violate the Code of Professional Behavior.
8. The student is responsible to make sure all notes and orders are cosigned by a
supervising physician.
9. The student must never forge a physician's signature, even if told to do so by the
physician. This includes but is not limited to: prescriptions, physician's orders, forms
for restricted medications, and discharge summaries.
10. All information reported to the team from the student must be accurate to the best of
the student's knowledge. The student must not report any portion of the patient's
history or physical examination unless s/he has firsthand knowledge of the
information being reported. The student must report only laboratory values or test
results that s/he has personally seen or seen report of. The student is expected to
admit that s/he has forgotten to ask, check, or look up something if such is the case.
11. The student is expected to treat all patients, employees, colleagues, and superiors with
respect.
12. The student is responsible for disseminating information to the student group/team
once asked to do so. For example, a student informed of the time of rounds, the

82
teaching of a procedure, or a special teaching session must call the other medical
students involved and inform them.
13. The student must have specific authorization and/or supervision by his or her
supervising physician in order to perform any procedure.
14. The student is expected to turn in all of his or her assignments on time, and the
content must be original work completed for that assignment. Any incorporation of
the work of others must be cited. The student is also expected to complete all
requested course and instructor evaluations.
15. The student is expected to consider the professional behavior and well-being of
his/her peers, and to report behaviors of concern to the course or clerkship director, or
to the Associate Dean for Student Affairs.
16. Sexual advances, gestures, improper propositions, harassment, battery, threatening
behavior, stalking, illegal drug possession, and any conduct breaking the law will not
be tolerated.
17. The student must abide by all University of Southern California policies as described
in the University Catalogue and the SCAMPUS student guidebook (Section 11.00-
11.55, Behavior Violating University Standards).

83
Appendix C

Medical Student Professionalism Assessment

0BInappropriate ◄———————
————►
Too Little ◄----------------------
----------- ►
Appropriate

1B◄——————————►
Inappropriate
2B◄------------------------------ ►Too
Much
HONESTY/INTEGRITY
* * * *
3BTruthfulness Misrepresents
position/status;
misuses resources;
falsifies data;
plagiarizes; cheats;
lies

Displays honesty,
forthrightness, and
trustworthiness

Displays
insensitivity and
tactlessness

Adherence to
Ethical Principles
Engages in
unethical behavior
(e.g., accepts
inappropriate gifts,
violates
professional
boundaries, steals,
engages in
fraudulent
behavior);
overlooks
inappropriate
behavior in
colleagues

Models ethical
behavior;
confronts or
reports
inappropriate
behavior in
colleagues

Appears
sanctimonious;
displays
intolerance; always
finds fault; appears
overly critical

RESPONSIBILITY/RELIABILITY/ACCOUNTABILITY

84
4BPunctuality Is late; misses
deadlines

Is punctual; meets
deadlines

Emphasizes
timeliness at the
expense of
thoroughness

5BCompliance Ignores policies,
procedures, rules,
and regulations;
misses required
sessions

Follows policies,
procedures, rules,
and regulations;
attends required
sessions

Displays
inflexibility;
rigidly relies on
rules to the point
of obstructionism

6BAccountability Avoids
responsibility and
work

Appropriately
assumes
responsibility; asks
for help when
necessary

Assumes too much
responsibility;
displays inability/
unwillingness to
delegate

7BFeedback Makes excuses;
displaces blame;
resists feedback;
appears defensive

Admits errors;
seeks and
incorporates
feedback

Appears afraid to
act for fear of
making errors;
assumes blame
inappropriately;
requires constant
reassurance and
feedback

RESPECT FOR OTHERS (e.g., colleagues, faculty, hospital and administrative staff)
8BAppearance Displays poor
hygiene; wears
dirty/sloppy
clothes

Maintains neat
personal
appearance

Appears to dress to
draw attention to
self; although neat,
dresses
inappropriately for
the occasion

9BInteractions Appears insecure
and unable to act
independently

Respects authority
and other
professionals;
appears
appropriately
confident; inspires
trust

Appears arrogant,
overconfident, and
demeaning

Teamwork

Does not
participate

Works well with
others

Appears dominant,
authoritarian,
uncooperative, and
overbearing

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10BALTRUISM
Concern for
others
Concern for self
appears to
supercede concern
for others; appears
unwilling to
extend self

Shows appropriate
concern for others;
goes “the extra
mile” without
thought of reward

Appears selfless to
point of taking
needless risks;
over-extends self
to own detriment

11BEMPATHY
Compassion Exhibits little
compassion for
others; at times,
appears cold,
indifferent, and
“heartless”

Can put self “in
others’ shoes,” but
still maintains
objectivity

Appears
emotionally over-
responsive and
unduly empathic,
resulting in an
inability to be
objective or
effective

12BCOMMITMENT TO EXCELLENCE
Goal-setting Appears aimless
and educationally
adrift

Sets and achieves
realistic goals

Sets unachievable
goals

Motivation Sets low standards
of achievement;
appears
complacent

Seeks additional
knowledge and
skills; strives for
excellence

Appears overly
competitive and
perfectionistic

RESPECT FOR PATIENTS
Relationships Appears
disrespectful and
insensitive to
patients (beliefs,
opinions, gender,
race, culture,
religion, sexual
orientation, and/or
socioeconomic
status)

Demonstrates
respect for, and
sensitivity to,
patients (beliefs,
opinions, gender,
race, culture,
religion, sexual
orientation, and/or
socioeconomic
status)

Enables
inappropriate/
unhealthy patient
behavior

Confidentiality Disregards patient
confidentiality

Demonstrates and
maintains
sensitivity to
confidential
patient information

Inappropriately
upholds patients’
or others’ right to
confidentiality,
putting them and
others at risk

* Requires written comment
6//05

86
Appendix D

Year I PPM Student Reflection on Personal Challenge/Dilemma

Critical reflection is an important personal skill. It is a mechanism of self-supervision that
enables professionals to keep developing long after they have completed their graduate
programs. In fact, a number of professions (e.g., dentistry, medicine, nursing, physical
therapy, psychology, teacher education, and social work) stipulate that students preparing
for those professions learn reflection skills.

For every question please write as many paragraphs as necessary in order to provide your
most detailed and complete view of the situation. We are interested in Uyour personal story U
of a challenging experience or dilemma, for example:
 You were involved in an ICM group discussion that became too heated or
personal for you
 Your group couldn’t decide who was going to do the dissection in GA lab
 You had a disagreement with one or more members of your ICM or PPM group
 You felt you left a patient in distress after an interaction with them
 You weren’t prepared for an ICM, PPM, GA lab
 You didn’t treat one of your peers, faculty, patients with respect
 You didn’t present the full truth about yourself or a situation
 You felt a loss of emotional control
 You were late or absent for a required activity
 You didn’t ask for assistance when it could have been helpful
 You enabled others to act or do something inappropriate
 You felt your reactions to someone or a situation were inappropriate
 Your values or biases affected your ability to accurately comprehend a patient,
peer, faculty

1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA
lab; MDL; lecture hall) setting that has occurred since you started medical school,
in which your own behavior or reactions directly affected the event that resulted
in your feeling confused, upset, or left you wondering.

If there has been more than one such experience during this period, please choose
the one that had the greatest impact on you.

Please describe the experience in detail, including (a) what UyouU were doing, (b)
who else was involved, and (c) what about this experience Uleft you U confused,
upset, or wondering.

2. How long ago (in days; months) did this experience occur?

87
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the
event.

4. What internal factors (i.e., your personality traits; emotions; values; biases)
influenced your response to the event?

5. What external factors (i.e., setting; other people; time of the event; etc.)
influenced your response to the event?

6. If faced with a similar experience while in medical school, how do you think you
would react differently?

7. What conclusions have you reached based on your subsequent thinking about this
experience?

8. What questions or concerns does this experience raise for you to explore in your
future practice as a physician?

9. Have you ever received formal training in the use of critical reflection?
a. Yes
b. No

10. If yes, in what course or program?

11. Is English your first language?
a. Yes
b. No

88
Appendix E

Medical Student Reflections of a Personal Challenge/Dilemma

Integrative Complexity Level One

92
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
There was a time that I did not preview the anatomy lab before lab time and I felt lost in the
lecture & disection.
2. How long ago (in days; months) did this experience occur?
3 months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
My immediate thoughts were that if I worked through it i would be alright.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My sense of confidence and ability to not stress over things that I know will be alright.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
My anatomy group was there, but I don't know if any of them realized that I hadn't prepared.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would probably act the same.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
That it wasn't a big deal and everything worked out fine.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
None other than I just need to know that being prepared is better than not being prepared.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

37
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
Clinical. I remember an experience interviewing a patient were I was constantly interrupted

89
by my mentor. His comments were not constructive, and they made me look stupid and
incompetent in front of my peers and patients. While his comments were probably well-
meaning, they were really annoying, and I kind of lost my composure and did even worse as a
result.

2. How long ago (in days; months) did this experience occur?
4 months
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
annoyed, self-conscious
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
pride, impatience
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
public, in front of peers/patient
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
just be prepared for criticism, don't take it personally unless it is absolutely meant that way,
and calmly confront when necessary
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I'm going to have to face lots of criticism, constructive and destructive. I can learn the
differences from my experiences and be sure not to reciprocate or do the same when I am in
the opposite position.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
Sometimes I dread having to take crap from superiors for the next ten years.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?
NA
11. Is English your first language?
2 - Yes

75
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
There has been no such incidents.
2. How long ago (in days; months) did this experience occur?
N/A
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
N/A

90
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
N/A
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
N/A
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
N/A
7. What conclusions have you reached based on your subsequent thinking about this
experience?
N/A
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
N/A
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

79
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
Someone asked me to defend them in a situation when I did not witness but thought they may
be guilty. I was confused about what to do because it was my friend but did not like to lie for
them.
2. How long ago (in days; months) did this experience occur?
3 months
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was upset at being put in a situation where I would have to choose between a friend and
telling the truth.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I do not like lying so this influenced my decision.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The pressure put on me by my friend was a bit of an influence in the event.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I did not need to defend him in the end so I can not say how I reacted or how I would react
differently.

91
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I think that I would do what I feel is right rather than try and please a friend.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
Close colleagues may ask me to do things which I am uncomfortable with but I might always
do what I feel is right.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

93
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I have attended several lunchtime meetings where the guest speaker was an attending
physician in a surgical specialty, and I have generally left all of them feeling discouraged.
I've felt discouraged for several reasons: 1) I have realized how much weight is placed on the
Step I score; 2) Surgical residencies are very competitive; 3) I'm expected to apply to
somewhere in the neighborhood of 100 (100!) programs, just to get a dozen or so interviews;
4) I have lived in Los Angeles for 19 years, and I like it here. I have no interest in moving
someplace else to do a residency, but it's very likely I will have to.
2. How long ago (in days; months) did this experience occur?
A couple months ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
It bothers me a lot that a test that students take on one day is such a deciding factor for the
course of our career. Especially because it doesn't take "people skills" into account. It also
bothers me a lot that "caring" people are expected to go into primary care, while surgeons are
expected to be, well, not so caring.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I wanted to go to medical school after many years of working as a yoga instructor because I
wanted to learn more about psychosomatic back pain. I know that sounds like an odd area of
interest, but a woman I met many years ago told me about it, and she told me about her
physician in New York who had cured her back pain. I started to realize that this was a
common ailment in my clients, but when I would suggest that emotions can play a role in
their back pain, they generally didn't believe me, particularly since most doctors say
otherwise. I got pretty frustrated after a while, so I decided that I would become a doctor.
That way, I could really understand it myself, and I would be better at educating people about
it.

I've come to realize however, that my interest in back pain doesn't fit neatly into a specialty--

92
psychiatry really doesn't address it; physical medicine uses physical modalities, and I'm more
interested in treating pain through psychological modalities. And orthopedic surgery
dismisses the role of emotions entirely.

I've also come to understand the pecking order among doctors who treat back pain:
orthopedic surgeons will always be taken more seriously than anyone else. And although I
hate the thought of my yoga clients or my future patients having unnecessary surgery, from a
selfish standpoint, surgery is about a thousand times more enjoyable than prescribing
medication to patients.

So, I'm still undecided about a specialty, but I have a feeling that I will work toward
becoming an orthopedist in order to really understand back pain and in order to be truly
effective as an educator.

One thing that did make me feel better was Dr. Levine's lecture on The Art of Medicine. She
is truly a caring physician, and if I ever have lymphoma, she is absolutely the person I'd want
as my doctor. She also told a story in a different lecture, about a particular hematologist who
was criticized for some theory he had. And then she laughed and said to the class, "You
know, if you ever have a truly novel idea, you will be roundly criticized by your peers." And
I have a feeling that if I become an orthopedist, I will be laughed at for asking my patients
about the emotional stress in their lives, but I guess that's just how it's going to go.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
N/A
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I probably wouldn't react differently.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
Since those lunchtime meetings, I have had the chance to scrub in and assist with a couple
ortho surgeries, and I really really enjoyed enjoyed it. I'll try to get involved with more
hands-on and research experiences in ortho and trauma surgery to help me make a decision
on a specialty.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
What I said before--I need to figure out what specialty fits my interests best.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

93
136
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
We were listening to a volunteer who came into our PPM meeting to teach about cranio-
sacral therapy. We listened for about half an hour to the cranio-sacral therapist explain what
she does. As she was wrapping up her presentation, one of the students in our MDL made a
very rude comment that affected me. I was surprised, confused, and upset. i felt embarrased
too. i encouraged one of my colleagues to say something, which she did. what upset me was
the way he was so rude to our guest. i couldn't understand why he would say what he did,
even though many of us were thinking the same things.
2. How long ago (in days; months) did this experience occur?
four weeks ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
i was first shocked. i couldn't believe he said what he said. then when it sunk in that he
actually said what he said, it was embarrassing. i felt bad for the speaker, and was upset that
our group would treat a visitor this way. i shook my head quite a bit. i probably got more
upset than i should have because i dont have strong positive feelings for the student.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
my bias against the student played strongly. i would have been much more understanding or
would have given more lee-way to someone i respected or even liked. the value i place on
treating people the way i would like to be treated also contributed to my reaction to the
student's comment. i value respect, and to see someone being so disrespectful in my MDL
was offensive.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
we had just sat through 45 minutes of uninteresting lecture and were tired and bored.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
i need to hold my cards a bit closer to my chest. i tend to wear my emotions on my sleeve.
often in medicine there is a need to keep a poker face, a skill i would like to develop.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
i need to lean to better keep my poker face when things surprise me, when I'm offended, or
upset.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
What does English as a first language have to do with this assignment?
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

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138

1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
There has been more than one time in our PPM discussions where I have been left
wondering, not about my own reactions, but about other peoples attitudes towards the topics.
I was surprised by a member of our class, surprised at how someone who was going to be
tending to patients at LA county hospital could be so close minded and jusdgemental. After
leaving those sessions, I wondered how it was that this person could have gotten to where
he/she was today by acting that way.
2. How long ago (in days; months) did this experience occur?
happened once at the begining of the year, once a few weeks ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was annoyed.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I am a pretty emotional person as well as open minded, when other people are not open
minded or jusdgemental, it bothers me.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
Other people were upset by the actions too, which prompted me even more to be vocal about
it.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
probably not any different, it didn't end up being a bad situation,
7. What conclusions have you reached based on your subsequent thinking about this
experience?
nothing
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
really none
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

95
140
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I was in ICM at County and was unable to answer some of the follow-up questions of my
ICM leader related to the patient's case.
2. How long ago (in days; months) did this experience occur?
About 3-4 months ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I felt nervous, and disappointed.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I feel best when I am prepared, organized and informed.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
My ICM group members were able to answer questions, that I was unable to, which made me
feel worse.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
Yes, I would try harder to think rationally and at least think of a reasonable answer, as
opposed to not answering at all.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
ICM is helping me think under pressure.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
It has already become easier with more experience in these type of situations.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

96
142
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I have had a really hard time focusing on studying during heme. I've been trying, and I will
sit for long periods of time working on a lecture, but come away frustrated and tired, not
feeling like I have learned anything. So when I get frustrated I eventually give up and just
ignore everything I have to get done. Then when I try and get started some days later I get
overwhelmed by all that I have to do and when I can't get as much done as I'd like to I get
frustrated again and give up. Now that it's down to crunch time I finally have gotten so
terrified about learning everything in time for the exam I am studying well. I just don't
understand how I couldn't study before and why I couldn't focus. No one else was involved,
but me.
2. How long ago (in days; months) did this experience occur?
During heme, until only a couple days ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I'm so mad at myself for not being able to get myself focused and let myself get so behind.
It's a motivator now, but I wish I could have been motivated from the get go. I don't
understand why I let myself harm my chances at success for no good reason, and I really
don't know what was going on in my head.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I honestly am at a loss. My mind just was not where it was supposed to be and as much as I
tried I could not make myself focus, then when it didn't work when I did try, I figured-why
even try? And then it would be a circlular process-I'd try, then give up. I'm so frustrated with
myself right now!
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
Nothing. It was just me.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I need to somehow make myself study and start being on top of lectures from the very first
day of the system. I will try studying with people to force myself to focus. I just make myself
do it because I hate the extreme pressure I'm feeling right now because I'm behind and I
never want to feel this way again. I'm usually a good studier and I enjoy learning and want to
learn as much as I can. I just need to remember this.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I need to remember that I must get through all of this to be a doctor, which is what I want
more than anything. Sometimes it's hard to relate this book learning to the actual wonders of
interacting with people. I do enjoy learning the medical science, I really do, it's just
overwhelming at times. I just have to remember that when all the science comes together it
will be fascinating. And I can use it to help people, which is why I'm here!
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I need to be organized and efficient with my time.

97
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

143
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I feel that I am quite skilled at handling challenging situations and interacting with people at
a level that makes them comfortable, while still discussing issues that we might have. There
have been situation where I had to be agreeing or respectfully disagreeing or simply not
being stubborn to prove my point. None of the circumstances were surprising or challenging,
but they've required me to use various interaction methods. The most recent situation was
when a group member was very obviously not fond of our ICM instructor's
teaching/interacting methods and made it more obvious than she may have realized. I wasnt
sure if this person was aware of her attitude and that it may become a problem in future years
when we have to take a subordinate position to many other physicians. I ended up talking to
this group mate about it and I feel that we were able to productively communicate over some
issues this person was having.
2. How long ago (in days; months) did this experience occur?
some weeks ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I thought my groupmates attitude was immature and unprofessional. I felt I needed to talk to
the groupmate and did so.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I believe that everyone has a different viewpoint on issues and actions need to be evaluated
on a personal basis. Both the instructors approach and the students' feelings need to be
respected, however, no one should be disrespectful in expressing their feelings.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
No external factors.
6. If faced with a similar experience while in medical school, how do you think you would
react differently?
Aren't we in medical school? I don't get this question.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
None.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
None.

98
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
1 - No

149
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.

Sometimes he gets in the way and he’ll start dissecting (or aimlessly picking) away at the
organ or structure we are attempting to identify. So I, in the nicest way possible, will ask him
to do something else, or simply move, because he’s not familiar with the anatomy. Basically,
my patience with Timmy can run thin, especially when he’s plucking away and precious
anatomy that could be better utilized by someone else’s hands.

2. How long ago (in days; months) did this experience occur?
A couple of times last semester.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
Generally, I think I am a pretty nice, patient guy. So I naturally feel bad immediately after
telling Timmy to get out of the way (nicely). Sometimes, I think I intimidate him.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
Patience. In medical, time is precious. There are always so many other things that you could
be doing with your time: studying, researching, volunteering, hanging out with your friends
or family. I don’t enjoy taking an extra hour on Fridays to have Timmy delay and ruin our
group dissection. My group members agree, but I am usually the one to say something
because I can do so gracefully or jokingly, without offending Timmy much.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
My group members are also impatient with Timmy. So I take action for their interests as well
as mine.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
Honestly, no. I feel Timmy and I have a good working relationship. There is no tension
between us.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
Nice guys really do finish last. If I were to be the nice guy, Timmy would pluck at our
cadaver for an extra hour and delay the lab. We really would be the last dissection team to
leave the lab.
More importantly, I think that I am learning when it’s important to take charge to finish the

99
task. I am starting to recognize when it’s best to explore and when it’s best to be objective. In
lab, (and I imagine in surgery most of the time) its best to be objective and finish the task at
hand.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
Doctors, especially surgeons, can sometimes come off like jerks. In this self evaluation, I
probably sound like a jerk. I REALLY don’t want to become one. As a physician, I need to
be cognizant of how my peers and co-workers perceive me. Point being, I need to know when
to be patient at a doctor. (I don’t feel like this will be a problem.)
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

159
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
One time in the past few months where I think I showed some immaturity in my actions was
showing up late for ICM. I know that it doesn't seem like a very big deal, but it meant
something to me. When I entered medical school I told myself that I was here to study and
learn and not to have another "college" experience. Unfortunately I have occasionally lost
focus and when I was late to ICM because I was out late the night before is one of those
times. I was disappointed in myself and unfortunately feel that my actions gave a negative
impression to my instructor about my ICM group
2. How long ago (in days; months) did this experience occur?
This occured a few months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I am already the youngest one in my ICM group and I obviously want the respect of my peers
so I felt pretty embarassed.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My driven personality and desire to achieve the goals I set for myself strongly influenced my
response
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The social dynamic of letting down my ICM group infront of our professor was an important
factor
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I think I would react even more strongly because I don't like making the same mistake twice.
I understand being late to something if it is for unexpected reasons (like car trouble etc) but
for me to be late to something I have commited myself to for no reason other than partying

100
too hard is unacceptable
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I think I just need to refocus myself and remember I am not paying 40K+ a year to party on
weekdays but am instead here to learn how to be an effective and capable physician.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I think the mentality of making sure you live up the standards you have set for yourself will
be equally important to me in practice as it is in medical school. Therefor I need to ask myself
what standards I will be hold myself to in school, life, and work.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

160
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I sometimes get excited about a "project" and ask questions or verbally try to initiate a plan.
Several times during GA lab I felt like I was being ignored; I asked questions or made
comments that went unanswered. I thought that I may have been too aggressive.
2. How long ago (in days; months) did this experience occur?
Several times over the semester.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was confused and frustrated. I did not want to participate.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My personality and expectations.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The other people in the group; they all have different experiences and backgrounds, i.e. age.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
Change my expectations.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I can only control my actions.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
What kinds of people will I be working with? As physicians do we work on teams? What do
my colleagues think? Who will be on my team? What accountability does each person have

101
to the group? How is it enforced?
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

Integrative Complexity Level Two

80
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
Last semester, I struggled somewhat with gross anatomy. I tend to be more of a
mathematical/analytical thinker than a visual thinker; thus, I despised gross anatomy. Because
I struggled with the subject, I somehow decided to ignore it. I started showing up late and
leaving gross anatomy labs early. I skipped 2 labs by conscious decision. One of my ICM
group members offerred to meet me in the gross lab to go over the information, but I declined
the offer. When exam time came around, I completely crammed for the exam, studying for
1/2 a semester's course for a period of 1 day. I took the test, expecting to fail. However, when
I got the test results, I had passed the exam. This left me somewhat confused. I had not put in
an iota of an effort for the course; in fact, I probably put less time into gross anatomy than
any other medical student in the country. But somehow, I had passed by a decent margin.
Clearly, I should have studied more. However, I almost wish I had failed the exam. I would
have still passed the semester, and had an impetus to work harder the next time we have gross
anatomy. However, now I do not look forward to anatomy starting again in March.
2. How long ago (in days; months) did this experience occur?
2-3 months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
Immediately after I got my score back, I felt relieved, almost joyous, that I had passed. I did
the absolute minimum of "work" and had come out on top. In essence, I felt like I was "the
s***". However, a few days later, I was left confused. Should I have put more time into
gross? I definitely could have.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I have a tendency to slack off when doing things I do not like doing. In addition, I generally
have an aversion to 3D thinking. In addition, I do not have a very competitive nature; I am
not obsessed with getting high scores or grades.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
During the first 3/4 of the half semester, I would live casually. I spent most of my time
socializing or doing nothing, studying for a little every day for other topics, and not studying
at all for gross. During the few weeks before exams, I would always put off studying for
gross in favor of studying for other subjects which I found more interesting. Thus, I would

102
use pharmacology as an excuse to not study for gross.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I honestly have no clue what I am going to do when neuroscience (and anatomy labs on
fridays) starts. I have an interesting dilemma: 1. I hate gross anatomy. 2. I can do well in the
subject if I study for it appropriately. 3. I can pass the subject despite ignoring the class's
existence for extended periods of time.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I haven't fully reached any conclusion yet. The hematology unit has provided me with a break
from anatomy class. However, I think I should possibly try to find another way to study for
gross anatomy. I don't think I learn efficiently while in lab. I should probably try to figure out
some way that will make the subject a little more enjoyable for me.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
One question this could possibly raise is how will I handle challenges I face in practice? Will
I just ignore them and hope to wing it? Or will I actually put in a solid effort and "do my
best"?
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

8
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I do not feel that I have had any experiences thus far in medical school that exactly match the
criteria posed in this question. However, the spirituality competency PPM session did leave
me with some questions that I feel were never addressed to my satisfaction. Specifically, I do
not understand how we, as physicians, can in good conscience attempt to persuade patients
with deeply held religious views to receive medical care that is specifically prohibited by
their most fundamental beliefs. I understand the need to inform patients of the risks
associated with refusing medical treatment on religious grounds and think that as physicians
we need to be vigilant about explaining the consequences of medical inaction on the part of
patients. However, if a patient understands these risks and is an adult capable of making up
his or her own mind, further persuasion to receive medical care is, to my mind, insulting to
the intelligence and dignity of the patient. If a mentally competent adult believes something
to the point that he or she is willing to die for it, I am unwilling to try to persuade them
otherwise. To do so is to implicate: "I respect your views, but I think they are in fact wrong
and that I know better than you the true nature of reality and its relationship to God." This is
completely untrue and insulting to anyone.

When I raised this issue for discussion, the response I received was: "Although this may be

103
true, you do not understand how hard it will be to let someone die after working so hard as a
student and resident to learn how to save them." This left me dumbfounded. This approach to
medical care makes the issue of health more about the hang-ups of the physician than about
the wishes of the patient. Medicine is full of moral and ethical dilemmas and this is part of
what makes medicine so appealing. However, to lose sight of the real reason for medicine's
existence, that is to help patients live healthy lives in accord with their personal beliefs, is
unconscionable.

Our MDL discussion about this topic largely revolved around how touchy an issue religion in
medicine can be. However, I do not see it that way. In the case of adults with deeply help
religious views, the responsibility of the physician ends at explaining the risks associated
with medical inaction. If the patient understands he or she may or will die without treatment
and is prepared to accept this, physicians are obliged to swallow their pride and respect their
patients wishes. There is no room for debate on this issue, as physicians know no more about
God than anyone else. Our patients come to us for medical advice and in some cases,
treatment. We are trained to give medical advice, and should not presume to to know more
than our patients about matters outside of our area of expertise.
2. How long ago (in days; months) did this experience occur?
Two months? (I don't really remember)
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was disappointed. I couldn't believe a room full of educated people thought there was much
room for debate on the issue. I understand things get much more complicated in the case of
parents refusing treatment for their children, but in the case of informed adults, I don't see
where any leeway exists. Pressuring people to disregard their most deeply held beliefs
because you don't have the strength to let them die with dignity is ridiculous.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I think my values are pretty clearly expressed above.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
None.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
This happened in medical school.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
That many people have not thought deeply enough about their limits as physicians and about
the nature of life and death. If people took a moment to think about what it means to be
willing to die for an idea, they would never question a patient's desire to not receive medical
treatment based on religous views.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I think the real debate is concerned with how to approach patents who do not want their
children to receive medical treatment because of their own religious views.
9. Have you ever received formal training in the use of critical reflection?
1 - No

104
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

19
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
Once incident that comes to mind is one that occurred in ICM. One of our ICM instructors is
particularly fond of going over each of our histories in front of all six of us in the group…at
length. His input is appreciated, but we end up hearing six cases that we have already heard,
because we always rehash our patient interviews immediately after each ICM session as well.
Our other ICM instructor, on the other hand, requires us to turn in our histories twenty four
hours after our session, reviews them on his own time, and hands them back to us with his
comments on them. The whole group unanimously prefers this technique, since it is quicker
and more practical. Nearly everyone in the group constantly complained about the inefficient
way our other ICM professor operated. One day, this ICM professor asked us if we would
prefer to keep reviewing the histories his way, or if we would prefer to do them the way our
other professor had been doing them. No one spoke up at firs, so I finally said that I prefer the
other professor’s way because it was more efficient. Now, I only said this because I was
expecting all of the members of my ICM to echo my sentiments. However, much to my
surprise, they all remained silent, and the ICM professor took their silence as a confirmation
that the majority approved his methods. This episode upset me greatly because I felt that I
had stuck my neck out, and that no one in my ICM group had come to my defense. I made it
know to them that I did not appreciate their lack of support in this particular situation.
2. How long ago (in days; months) did this experience occur?
This experience occurred about two months ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was angry and frustrated. I also felt that I could not trust my ICM group.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I am usually vocal, and I am not afraid to let my opinion be known.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
Everyone’s silence influenced my response. I felt it was my duty to be the one to say
something, and that everyone would follow my lead.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would not say anything in that situation. Especially to that instructor, because even thought
he was asking for criticism, it is clear that he really was not seeking it, but rather asking out
of formality.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I have to be more careful and tactful with my comments.

105
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I will always be open to criticism from my peers and patients.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
1 - No

31
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
During a patient interview at which our ICM instructor and all 6 of our group members were
present, I became very frustrated with the way that our instructor was treating both the patient
and the student conducting the interview. I felt that our instructor was being rude and
disrespectful to the patient by speaking about him to us as though he wasn't there.
Additionally, I thought our instructor’s comments were extremely inappropriate, since he
directly suggested that the patient was an alcoholic, when this was not the case. The student
had started to establish a good rapport with the patient up until to this point, but after this
outburst from our instructor, the patient was clearly uncomfortable with continuing the
interview, and it took some time for the student to regain his trust.

Our instructor had already behaved in ways that made us uncomfortable before this event. I
considered this to be the last straw, and decided that I was going to go to the ICM office and
file a complaint, since I felt that he was not modeling the type of behavior we were supposed
to be learning.

While we were discussing the case with our instructor after the interview, I declined to
partake in the conversation because I was so frustrated with our instructor’s behavior. Our
instructor noted that I was withdrawn, and asked me what was the matter, but I didn’t share
my thoughts with him. I regret having behaved in what I believe was a very passive
aggressive way. I should have let him know what was on my mind, but I did not have the
nerve. I feel that it was immature to have just acted displeased without doing anything about
the problem.
2. How long ago (in days; months) did this experience occur?
About 4 months ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was frustrated and felt compelled to do something about what I thought was completely
inappropriate behavior.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I feel responsibility to act when I believe there is a situation in which action needs to be taken
by someone.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your

106
response to the event?
I knew it was inappropriate to intervene at the moment that the instructor was making his
comments, since it was in the hospital, in front of a patient.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I think I would try not to get frustrated, and try to behave in a more productive way. I would
recognize that even though I couldn't do anything at that very moment, I could effect change
by addressing the problem at a more appropriate time.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
That I need to control my frustrations better, and that it will be beneficial to develop the
courage to deal with problems head on.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I question my ability to criticize authority figures when criticism is deserved.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

36
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
During one of our routine visits to county on a normal ICM day, another ICM member and
myself had the chance to interview an interesting case. Albeit we were on the psych ward, we
had a 17 year old male who was in the hospital because of increased irritability and problems
with drugs/law. His family situation was no better: his mother a crack cocaine user and his
father an abusive off/on influence in his life. While interviewing the patient, my ICM
member and I found out that he had been diagnosed with a brain tumor. We asked several
open-ended questions regarding his knowledge of his condition--we basically ended up
learning that he did not know the full extent of his disease. He believed the tumor to be
benign, and this fact (being that it was benign) played a major role in his therapy.
He was turning his life around--he had learned to do away with drugs, and trouble, and anger.
He decided he wanted to live out his dreams and progress in life. This was all very
rejuvenating, as he was a young man who had finally figured it out. When my colleague and I
checked his chart to be thorough, we found out that the patient had a glioblastoma. This was
awful--I couldn't believe that he didn't know what was wrong with him, or couldn't come to
terms with it. I wanted to run into the room and tell him the horrid prognosis and have him
prepare, considering he was putting so much effort into reorganizing his life. I asked the
nurse if he knew his condition..."ya Mr. O knows all about that whole thing..." I didn't believe
her. She said it with such a lack-luster tone that I wanted to jump over the counter and yell at
her. While at the same time, I couldn't speak. I didn't know what to do. My ICM-mate and I
just looked at each other blankly--guess it was going to be a bad tuesday.

107
2. How long ago (in days; months) did this experience occur?
about a month ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was mostly in disbelieve and shock. How could a patient not know the extent of his
condition? Did his parents not want him to know? Why wasn't he on chemo? I was confused
because I didn't know why those measures weren't taken.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I guess I really like being in control of my life, and the fact that the patient was misinformed,
whether willingly or unwillingly (via denial), just bothered me to no avail.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
It was in the hospital, and the psych ward at that, so it was a bit daunting. I also didn't know
the proper protocol, nor what my role as a med student forced me to do/or not do.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would be less shocked, but on top of that I'm not sure.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
Sometimes patients don't get what's wrong with them. Sometimes patients don't want to
understand what's wrong with them. Sometimes patients aren't adequately informed by their
physicians or care takers.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
it's hard to grasp what patients need to know and what they don't need to know. This is
something I'll learn through experience, undoubtedly.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

42
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I signed up to teach a Drugs/Alcohol class at Juvenile Hall with another member of my ICM
group. We were discussing our thoughts on substance abuse/dependence and the conversation
got very heated. I expressed my beliefs that substance dependence has a strong genetic
component and needs to be treated like a lifelong, chronic illness, with compassion and
patience. I expressed that addicts do many bad things, but that they cannot be hated or blamed
for all of it, as many have experienced psychosocial or other types of trauma or stress
preceding and during abuse that might make me vulnerable to substance use as well. My ICM
partner had a very different belief, that many addicts are selfish and need to not be coddled or

108
treated with as much sympathy. Also, that most just start using to have fun and are self-
absorbed for continuing to use despite the negative effects to themselves and others. I was
very upset because I have family members that suffer from substance dependence, and have
worked in a drug/alcohol rehab for many years. My opinions were researched and based on a
lot of exposure to the field and yet they were blatantly rejected. I also felt especially upset
because medical students and future physicians are in such a position to make a difference in
patients with substance abuse, and this particular student seems like he will do more harm
than good when working with this type of patient, which are prevalent in LAC, with his
unwillingness to listen and lack of sympathy. I have encountered these beliefs before, but it
seemed much more upsetting to see in a colleague.
2. How long ago (in days; months) did this experience occur?
two months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was very angry and defensive because I felt that my beliefs were much more based on
experience and fact. I was frightened that a colleague and future doctor was being so narrow-
minded and unsympathetic.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I am emotionally tied to the subject of substance dependence because I have family members
suffering from it and I know that one incident of addiction can have devastating effects on
many people. Therefore I felt personally motivated and desperate to change this person's
mind before they hurt others with their unsympathetic beliefs.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
It was especially awkward because the person is a member of my ICM group and I was
nervous to cause tension within such a small group. I also felt pressured because we were
teaching a class on Drugs and Alcohol in a few weeks and I didn't want him to approach the
subject matter like that in front of inmates struggling with substance dependence.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I think I would be more effective if I was less defensive, and I would also like to be able to
cite research to support my argument.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
That these ignorant beliefs about addiction are prevalent even in an educated health care
setting, that they are harmful, and that I need to help educate people.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
It scares me that people like this will be unsympathetic and not treat addicted patients
properly. It motivates me to educate others/myself about it.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

109
48
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
One thing that I have learned about myself up to this point is how different my life was to that
of my classmates. It was the "Walk Across the Line" exercise during a PPM session.
Although at first I felt alienated, I now recognize how my unique persona and life provides
my peers a realistic, first-hand experience to the lives and struggles amongst minorities and
the underserved.
2. How long ago (in days; months) did this experience occur?
This was during PPM and lasted three days.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I felt alienated and different.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My personal experiences as a Chicana of Lincoln Heights, Los Angeles and raised by a single
parent Mexican mother with five other siblings.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
My MDL classmates.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I have learn to be proud of what I experienced throughout my life to be where I am now. I
now will take any sort of feelings of "different" as being "special" and able to provide a
source of real insight to the lives of many of the patient population of LA County Hospital.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
See number 6.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
My continued goal of becoming a culturally competent physician.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
1 - No

63
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
One night after class I was working with the emergency medicine student group in the ER at
USC/County Hospital. I was asked to help with a patient by maintaining manual ventilation

110
on a patient who was admitted for end-stage cancer and liver failure. I walked with the
transport team, meanwhile pumping her oxygen mask, as we relocated her from the ER to a
more permanent room. When we got to the new ward, I had no clue who the doctors were or
even what unit we were in…I just followed and pumped. The nurses and doctors who
received us worked on hooking her up to machines, transferring beds, etc. However, during
the process, two female health workers started commenting on the patient’s (a female) hairy
legs, stating that she need to get some Nair (hair removal cream) and was looking pretty
rough. I thought to myself that OF COURSE she is looking rough, she is going through a
painful and drawn out death. Not knowing these doctors/nurses and not even knowing much
about the patient, I kept my head down and my mouth shut but still felt extremely offended
the how insensitive those women were.
2. How long ago (in days; months) did this experience occur?
A week and a half ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
The first was disbelief that these healthcare workers could be so insensitive as to ridicule a
dying woman about her hygiene. Then I felt offended for that patient who in no way could
defend herself…and who knows, maybe could even hear what was being said? Then I felt
embarrassed that I had witnessed this and couldn’t do anything about it.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My personality and tendency to look out for the “underdog”, my emotions of empathy for this
dying woman, a value of respecting all people unless you have a very good reason not to, my
fear of overstepping my boundaries as a first year medical student
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
Being in an unfamiliar setting with unfamiliar people, having limited background information
about the patient and her medical condition
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
My first thought is that I wouldn’t be able to bring myself to react differently given the
circumstances. I would hope that I might, in the future, make a statement that defends the
patient but maintains respect for my medical profession “elders”.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I’ve considered the perspective of the health professionals who made the comment and
wonder if they were fatigued, burnt out or just plain desensitized to death. They probably
assumed that the patient was unconscious or just needed humor to cope with a situation they
face on a daily basis (watching someone die and not being able to help).
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
This makes me think more critically about what should and should not be acceptable when
working with a patient (dying or otherwise). It is true that as we are exposed to dramatic and
devastating situations on a daily basis, it is a common protective mechanism to distance
yourself from the event. Still, I want to use this situation to keep myself grounded and
connected with the patient’s best interests regardless of my personal or professional state of
mind. I want to maintain respect for my patients and maintain respect for illness and death as
well.

111
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

71
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I would say that the last gross anatomy session left me confused, upset, and wondering.
Inevitably, I get impatient with my own and my group’s inadequate preparation for the
detailed gross labs. My impatience during the lab leads to disinterest and loss of focus, which
does not help the situation. The result this week was an incomplete dissection.
2. How long ago (in days; months) did this experience occur?
A week ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I felt personally frustrated, educationally lost, and emotionally guilty for offending this poor
man’s body with my inadequacy.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My personal factors which influenced my response to the event include: my sympathy for the
person who has passed, my belief that his spirit is aware of what I am doing to his body
which he will possess again someday when he is resurrected, and my own perfectionism and
impatience with mediocrity.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The noxious smell in the gross lab, the length of the labs, the imperfect preparation of group
members, and the fact that my group members don’t share my belief system all influenced
my response to the event.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I am doing what I can and trying to explore new ways to prepare for gross lab, including
communicating with my group members regarding my concerns, so that future gross anatomy
sessions will not leave me as confused and upset.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I have concluded that I have a weakness in gross anatomy dissection, and that I must prepare
in order to have a good attitude in order to have a productive session.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I am concerned that I will not learn anatomy well enough to allow me to consider all
specialties as options, particularly surgery, which I am truly interested in.
9. Have you ever received formal training in the use of critical reflection?

112
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

72
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
Along with another student from my ICM group, I interviewed a patient who during the
course of the interview expressed that she was not only depressed but had seriously
considered buying a gun and killing herself. Obviously, this is a very upsetting and serious
conversation, and the other student and I left the interview and immediately went and
contacted the fellow who had come through the room during our interview to briefly check on
the patient. When we informed the fellow that his patient seemed severely depressed and had
expressed a somewhat definitive plan about ending her life, he blew us off, saying "we're on
it." I felt like there was nothing more I could do, and because I'm only a medical student and
not a physician, I didn't think there was a way I could convey to this fellow the seriousness of
my and the other student's concern.
2. How long ago (in days; months) did this experience occur?
This occurred about a month ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was angry and frustrated, not only about my inability to do much in the situation, but at the
doctor's lack of concern and compassion and outright rudeness.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I think I am pretty empathetic, and I want to be a doctor in part because I enjoy helping
people work through difficulties in their lives. I think anyone who is remotely compassionate
and empathetic would have been effected by this woman's story of her difficult
chemotherapy, her bleak future and her ongoing suffering.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The fact that I am a first year medical student with little if any clout in a large public teaching
hospital showed me just how inconsequential my empathy and concern for this patient was in
the end. That's a somewhat depressing fact in and of itself.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
If this happened again, I might go ahead and page the psychiatrist listed in the patient's chart
and speak directly to him or her about my concern for the patient's wellbeing.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I think my judgment and instincts are pretty sound when it comes to interacting with patients.
I wish I'd had the courage to push the fellow to address that patient's needs in the moment
rather than accepting his lack of interest and annoyed reaction to my concern.

113
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I think there is a huge disconnect between how we are taught to listen to and empathize with
patients in the first and second years of medical school and the experience of patient care we
will have third and fourth years and beyond.
9. Have you ever received formal training in the use of critical reflection?
2 - Yes
10. If yes, in what course or program?
When I was a graduate student at UCLA, prior to finishing my master's and entering into the
doctoral portion of my coursework, I was asked to critically assess my work over my first two
years in graduate school in writing and then defend my statement in front of several of my
professors.
11. Is English your first language?
2 - Yes

81
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
During an SPP session, the patient used a word that I didn't understand, and I sort of felt
vulnerable and insecure, and less confident about my own abilities as a physician.
2. How long ago (in days; months) did this experience occur?
This occurred 2 months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I felt a little stupid in front of my friends.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
Sometimes I lack self-confidence, and the fact that I was unable to understand what the
patient was feeling only consolidated my insecurities
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
My peers also knew I didnt know the work
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would have simply asked the patient to explain what they mean
7. What conclusions have you reached based on your subsequent thinking about this
experience?
Its ok to not know things.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I worry about being able to communicate with my patients
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

114

11. Is English your first language?
1 - No

95
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I signed up for one of the community volunteer programs, when my scheduled day came, our
classes had been cancelled, and I was at home studying when I realized I was late to the
event. I sent my partner a text message that I wouldn't be able to make it -- I wonder now if it
would have been more responsible to call.
2. How long ago (in days; months) did this experience occur?
Couple of weeks
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I felt guilty about not being courteous to my partner, because he did not receive my message
until after the event. I know he spent time waiting for me.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I realize now that I didn't have the courage to cancel in advance, because I was dreading
going, and dreading trying to find a replacement, so I planned to go, but then ended up not
fulfilling my agreement to go.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
My partner was home, which made it even harder to muster the will to drive up to school (1
hr drive)
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I'd do what i know is right and cancel in advance.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
That I need to remember to treat my colleagues with the courtesy that I expect of them.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I wonder about balancing my personal desires with my professional responsibilities.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

115
96
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
On several occasions, one of my ICM members would single me out and say things to me
that made me feel like I was being sexually harassed. For example, one day I was putting
away my things at my MDL desk before Gross Anatomy lab and this person came up to me
from behind and asked me if I would like to "palpate his pubic symphysis" in an extremely
creepy voice. I was really shocked when he said this to me because I had no idea where this
statement was coming from or why he decided to say something so unprofessional towards
me.
2. How long ago (in days; months) did this experience occur?
This happened about two months ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
Immediately, I was stunned. I didn't know what to say in return because I was so offended
and shocked. I felt like I had been sexually harassed and I began to feel really uncomfortable
within my ICM group.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I feel that being a woman, I was more seriously affected by this statement than if I had been a
man. I am sensitive to things that are spoken directly towards me and I am really sensitive to
the tone in which they are spoken. I also believe in respected other human beings, and that
means not saying things that make me feel like I am a piece of meat.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The fact that I was in my MDL and there were no other people around made me feel all the
more uncomfortable with what was being said to me. Because it was said to me in medical
school, I was all the more shocked that someone who wants to be a physician could actually
treat women like this.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
Instead of being stunned and shocked into silence like I was before, this time I would look at
the individual in the eye and say in a loud and clear voice, "Don't you ever say something like
that to me again...EVER. Do you understand? I will report you for sexual harassment if you
do. Got it?"
7. What conclusions have you reached based on your subsequent thinking about this
experience?
Immature people have no problem whatsoever taking advantage of you and messing around
with you if they can sense that you are meek and humble.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
How many physicians still sexually harass their coworkers today?
How can people enter this profession without having value for other human beings, both male
and female?
How many sociopaths are accepted into medical school?
9. Have you ever received formal training in the use of critical reflection?

116
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

104
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
The one time that I did not feel comfortable and may have been somewhat upset, was the
PPM session about religion. I grow up in the “holy land” were religion is unfortunately a very
problematic issue. I feel that I have talked or even over discussed my background in many of
the class’s discussions, but I feel that it is a very important as well as sensitive issue for me.
The PPM session was extremely interesting and important. But I did not, and still don’t feel
like us (the students) writing about our own believes and religious affiliations was helpful.
Furthermore, I felt that sending that assay to a person (a reverend), who I never met, was
somewhat an intrusion of my personal belief. Perhaps it is my background but I could not
shake this feeling away. Please understand that the reverend has nothing to do with this, she
actually was extremely nice and did seem to understand, as she also have lived for some time
in Israel. But again I did not appreciate this exposure and still do not understand how it will
affect my respect to the patient own personal belief.
2. How long ago (in days; months) did this experience occur?
A couple of months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
Uncomfortable, upset and some what felt that my privacy and belief were violated
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
As mentions above my background, being an Arab Israeli and American, ground up in Israel
and experience the problems of the Middle East and the way religion is used in this conflict.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
No one really, just the idea that I will have to disclose my belief to some one I have not met
and don’t know
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I don’t think that such an issue will come up, but if a patient is interested in knowing my
belief, I will not hesitate to till then the truth. I am a spiritual person.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
Religion is something personal and the idea to force some one to disclose if they do not wish
to, is not a “good idea”.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
let the patient be the lead in there willingness in disclosing there personal beliefs

117
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
1 - No

161
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I was going to go first for the standardized patient where we were learning about the sexual
history. For some reason, I thought that since I was first, I wouldn't do the sexual history,
because that would come later. However, after my usual introduction, I asked the patient what
brought him in to see us today, and of course he answered "An HIV test". I froze. I didn't
know what to ask, how to ask it, or if it would be ok to talk about that yet. I "timed out",
which I rarely do, and ended up flubbing my way through my section of the interview.
Generally I think I do well with patient interviewing, standardized or otherwise, but I've had a
couple times when I've felt unsatisfied with my skills when I left the building. I think I'm
coming to terms with it though, because I'm here to learn, and I'd much rather make mistakes
here, with people watching and critiquing, as opposed to when I have a real patient to take
care of.
2. How long ago (in days; months) did this experience occur?
I've had a couple standardized patients with whom I said the wrong thing. The dying patient I
stupidly said "I understand how you feel", when I don't... I don't know, the most recent one
was probably in December.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was disappointed in myself, because of all the skills I'll have as a doctor, I think my
personal skills, including interviewing and making the patient feel comfortable, mean the
most to me. I value what other people think of me, so it made me more disappointed in
myself that my groupmembers and professor had shared in my mistakes.
However, I love my group and professor, so it's ok. I can try to be the "most improved"
member.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My personality... I want to be liked and I want my patients to feel like they can trust me.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
Having other people there made my reaction stick with me.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I don't think I will, I think I'll just keep learning from my experiences. I think I learn the most
when I fail, so it won't be bad if I do so again (in the end). I try to embrace the mistakes I
make.
7. What conclusions have you reached based on your subsequent thinking about this

118
experience?
I'm getting to know myself better, and I think rethinking my mistakes will help me in similar
situations in the future, so I don't make the same mistakes again.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I just hope I learn as much as I can here, so I make as few mistakes as possible once I'm
caring for patients.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?
N/A
11. Is English your first language?
2 - Yes

Integrative Complexity Level Three

107
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
The ICM experience that most directly influenced me was when I interviewed a patient who
had overdosed by taking some unknown medication. She came into the hospital unconscious,
but was revived quickly and appeared to be in good condition when I interviewed her. Her
case appeared simple, so when I went to discuss my case with my mentor, I flippantly
described the case as "boring." He questioned why I said that, and I told him about the
seemingly mundane details: the lady swallowed some pills accidently and it was an open and
shut case. My mentor asked that I go back into the room and ask the patient more about her
psychological state of being. Upon doing so, I was able to dig out an intense depression that
she had been feeling for a long while, and had denied earlier in the interview. The case ended
up being one of the most provacative and interesting of my ICM interviews, and I felt very
ashamed and embarassed for not recognizing this earlier and even going as far to describe the
case as "boring" to my mentor.
2. How long ago (in days; months) did this experience occur?
2 months
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I felt very ashamed and embarassed for treating the patient as "boring."
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My values that made me want to become a doctor influenced my response, because I didn't
think I would be one of those health care workers who treats patients differently depending
on how interesting a case is.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
My mentor's emotions influenced my response, because he seemed curious as to why I
described the case that way.

119
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would look for other interesting things in the patient. I learned that even situations and
histories which initially seem mundane can have very interesting facets behind them, and I
should work to get every piece of information I can from the patients.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I have reached the conclusion that I will interview every patient extensively no matter how
interesting or mundane their case seems.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I think that this situation has left me wondering if this will ever happen again as I become
more and more hurried and stressed higher up on the medical ladder.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

10
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
One day in ICM, we set about interviewing patients as usual. We were on the surgery ward.
Usually, our ICM instructor will talk to patients first and introduce them to us. On this
particular day, my ICM instructor approached a woman who appeared very tired and
annoyed. He chatted with her for a minute, and she revealed that she hadn't been able to sleep
the night before. Yet he continued to ask her if I could interview her, and she agreed.
I began the interview and could not help noticing that the woman seemed irritated at my
presence. I also noticed that she was in a lot of discomfort. It seemed to me at that point that
the only reason she had agreed to let me interview her was that the doctor had asked her to.
She was clearly not in the mood to have a medical student waste her time.
Continuing the interview, because I figured I couldn't leave right then or my instructor would
be irritated, I saw that she was having intense spasms of pain. We paused a few times while
she went through these spasms, and I told her I would finish quickly so she could get back to
resting. It was probably the fastest interview I have ever done.l
What I found upsetting was the fact that my instructor had put this poor woman in the
position of dealing with something so trivial when there were other people who could be
approached. I was also upset with myself for not dealing with the situation more
appropriately, and finding some way to make the patient more comfortable.
2. How long ago (in days; months) did this experience occur?
about 2 months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was initially irritated at my instructor and at myself for not finding a way to distract her

120
from her pain. I was also irritated at myself for not finding a way to get her out of the
situation more easily. I also did not really know how to react to her irritation at having to be
interviewed
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I can be kind of submissive sometimes, and I do things to please people. I didn't want to
offend my instructor, so I stayed to do the interview. I also felt uncomfortable sitting with a
woman who clearly did not want me to be there.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
Well, we were in the hospital - perhaps the fact that she just had a surgery that had caused her
this pain was an influence. Perhaps the fact that all my other group members were not dealing
with this with other patients made me more resentful.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
If faced with a similar situation, in which I observe that the patient does not wish to be
interviewed after she has agreed to do so when the doctor asks, and in which the interview is
not of any help to the patient, I think I would assure the patient, once the doctor was gone,
that she did not need to do this if she didn't want to, and that if it were too taxing, she would
be perfectly free to ask me to leave. I think it would be important to make it clear to her that
she was not obligated to have me there and that if she wanted to be left alone, that would be
absolutely fine.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I should be more assertive, and I should directly confront what I believe a patient wants.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I suppose in the future, that I would want to make sure nothing was done for the sole purpose
of "practice," especially if it would be making a patient uncomfortable.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

12
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
Last semester, my grandma passed away. This is one of the most difficult situations that I
have had to deal with. I was very close with my grandma; she was an amazing woman and a
huge part of my life. What made the situation even harder was to hear how upset my dad was.
He would get a sparkle in his eye whenever she was around. Even writing this reflection
today is bringing back a flood of memories and emotions.

121

I had to grapple with the decision of whether or not I would fly home to Vancouver to be with
my family and go to Baba's funeral. Being the week before the CORE 1 exams, my life was
pretty hectic. I was trying to do as much studying as possible to stay on track for the
impending exams, which actually helped to keep my mind off the situation. Meanwhile, I
kept going back and forth in my mind, trying to figure out if I should go or if it would be
better for me to stay at school, finish my exams and then go back home afterwards. With the
help of my parents, I finally came to the decision that I would stay at school because the
whole situation at home would be too emotionally draining for me. I ultimately knew that this
was what Baba would have wanted. It was important to me to spend time with my family and
mourn in my own way, but I didn’t need to be there that weekend at the funeral for this to
happen.

2. How long ago (in days; months) did this experience occur?
Last semester before the CORE 1 exams. About 4 months ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
When I first heard that my grandma passed away I was devastated. Even though she had not
been well for some time, I didn't see it coming. I was also upset because it was such a
stressful time for me already and when I first found out all I wanted to do was be at home
with my family.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I am generally a very emotional person who tends to cry easily, so when I found out I was
very upset. I am very close with my family, so I am not surprised that this was hard for me
and that my first reaction was wanting to be around them. Even though I am an emotional
person I tend to want to be in control of these emotions. I only talked about my grandma
passing away with my boyfriend, my roommate and my family because it wasn't something
that I wanted to share with other people. I think this is mostly because I hate feeling
vulnerable in front of other people.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The timing played a huge role in my reaction to the situation, as it was right before my first
set of exams in medical school. It wouldn't have been hard to decide whether to go home or
not if there were no exams coming up. Also, just being away from my family played a huge
role in my reaction to Baba's death.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I think that if I was faced with a similar ecperience in medical school, I would probably react
in the exact same way. I would be very uspet and look to my family for support. I would also
look to my family for advice in deciding what to do. I cannot say for sure if in a situation like
this one I would decide to go home or not.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
After going through this situation, I have realised a lot about myself. I have the ability to
decide when I am going to face my emotions, when I am going to be upset versus when I
need to focus. I am able to delay my emotional reactions when I need to to get what I need to
do done. I am not tottally sure if thi is a great quality to have or not, but I am aware of it,

122
which I think is important.

I also reaffirmed the fact that my family is a huge part of my life and it is them that I turn to
when I need support.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I think that the way I reacted to this situation, in being able to go through my emotions when
I want, may actually help me in the future as a physician. I am going to have to deal with a lot
of very difficult situations and knowing that I will be able to face them with a level head is
reassuring. On the other hand, I cannot and do not want to be able to turn my emotions off all
of the time. I will come home at the end of a hard day and reflect on the things that I have
seen and had to deal with.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

21
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I was having a conversation with one of my classmates concerning the work I have been
doing with statewide universal healthcare and we were coming up with ways to improve
student involvement. Another of my colleagues joined the discussion saying that Single-
Payer Healthcare (something of which I am a strong advocate of) was not only unrealistic but
also just a ridiculous idea. The conversation then became more of an argument (a heated one
at that) where I was no longer feeling that I was gaining anything from the conversation
except a headache. So I left the room in hopes of not pressing too many buttons including my
own.

I left feeling upset and wondering. What really upset me is that while many of my colleagues
arguments were common complaints about the system I support he never once had his own
solution and spent his time just shooting my ideas and ideals down. He did not allow for a
proper discussion to take place and through hindsight neither did I. I think this is what makes
me most upset with the situation is that I didn't help things at all. I also walked away
wondering if what had happened was a good or bad thing. Good because I had another
student at least active in his healthcare beliefs but Bad in that this may have wedged a rift
between me and my classmate that may not have occured if introduced in a better setting.
2. How long ago (in days; months) did this experience occur?
1 week ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was hurt because I felt attacked. Angry because, while I don't mind arguments against what
I believe, I mind people that just crush other people's solutions without ever offering a
solution of their own.

123
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I know I stand strongly for a Single-Payer system as the model for universal health care in the
US and because of this I know that a lot of my values and beliefs of healthcare as a human
right and that everyone deserves help influenced a lot of my argument.

I also am not a very extroverted person, nor am I someone who argues (even if I believe I am
perfectly correct) so to have to deal with a situation that was both loud and hostile.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The main external factor is the volume of the conversation. It turned into a who can talk
louder contest. It was very off-putting.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would ask my colleague to please lower his voice, ask him if he actually wants to have a
conversation or just wants to continue beating my argument without offering a counter and
then proceed to tell him what I have learned and listen to why he feels the way he feels and
not just listen to what he feels.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I feel like I give up to quickly when it comes to things that bother me or that I feel isn't going
to be particularly helpful to me in any way. I also have learned that a lot of people are not
educated in the way our current health system works or even what is really wrong with it.

I think the biggest thing I have gained from this experience is that I need to continue to be
open to other people's opinions as long as they are also open to at least hearing
mine...otherwise it seems that we'll just get stuck in a big loop.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I feel like this makes me question how strongly I can stand up for my patients in the future
and how well I can deal with people unwilling to simply agree to disagree.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

24
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
During a clinical experience involving a drug addict who required 24 hour supervision, I
found myself judging the patient and allowed it to direct my attitude and evaluation of the
patient. Another student was in the room at the time, and stated that she did not notice any

124
difference in my attitude nor did she feel that the patient was able to percieve any variance in
my attitudes, but I knew that I was judging the patient and it was not a good feeling
2. How long ago (in days; months) did this experience occur?
A few months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
My immediate reactions to the patient came from prior experiences with drug addicts and
violent patients. I have worked in the medical field long enough to have had many run ins
with these types of patients and often they have been negative. Still, this is no reason to
automatically judge a patient with these problems. My immediate feelings were to write-off
everything that the patient said. For instance, the patient believed that he was assaulted by the
police and hospital employees unjustly and my reactions were to side with the police and
hospital employees. I shouldn't side with anyone, since as a doctor I have to keep an open
mind. I also worked to close myself off from the patient, which is a defense mechanism
which doesn't allow them to see what I am actually thinking and can be intimidating. This is
something from my days back in the ambulance where you are alone with the patient in the
back of the ambulance and if you feel they may become violent, you close yourself off so that
they do not see any weakness in your attitude or demeanor. Though probably a necessary
defense then, in the hospital setting this is not necessary.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
As stated above, I believe that my past experiences in medicine have clouded my view of the
patient.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
I believe that the sitter in the room influenced my opinion of the patient in a huge way. I
know why sitters are assigned, and so I knew a lot about the patients behavior in the hospital
thus far, or at least felt that I did. Honestly, I do not check the chart prior to entering the
room, and so if the sitter had not been in the room, I would have been able to enter the room
without bias like I should have.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would try to keep a more open mind toward the patient regardless of their lifestyle or how
they have acted in the hospital prior to my entering the room.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I believe that I have a propencity to judge patients prematurely and have been working on this
flaw since entering medical school
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
As stated above, I have been working on this and hopefully will be able to have a more open
mind in the future.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?

125
2 - Yes

46
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
After reviewing my thoughts (for several minutes) surrounding the past months since
beginning medical school, I am still unable to come up with a situation that specifically meets
all the above specifications. I have a wonderful ICM group, a great MDL, and life at school
has been largely devoid of difficult experiences.

The only situation that does come to mind took place while I was working as a camp
counselor at Camp Ronald McDonald for Good Times, and it involved a hyperactive,
disobedient, troubled 12 year old named Billy (not his real name).

I am aware that the above description may apply to many 12 year-old children, but allow me
to explain my use of the word 'troubled.' Billy was placed in foster care with his younger
sister at an early age, when they were abandoned by their (alcohol and/or drug addicted)
mother. He spent time in many different homes during his early life. Then, a few years ago,
his sister died from cancer. During the acute phase of his sister's illness his mother returned,
only to leave his life again after her death. Now he lives with quasi-relatives who are quite
elderly and strict. He is, understandably, holding on to a lot of anger. Finally, this was his
first camp session since his sister died, and it was in our (my co-counselors and I) hands to
make him feel like camp was a welcoming, safe place.

So, the situation: Throughout the course of the four-day weekend Billy was having a rocky
time following rules. He constantly tested the limits of our authority as counselors, and he
would repeatedly break the same rules over and over again, sometimes only minutes after
previously being told not to. Unfortunately he was encouraged by the other boys in the cabin,
who, of course, found the rule breaking humorous. We allowed him as much freedom as
possible, trying not to be like the strict authority figures whom he had come to know in his
life.

True problems arose when he began verbally abusing (calling names, threatening) other
children in the cabin, and even sneaking the occasional push or shove when we counselors
were not looking. As I caught on to his actions, I paid much more attention to him 'out of the
corner of my eye' to monitor his actions when he thought no one was doing so.

The specific event that I recall occurred when I came out of the bathroom to find Billy
shoving another boy, this time hard enough to make him fall. I stopped the action
immediately and took Billy aside to talk with him, being very serious and reminding him of
the consequences involved if he should choose to harm another camper. Billy said he
understood, I let him back into the group, and he almost immediately taunted the boy he had
pushed. At that point I became very frustrated and, allowing my nerves to get the best of me,
raised my voice and took him outside the cabin by the arm. At that time I felt very upset, as it
seemed there was nothing I could do to make Billy stop acting out.
2. How long ago (in days; months) did this experience occur?

126
I volunteered at the camp (which has camp sessions at various times throughout the year)
about three weeks ago, Jan 18th - Jan 21st.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was extremely frustrated at Billy's actions. Secondary to that initial frustration, I became
upset with myself for becoming so frustrated such that I raised my voice with him. I saw a
change in his face the instant I went from a friendly counselor to a stern authority figure, and
it was not a good change. This also made me upset, as I knew how important it was for him to
understand that camp is a different than anywhere else he has been.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
Personally I am a very calm person. I am not very easily agitated, even when someone else is
directing anger towards me. Also, I am a 'good kid' as my parents always said. I listen to rules
(mostly) and no what behavior is appropriate and what is not. This can cause me to become
frustrated when other people do not act in the same manner.

I became angry at me, however, because I normally pride myself on being able to 'put myself
in other peoples shoes.' When I see someone do something I disapprove of, or something that
effects me negatively, I can normally step back mentally and try to understand their motives.
This is part of what allows me to stay calm, even in the face of aggression.

i am calm, follow rules, hard to understand ppl who dont
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
Certainly the setting and the people around. At that point in the weekend I was becoming
worried for the safety (mental and physical) of the other children. Even though I wanted Billy
to have a good time at camp, the other children deserved that as well.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I think that I would try even harder to remain neutral, calm, and to see the situation from the
other person's point of view. I do not anticipate anyone here displaying naked aggression
towards other students, but I am sure I will face aggression/other strong emotions directed at
me in my years of medical training to come.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
Well, I realized that I may not be in complete control of my temper and my ability to
empathize with others, although I think I do it fairly well. In truth I am a very self-analytical
person, and I had already considered some of what I have discussed here in my own private
time.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
None not already discussed, I suppose.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?

127
2 - Yes

62
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
During the beginning of the school year we received orientation about all the aspects of the
medical school that were basic to our knowledge of how things worked here at Keck-USC.
We were given a lecture by a studies skills professor, which made me feel as if I could handle
the material in medical, yet I still felt uncertain about my abilities. Toward the end of
orientation week, we were asked if we knew what Keck-USC Medical School expected of us
by a show of hands, I didn't raise my hand. Even though I didn't raise my hand and I had
mixed, confused feelings about how to handle the curriculum, I didn't seek help and as a
result I failed Core I.
2. How long ago (in days; months) did this experience occur?
It occurred 5 months ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I felt independent, almost as if I were alone, and if I were to seek help it was because there
was something wrong with me.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My internal factors that influenced my response to the event were that I should be strong and
figure things out myself because only the weak sought help.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The external factors that influenced the event were the illusion that everyone else had things
figured out so I should also. Plus, I felt that I would be ridiculed for seeking assistance early
on.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would definitely not allow myself to feel weak for asking for help, even if another person
that is giving me the help or others around behave or react in a way as to imply that I am
weak. I will remember that it takes strength and wisdom to be able to seek help when it is
needed.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
My conclusion is that when something doesn't feel right then maybe its not right, e.g. feeling
uneasy about my ability to handle the material in medical school. As a result, I should seek
input from a person, who is qualified to help me resolve my uncertainties and confusions.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
The questions or concerns that this experience raises for me to explore in my future as a
physician include not being able to seek the help of others due to the inability of others to
help me for example if I have a difficult diagnosis to make and I can't find help from
colleagues. Also, will I be able to know how/when to seek help when an aspect of medicine is
too much for me to handle? Will the profession of medicine overwhelm me and cause me to

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be bitter about life or will it be profoundly satisfying since I put so much hard work into it
and now am be able to see the fruit of that work and the important, worth-while contribution
to my community and society?
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

83
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
Several weeks ago, during ICM, I was assigned to interview a middle-aged male patient at the
county hospital. In the previous couple months, I had interviewed a number of patients, and
had always had good experiences. The patients were willing to share their stories with me and
some even took a personal interest in me and asked me about my life, school, etc. With that
background, I was a bit put off by my new patient, who seemed rude from the start. He was
rather cynical and negative, and would respond sarcastically even to genuine inquiries about
how he was feeling ("How do you think i'm feeling, I've got cancer!"). Though I explained
that I was a 1st year student and was still learning the ropes, he had little patience for me
when I took too long to write down notes or had to ask him questions twice. The encounter
made me feel quite uncomfortable, and I terminated the interview somewhat early, before
obtaining a thorough history and review of systems.

The patient's negativity and impatience with me left me feeling anxious and unsure of myself
and my interviewing skills. I felt conflicted, because I wanted to leave his presence as soon as
possible, but I also felt obliged to complete the interview.
2. How long ago (in days; months) did this experience occur?
~2 months
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
My initial response was to feel angry at the patient for treating me as he did. I considered that
if the patient treated his medical team the same way, it was likely that his quality of care
would suffer, because he would be motivating his doctors and nurses to avoid him. I felt like
he deserved sub-optimal care if he was such a jerk as to drive people away. At the same time,
I felt conflicted, because I thought that I might be making the fundamental attribution error
by attributing his behavior to his personality rather than his circumstances. I have taken social
psychology, and I understand that normally nice people may behave poorly when they are
suffering from physical or emotional pain. Considering that the man was being treated for
cancer, it made sense to cut him some slack. Nonetheless, I still felt hurt about the things he
said to me.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I tend to be hypersensitive to criticism, especially when I am being criticized about something
that is important to me. Being a successful medical student is a big part of my self image, and

129
when the patient insulted my abilities in this area, I did not take it well.

I also tend to be rather unsympathetic to the complaints of patients who are getting free or
reduced-cost care. My gut feeling about these patients is that they should be grateful for any
care that they get, since they are already draining the system. However, that is just my gut
feeling, and when I think about the issue, it becomes obvious to me that all patients should
receive the best care that we can provide them, even if they are not very kind, and even if
they cannot pay.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The fact that the interview was only for ICM purposes and would not contribute to the
patient's care made it easier for me to end it early.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would want to take a 2 pronged approach to the next hostile patient that I encounter. I would
want to quell my own negative emotions by reminding myself that the patient was probably
going through a lot of stress and pain, and that I might just be getting them on a bad day. I
would also want to try to be extra empathetic and supportive, as this patient probably needs it
more than anyone. Moreover, I have found that people usually aren't so hostile if they feel
connected and understood by someone else.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
That I should always try to see a suffering person behind the angry facade, and that I should
try to see hostility as a symptom of pain, rather than as a personal attack on me and my
clinical skill.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
While showing empathy to hostile patients is a good start, I want to know more specifically
what the best approach is to these patients, and if there is anything else that I might do to
improve my interactions with them.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

101
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
GA lab was difficult in the beginning. Our group didn't share responsibilities well. Everyone
wanted to dissect. Nobody wanted to read the lab guide because then it became hard to get a
turn with a scalpel. Some people came to lab unprepared. I made it a goal for myself to try
and facilitate a better dynamic by the time we dissected the heart.

130

I came up with a rotation of jobs and emailed the group. I was nervous about it, because I had
been stomaching a lot of frustration and I didn't want to appear critical in an unconstructive
way. However, the group was receptive to my ideas.

Our heart dissection was a highlight of my year. We all took turns teaching each other
different sections of the the dissection and everyone had their turn to dissect. It was also very
productive and I did not have to study the heart much after our dissection. Overcoming our
group problems in GA lab brought our group closer, and helped us learn how to be more
productive together.
2. How long ago (in days; months) did this experience occur?
This happened in the beginning and middle of Core 1. It may have been 4 or 5 months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
Please read my response to #1.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I was overwhelmed by the coursework in Core. Furthermore, I learn things best when I am
actually holding something in my hands. When other group members didn't invest as much as
me in our GA lab sessions I felt very frustrated. I was frustrated both because I didn't feel I
had time to waste, and also because I felt I was losing a hands on experience that is more
effective for me than a text book.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The people in my group influenced the event. Some of my ICM members helped me find a
solution and others were the source of frustration.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would try to be more patient. The more frustrated I get, the harder it is to be patient.
Although, I suppose the most important time to be patient is when I'm frustrated.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
It took effort for me to hold my tongue for weeks until I'd formulated a clear constructive
opinion. But, in the end I feel I did the right thing, and I hope I would react the same way
again.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I am drawn to teamwork environments which is one reason that I think a lot about emergency
medicine. But teamwork can be as challenging as it is rewarding. This experience makes me
realize that the group dynamics can be just as challenging as other aspects of patient care.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

131
118
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I can't say I've had many unpleasant experiences in med school, but a recent incident in an
ICM workshop comes to mind. Prior to this experience, I had been feeling rather confident
about my ability to communicate and establish a rapport with patients. In this particular
workshop, when the standardized patient revealed that she was a devout Christian, I thought,
"oh, I have this one in the bag" since in the past my own religious experience has helped me
connect to several real patients. When it came my turn to interview the SP, I asked if she had
a mammogram, and she replied adamently, "My husband prays to God that I won't get breast
cancer, so I don't need one." I was totally flabbergasted, and in confusion and nervousness,
burst out laughing. I tried to tell the SP, "Well, God is good, but you still need a
mammogram," (which in retrospect is CLEARLY an insensitive remark), but our instructor
called a time out, and one of my ICM members had to deal with the mess I'd just created.
2. How long ago (in days; months) did this experience occur?
It was in the Patient Education ICM workshop (so just about a month ago).
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I felt bad that I had "performed" poorly, particularly in an area that I'd previously considered
a strength. I was also embarrassed and ashamed that I had reacted so immaturely and
insensitively to a patient's concerns (of course, I was also relieved that it was only with an
actor, and not a real patient!)
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My faith is a very important part of who I am, and it bothers me when either my own beliefs
or other's are mocked or belittled. So I felt even worse about laughing at a patient's religious
views in front of my whole ICM group.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
I guess I was nervous, since I did have my ICM group and an instructor watching the
interaction. Also, the SP was a fabulous actor, and became quite visibly upset at my outburst.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I hope I would have been more sensitive and less hasty to respond. I should have asked the
SP, "tell me more about why you feel this way" and to explain her beliefs (and possibly fears)
about the mammogram.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I need to be respectful and sensitive to ANY belief that my patient holds, even if it seems
completely irrational and contrary to sound medical advice. I should let the patient explain
their perspective before I try to educate and 'correct' their misunderstanding.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
How can I be consistently show respect and sensitivity to my patients while still giving
quality medical care? (It's harder than it sounds).
9. Have you ever received formal training in the use of critical reflection?

132
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

121
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I have been concerned in general, not so much by any one event, but instead by what I feel is
a lack of balance in my daily life in regards to my studies and other aspects of my life.
2. How long ago (in days; months) did this experience occur?
This is a situation that comes and goes, some days/weeks are more balanced than others.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I feel a real division between spending time on my studies and spending time developing the
other areas of my life outside of schoolwork. I've felt guilty when I do not study, but I've also
felt guilty about watching friendships, personal exercise habits and other interests fall out of
my daily life.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
My background as an English student is a double-edged sword--it made me accustomed to
leading a well-rounded life (because I had the time to), and it made me the type of person
who over-analyzes situations. I have a strong desire to be and mean more than just my school
work.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
It has been hard to see fellow classmates, seemingly successful in their coursework and very
involved in clubs, extracurricular activities, ski trips, etc. I've perhaps unfairly thought that
many of these students were involved in nothing more than resume builders without any real
commitment to such things and that is not something I want for myself. But this could be an
excuse i am making.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I am constantly trying to find better balance but it gets tough because with each new system,
I feel like I have to start all over again with figuring out how to study, how to learn, how to
get to the gym, how to make time for friends, etc.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
Keep trying. This is life--this is an ongoing process that is not going to one day solve itself.
But I feel confident I can improve it.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
This raises A LOT of questions. I want to be the doctor involved in research, involved in the
community, well-read in literature outside of medicine. I want to be the doctor who caught

133
the last Lakers game, who takes a sunday afternoon and spends it at the beach or the park or
with the family. At the same time I also want to be the doctor that knows the most up-to-date
treatments and cares for patients in the best way possible.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

134
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
There is a specific event that occurred at the beginning of the year that sticks out in my mind,
and when I look back on it now I am extremely upset at myself in regard to the way I handled
it. It was the third week of school and my roommates and I had decided to have people over
for a small party at our house. There were a couple of people in our class that we had judged
and labeled as people that we did not really want to associate with and did not want at our
house. The day of the party we were in class and one of these individual came up inquiring as
to our plans for that night, and it was obvious that he had somehow heard from other people
about the party. It was an awkward conversation and we simply ignored the “white elephant”
issue we were faced with. We quickly ended the conversation telling this individual that we
weren’t sure of our plans yet but if we did anything we would let him know. We of course
never did. Looking back at this now, I am extremely upset with the way I handled the
situation, because I judged someone without truly getting to know them. This went against all
the morals that I try to live my life by and was completely out of character for me.
2. How long ago (in days; months) did this experience occur?
5-6 months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
We the main problem was that at the time I did not even consider how this event would affect
the individual that we were avoiding. It was pretty obvious that he knew we were ignoring
him, and for some reason I acted completely out of the norm, as my usual personality is to
involve everyone in everything I do. It was a few weeks later that I realized how
inconsiderate and mean I had been.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
A couple of weeks after the event, my values and morals in a sense kicked back in and I
realized how wrong I was in my actions. To this day I am not sure what came over me and
caused me to act the way I did, but I am still angry with myself for ever acting in such a
manner.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
I think perhaps the fact that my other friends around me were acting in the same manner
somehow made it seem like it was acceptable to be genuinely mean and ignore the person. It
was the beginning of the year as well, and everyone was still in the process of forming

134
friendships and learning about themselves and others. It was a difficult and stressful time in
our lives starting school, and perhaps this was part of the reason for the extremely out of
character behavior.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I would never again act in the manner that I did that day. I attempt to include everybody in
everything that I do.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I have concluded that this was a strange experience in which I acted unlike myself and went
against my values and my personality traits, and I have made an effort since then to be
conscious of my actions so something like this never happens again.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I don’t think that I have any concerns in regards to this experience, but rather I take it as a
wonderful learning experience. It has taught me that judging people on initial impressions is a
terrible thing to do, and I have attempted since then to expand this to my medical education
as well. Judging patients based on looks is extremely common in the medical field, and I have
made a conscious effort as a result of this event never to participate in this judging.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

141
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA
lab; MDL; lecture hall) setting that has occurred since you started medical school,
in which your own behavior or reactions directly affected the event that resulted in
your feeling confused, upset, or left you wondering.
During the ICM focus experience at Our House, the grief support center, I found myself not
able to control my emotions. When forced to participate in a role playing experience with my
classmates I ended up losing all control of my emotions as I began to cry and left the room.
The role playing the center director designed for my turn was that another girl and I were
sisters who find out about our mother who died due to a heart attack. Coincidently, the other
girl and I both have lost our fathers in the last eight years. For both of us, the Our House
experience was difficult; but we did not think that the center director would be so insensitive.
During that week my mother was ill and her blood pressure was not lowering. I was
exhausted and easily pushed over the edge. Through out the morning at that horrid place I
was reliving my grief for my father; but when the center director "killed" my mother, I lost
all control. I felt my world fall apart as it crashed down around me. All my life I was raised
to not show weakness, but in that moment I lost all my strength as my defenses were stripped
from me.
2. How long ago (in days; months) did this experience occur?
four months ago, approximately.

135
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I hated myself for crying in front of strangers, but I hated myself more for crying in front of
my peers. I felt weak, angry, and humiliated.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
Maybe I never truly faced my grief about my father, maybe I should have handled the
situation more maturely. I did not want people to see me cry, so I left the room. After I
walked out I realized I cannot return because I could not stop crying. I felt a flood of
emotions that I was unable to control, but mainly, I felt that I humiliated myself in front of
peers.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
The week before the event I did not sleep much, nor did I relax much because my mother
was ill. I live with her, so I take care of her when she needs me. This time was scarier than
other times because I just could not help her. Her blood pressure was high, she was
experiencing discomfort and pain. I was terrified of the thoughts running through my head:
MI, death.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I did experience this while in medical school.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I realized that I must face my demons on my own time and not linger in grief or sorrow.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
To be able to become a good physician, I must learn to separate my personal affairs from
work.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

145
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
The experience that sticks out in my mind is the most recent OSCE. I felt like I wasn't myself,
and I really didn't perform as well as I would have liked. I was incredibly nervous, and for
some reason I froze. I am usually pretty calm with patients, and I feel I do interviews fairly
well, at least average for the point I am at in medical school, but I just felt horrible when I
came out of it. It was the first time that I was interviewing a patient, by myself, that didn't
already have a diagnosis. Plus, I had to inquire about her sexual history, which I don't have a

136
lot of practice with. I just didn't ask all of the questions I was supposed to, and I didn't pick
up on that fact that she didn't want to take an HIV test because she was scared. It seemed as if
she didn't want to know the results. I felt as if a real patient might have asked me more
questions to prompt me to think that she was uncertain because she didn't know the
implications of a positive test, but I still should have picked up on it. I left feeling
disappointed in myself, although I know it was a good experience that I will learn from.
2. How long ago (in days; months) did this experience occur?
4 days, Feb. 5.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
Please see above
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I realized that I felt unprepared in my medical knowledge to answer some questions that
might have come up. However, what I realized the most was that I was actually scared of the
patient, meaning I didn't want to possibly tell her that she could have HIV. I realize now that I
am going to be in countless situations where I have to deliver bad news, or I have to pose
possibilities that aren't what patients want to hear, but that was the first time I had to do that
and it scared me.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
I didn't like having an instructor who I never met watching me. Also, my friends who went
before me all said they did really well, so it made me feel a lot of pressure.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
I think I will remember how I felt, and try to make myself calm. I will keep telling myself
that I need to ask these questions, and that it's for the good of the patient.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I think that I need to pay attention to my emotions and how I feel, and decide which ones I
need to push to the side and which ones are helpful for me. I also think that I just need more
practice, which I will surely get.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
See above.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

Integrative Complexity Level Four

148
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own

137
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I was interviewing a patient for ICM at County and most of the time I force myself not to be
judgmental in anyway, however this particular encounter angered me and forced me to think
about where healthcare is going in the united states. She was a chronic heroine user since she
was 18 years old and has been smoking since she was 15 years old. She at the time of
interview was in her mid 50s. She is on welfare and told the doctor she was applying for
Medicare. She comes to the ER at County to get her asthma medication since its the only way
she will get it. I was angered by this since so much money is being poured into a person who
spends their money on drugs and cigarettes. Outside of that, she clogs up the ER for her
asthma when there are other ways to treat her chronic asthma. I caught myself the entire time
being angered by this patient and she was equally as annoyed with me since she was being
discharged at that very moment and didn't want to speak with us. I can't even consolidate all
my feelings about this encounter because even writing about it, it upsets me and frustrates me
that some medical conditions can be treated in a different way, with less money, and more
importantly better care for the patient. She should never get to the point where she can hardly
breathe because she doesn't have medications. the next logical question is the most difficult
of all: How do we solve this problem? Obviously we need to start with government
administration because the change that takes place there, trickles down the mountain to every
hosptial and health care center.
2. How long ago (in days; months) did this experience occur?
a couple months ago
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
I was frustrated and mad initial, shocked that she was a chronic drug user with no job and on
welfare, and secondly using the ER because she ran out of medications. It was overall
frustration not only at the patient but at the system. She doesn't have much of choice when
she runs out of medication, but through the interview, she didn't make much of an effort to
change her life. she didn't have a desire to work and i think that lack of want for change is
what upset me the most.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I think my belief of you get what you work for particularly drove this emotional response.
I've never gotten things without working for them. I dont beleive in freebies. I do think that
people need help getting back on their feet in certain times and thats fine, but i dont think that
people shoudl take advantage of a system that is trying to help them. There was a story on the
news a month ago where a middle school child participated in an essay contest where they
were to write about a new law. The winner had cerebral palsy because his mom was on drugs
when she was pregnant with him and he thought that a program should be implemented to
track how people's welfare money is spent, so that the money that is meant for food and
utilites is used for that and not allocated elsewhere. Such a simple idea, and yet a very wise
one. That way, people can learn how to allocate their money to essentials and not to things
that not only destroy their lives but also their health.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
Being that it was an interview, there was little to interfere with the response i've described
6. If faced with a similar experience while in medical school, how do you think you would react
differently?

138
It was mostly an internal response, so I don't think that my feelings towards this subject will
change. however I will make an effort to ignore them for the duration of the interview so i
may not inadvertently expose those feelings to the patient
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I think that this wont be the last time i interview someone like this, but at the same time, i
realize it may not be all their fault which is how I may have first reacted
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
I think that this is something i will have to learn to cope with working at County since this
patient will not be the last one i see like this. And I have to remind myself that getting angry
at the patient or at any one is not the solution. You have to work with each individual to
provide preventative care. I think thats the most important step as a future physician. The rest
is politics and something that is difficult to change. If the change can be made, it will
drastically change how we treat patients and how both physicians and patients view disease.
9. Have you ever received formal training in the use of critical reflection?
1 - No
10. If yes, in what course or program?

11. Is English your first language?
2 - Yes

47
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
I was speaking with an instructor about my family life and history in a pleasant conversation,
when he used the word “oriental” (I am Korean-American). He kept going without realizing
his blunder, and I didn’t say anything. I asked myself why I hadn’t, when normally I would
(as non-judgmentally as possible). Explain to the person the history of that word, a little
racial political and linguistic history from my perspective, and hope that I had educated
someone that day. But I didn’t. Maybe b/c he’s an older man (went to med school in the 50’s
and it’s a “generational” thing). Maybe because he’s my instructor, maybe because I like
him, maybe because I’ve learned to pick my battles, maybe a little of all of those reasons.
2. How long ago (in days; months) did this experience occur?
This experience occurred in the first few weeks of February.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
In my head… “Awkward. Does he realize what he said? No, I guess not. I mean, he doesn’t
mean it in an offensive way. But I’m so tired of “good intentions.” That’s not always enough.
But he’s old school. To him, this word is absolutely okay. Should I say something? Maybe
write him an email? I hate this.”
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
As a Korean-American, as a race studies student, and someone who is interested and invested
in racial politics, I always struggle with the idea of having to educate others about issues or

139
language in this case that they may have been previously unaware. Do I always voice my
opinion even if some may view me as aggressive, maybe even militant? Again, it’s about
choosing my battles. I came from an academic setting where there was an assumed
foundation of knowledge about critical race and gender issues. I understand that med school
is not that same environment.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
Another person from my groups was also in the conversation. I’m not sure what her reaction
was to the word. We didn’t talk about it. Maybe she didn’t even notice. Maybe I didn’t say
anything b/c I would want it to be a more private conversation between my instructor and
me.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
If it was a fellow student, I think I would absolutely say something. I think I would wait first
to see if anyone else (hopefully, someone not Asian!) would say something first. I am hyper-
aware of how I may protect myself as the girl who studies race, and I don’t want that image
to affect the conversations between my peers, my instructors, and me.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I think more before I speak. I’m more aware that I’m not surrounded by like-minded people,
and I need to know when it’s appropriate and worthwhile to speak up.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
Again, choosing my battles. Had it been a patient who called me oriental, I’m not sure I
would say anything. Because it’s not about me. It’s about the patient and his/her health. At
the same time, it’s important to acknowledge and name ignorance when I see or hear it
because silence does not induce change.
9. Have you ever received formal training in the use of critical reflection?
2 - Yes
10. If yes, in what course or program?
High school: Peer support counseling program; College: Minority peer counseling program
11. Is English your first language?
2 - Yes

152
1. Please think of an experience in the clinical (ICM; volunteer) or classroom (GA lab; MDL;
lecture hall) setting that has occurred since you started medical school, in which your own
behavior or reactions directly affected the event that resulted in your feeling confused, upset,
or left you wondering.
During my ICM rotations through LAC-USC Medical Center last semester, I came across a
patient who was suffering from chronic alcoholism, depression and suicidal thoughts. As an
ICM group, we were randomly assigned patients on the ward and told to interview them.
When I walked into the room I saw a decrepit male with bright yellow eyes. He had a tremor
and initially refused to look me in the eyes. I asked him for permission to take his history and
he mumbled that it was fine. Suddenly, when I began asking him certain questions he glared
at me and began to become hostile. Eventually, after overcoming my initial shock at the
situation, I felt more comfortable and was able to empathize with him. I understood where his

140
feelings of frustration came from: disappoiting his family and himself, being ordered around
by doctors and social workers and most importantly, not being able to let go of the grasp
alcohol held on his life. After understanding this I was able to direct my conversation and
behavior towards his situation. As almost having been transformed, he began telling me all of
his fears and frustrations. At the end of the interview I gave him some encouraging words and
thanked him for his time, and he looked at me square in the eyes and said, thank you for
listening and having that talk with me.
2. How long ago (in days; months) did this experience occur?
Approximately 5 months ago.
3. Please describe in detail your immediate reactions (i.e., thoughts; feelings) to the event.
My immediate reaction when the patient first lashed back was that of surprise and annoyance.
In my mind I was thinking, "why did he lash out at me?" "I didn't do anything to this guy."
Also, I couldn't help but think that many probably tried to help him, but with that attitude he
probably turned people away. At the end of the event, I was extremely satisfied with the
manner in which I chose to handle the situation. I stayed calm and decided to find out in a
non-threatening manner what his issues were. It was an eye opening experience illustrating
how split second impressions and decisions when we meet people can have drastically
divergent effects.
4. What internal factors (i.e., your personality traits; emotions; values; biases) influenced your
response to the event?
I believe that I stayed calm and didn't take offense to his attitude initially because I felt that it
wasn't a personal attack on me. I figured that he was probably frustrated with his life at that
point, and maybe even his health care. I stayed calm and reminded myself that anyone in that
person's position would not be in the lightest of moods. It was my job to put him at ease and
try to help him forget all of his problems, even if only for a few minutes. That way I was able
to find out a lot of what drove him and a significant portion of the events that led him to his
medical condition.
5. What external factors (i.e., setting; other people; time of the event; etc.) influenced your
response to the event?
I don't think there were any notable external factors that affected my response to this event. In
fact, I was extremely surprised initially when the event took place because there were no
external hints causing me to expect the patient's reaction.
6. If faced with a similar experience while in medical school, how do you think you would react
differently?
The way in which I reacted for the most part was fairly successful. I think next time I
experience this, I will have a better understand of the situation and not be as surprised.
7. What conclusions have you reached based on your subsequent thinking about this
experience?
I readily understand now why many patients, especially those that are easy to stereotype, are
frustrated with their medical care. Medical staff in hospitals may not take the time to
understand the background of an individual because it takes too much time and effort to do
so. They take the easy way out, which is to form and solidify their initial impressions and
simply treat the biological causes of ailments rather than address the human issues as well. In
this instance specifically, the patient confided in me that he was sick of being told what to do
and how to do it. He asserted that it was his life, and it was time for him to take control of it.
Later in thought I wondered how much more effective his treatment would have been if his
health care team included him in a team plan rather than having ordered him repeatedly what

141
he had to do.
8. What questions or concerns does this experience raise for you to explore in your future
practice as a physician?
Although I did in the end have a meaningful and cordial experience with my patient, I am
curious to know whether there were other ways in which a physician can approach his patient
to calm down situations. Also, I did not necessarily know what was appropriate to say to
someone who is suicidal. These are important questions that I have addressed in my own
time, but I think would be valuable to continue learning about.

9. Have you ever received formal training in the use of critical reflection?
2 - Yes
10. If yes, in what course or program?
Several class activities and retreats I have been involved with for leadership training.
11. Is English your first language?
2 - Yes

Abstract (if available)

Abstract This mixed methods, exploratory study examined the content and characteristic levels of integrative complexity of 45 first year medical students' written reflections upon a personal challenge/dilemma they had encountered in the clinical or classroom setting. As well, cognitive style was examined as a possible predictor of integrative complexity. All incoming medical students at the University of Southern California's Keck School of Medicine (USC-KSOM) take the Myers-Briggs Type Indicator

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Asset Metadata

Creator Logan, Moreen E. (author)

Core Title Medical students' reflections on professional behavior: cognitive style as a predictor of content and level of integrative complexity

School Rossier School of Education

Degree Doctor of Education

Degree Program Education (Leadership)

Degree Conferral Date 2008-12

Publication Date 11/05/2008

Defense Date 09/10/2008

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag integrative complexity,OAI-PMH Harvest,personality type,professionalism,reflection,temperament type

Place Name University of Southern California (geographic subject)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Goodyear, Rodney K. (committee chair), Nyquist, Julie G. (committee member), Sullivan, Maura E. (committee member)

Creator Email mlogan@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m1748

Unique identifier UC1102826

Identifier etd-Logan-2381 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-126718 (legacy record id),usctheses-m1748 (legacy record id)

Legacy Identifier etd-Logan-2381.pdf

Dmrecord 126718

Document Type Dissertation

Rights Logan, Moreen E.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu