Reflective Practice and Stress: Helpful, Harmful or Uninfluential in Critical Thinking

Abstract

R emember the first time you watched a master clinician work through a diagnostic dilemma or clinical unknown case and easily arrive at the correct diagnosis? That person most likely seemed calm with little stress, asked the right questions at the right time, and often reflected on the information they gleaned from the case. If the clinician described how they arrived at their diagnosis, you were probably in awe at how they solved the case using their critical thinking skills. While critical thinking is essential for effective patient care, this highly complex process is not easily taught or measured.Critical thinking can be seen as having two components: 1) a set of information and belief generating and processing skills, and 2) the habit, based on intellectual commitment, of using those skills to guide behavior. 1 Thus, while possessing medical knowledge is a necessary part of critical thinking, many factors play a role in the process, such as data gathering skills, clinical context, patient preferences, personal reactions to stress and reflective practice. Research demonstrates that some stress and thoughtful reflection are beneficial to the thinking process, 2-4 yet there is no consensus on how to positively manage stress or use reflection in daily clinical care. Two articles 5,6 in this issue of JGIM explore the areas of stress and reflection on critical thinking among trainees.The study by Pottier and colleagues 5 explored the role of stressors on a medical student's history taking, physical examination, and clinical reasoning. The authors performed a study of medical students who participated in two scenarios with standardized patients with familiar disease processes. Students conducted a history and physical exam and were asked to generate a diagnosis with a differential based on the clinical data obtained during the scenario. During their patient encounters, students were presented with two stressors: extrinsic and intrinsic. Extrinsic stressors were manifested by the patient's cooperativeness and mood such that the patient was either: a) aggressive with negativity and lacked confidence in the student's competence; or b) pleasant without challenges to the student. Intrinsic stressors were defined as stressful components integral to the encounter based on clinical presentation, and were exhibited by a patient with either high clinical severity (dyspnea from an acute pulmonary embolism) or low clinical severity (acute abdominal pain in a relatively healthy patient). Students were randomized to two of four clinical scenarios with a balance of high and low clinical severity in an aggressive or pleasant patient. Subjective stress and anxiety responses were assessed before and after each experience, as were completeness in physical examination, communication skills, diagnostic accuracy and differential diagnosis argumentation. The authors found that each type of stress had a different effect on a student's anxiety and clinical performance. Results indicated that extrinsic stress increased personal anxiety, bu...

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