Abstract
Introduction
Medical students frequently encounter ethically complex, emotionally charged, and socially nuanced situations during their clinical training. 1 Opportunities for students to process and reflect upon these formative experiences, which are important for fostering personal and professional development, are unfortunately often lacking.2,3 As students transition from classroom-based learning to patient care, they begin to witness the subtleties of real-world medical practice, including the influence of social factors on health outcomes, quality of care, and interpersonal dynamics. Without formal spaces to process these observations, students may internalize conflicting messages about professionalism, communication, and patient advocacy.4,5
Clinical clerkships are a pivotal phase in shaping students’ professional identity, values, and understanding of medicine's broader social context. 6 While clerkships emphasize clinical skill acquisition and knowledge application, they often are not enough to fully teach the more humanistic, ethical, and societal dimensions of patient care.7,8 Recognizing this gap, medical educators have increasingly turned to structured, guided reflection as a means to help students make sense of these experiences, promoting empathy, critical thinking, and self-awareness.9-11
Reflective writing, in particular, has emerged as a powerful pedagogical tool that allows students to confront complex social and ethical issues that arise in patient care.12,13 In recent years, there has been growing attention to how reflective writing can help students recognize and address critical components of equitable care, such as bias, social determinants of health, and healthcare inequities. 10 Previous research has demonstrated the value of reflective writing in developing empathy and self-awareness and has shown that students are capable of identifying social determinants of health in patient care. 13 However, it remains unclear how deeply they reflect on these issues and whether they are given sufficient space to critically engage with these topics during their clinical rotations. 13
This study seeks to address these gaps by analyzing reflective patient logs submitted by third-year medical students during their neurology clerkship. As part of a novel curricular program, students who complete their neurology clerkship rotation at the Cleveland Clinic are required to submit a healthcare improvement log reflecting on a social aspect of care seen during their rotation to encourage critical reflection on their clinical experiences. The primary objective of this study is to characterize common themes that students identify and evaluate the depth of students’ reflections on these topics. By examining these reflective narratives, we aim to gain insights into how students perceive and respond to the healthcare environment, and how students would benefit from being given a space to reflect on their clinical experiences.
Methods
This was a retrospective, qualitative study to analyze the content of student reflections while on their neurology rotation at the Cleveland Clinic. The study was approved by the Cleveland Clinic Institutional Review Board. The reporting of this study adheres to the Standards for Reporting Qualitative Research (SRQR) guidelines (Supplemental material). 14
Student reflection assignment
Medical students who complete their third-year clerkship rotations at the Cleveland Clinic are required to submit patient logs for every patient encounter they experience to track meaningful clinical encounters. Additionally, during the neurology clerkship rotation, students are required to submit an additional Health Improvement Log reflecting on a social element of care that they witnessed while on their neurology rotation. Specifically, students were instructed to write a short reflective narrative about a patient experience or summative experience that includes reflections on bias, social determinants of health, health inequities, health care system challenges, and/or quality improvement opportunities that they noticed during their rotation. If students did not witness a qualifying experience, they were instructed to submit a log stating that no relevant incident had occurred. This reflective writing assignment was mandatory and completed individually by all students. Credit was awarded based on completion and submission, regardless of the specific content of the reflection. After writing their log, students were required to send the log for feedback to the clerkship director and assistant clerkship director. The clerkship director and assistant clerkship director responded individually to each student's log with a written comment, typically within 1 week. These responses aimed to acknowledge the student's reflection, provide additional teaching points, and encourage further critical thinking and professional development.
In addition to the written feedback, throughout the 4-week clerkship, students met with both clerkship directors weekly in a small group setting to provide a space to debrief and discuss these encounters further if students were interested in doing so.
Data collection
All student reflective logs and corresponding clerkship director responses submitted between June 5, 2023, and May 3, 2024, were downloaded from the secure Cleveland Clinic medical student portal. This portal is used routinely for submission and review of clinical logs across all rotations. A total of 46 students completed the clerkship during this period. All 46 students who completed the neurology clerkship during the study period submitted reflections and were included in the analysis (no students were excluded). After completion of the 2023-2024 academic year, all Health Improvement Logs were downloaded in bulk and reviewed to confirm that no identifiable patient information or student identifiers were present. Each log-response pair was then assigned a unique study ID and stored in a deidentified database constructed through the Research Electronic Data Capture (REDCap, Nashville, TN) for analysis.
Data analysis
The initial coding and thematic analysis were conducted by a medical student who had previously finished their clerkship rotations (NM). They had no involvement in the teaching, administration, or evaluation of the neurology clerkship. This allowed the student to bring an informed perspective on the clinical learning environment without introducing potential bias related to course leadership or grading.
We used thematic analysis to analyze the reflective logs. Thematic analysis is a flexible method for identifying, analyzing, and reporting patterns or themes within qualitative data, offering a structured yet adaptable approach for interpreting meaning across a dataset. 15 Specifically, we employed a hybrid approach that combined both inductive and deductive methods of thematic analysis. This allowed for the identification of themes that were both data-driven (inductive) and informed by an a priori framework (deductive), aligning with our research objectives.16,17
The analytic process followed a multiphase structure. First, the primary coder reviewed all student reflections and clerkship director responses to generate an initial set of codes and thematic categories using a combination of deductive and inductive approaches. These preliminary themes and definitions were then reviewed and discussed with a second coder, who was an independent research coordinator (ML). This coder also had no involvement with the clerkship. After finalizing the coding framework, the primary coder applied the revised codes to the full dataset. The second coder then independently reviewed all logs and categorized each reflection and response according to the shared framework. Discrepancies between coders were documented and resolved through discussion and consensus. This stepwise process helped minimize bias, enhance coding reliability, and ensure consistent application of themes across the full dataset.
Prior to the initial coder performing a preliminary review of the reflections, predefined categories included whether the log described an observation of bias, social determinants of health, health inequities, healthcare system challenges, and/or quality improvement opportunities. Additional themes that emerged during review were incorporated through inductive coding. Where applicable, subcategories were used to further characterize the observations, such as racial or gender-based bias, language barriers, insurance-related issues, or structural barriers within the healthcare system. In addition to identifying the content of each reflection, the emotional tone of each log was coded. The tone of each log was classified as frustration, empathy, inspiration, and/or neutral. The main takeaway or learning point described in each reflection was also documented, with examples including increased self-awareness, increased growth in professional identity formation, improved ability to deal with ethical dilemmas, and/or confidence in clinical skills and decision making. Reflections could be assigned to multiple themes and tones if appropriate.
Clerkship director responses were analyzed in parallel using a similar framework and the same coding/categorization process. Each response was categorized based on the nature of the feedback provided, including whether the response validated the student's reflection, offered a specific teaching point, encouraged further critical thinking, and/or provided actionable guidance. The tone of each response (supportive, neutral, and/or constructive) was recorded, as well as the emotional and professional development focus that the clerkship director focused on (ex. focusing on developing professional skills, emphasizing ethical dilemmas, and addressing emotional growth). The clerkship directors (CY and RGW) were not involved in coding or categorization of the logs or responses.
To ensure the trustworthiness of our qualitative analysis, we incorporated several established strategies.18,19 Credibility was enhanced through investigator triangulation, with both authors independently reviewing transcripts and collaboratively refining codes and themes to reduce potential bias. We maintained an audit trail documenting key coding decisions and analytic developments to support dependability and confirmability. To support transferability, we provided detailed descriptions of the study context, participant population, and representative quotes. These strategies align with established criteria for rigor in qualitative research.18,19
All coding was conducted using a structured REDCap database. No additional qualitative software platform was used. Descriptive statistics were used to summarize the frequency and distribution of identified themes, tones, and response types. Data are reported as counts and percentages.
Results
A total of 46 reflection logs from 46 different students were submitted between June 5, 2023, and May 3, 2024, and were included in the analysis.
Primary content coding (student logs)
In the initial phase of analysis, each log was assigned to a single category based on its predominant theme. Most commonly, students discussed observing bias while on the rotation.
Six logs described patients being dismissed or discredited based on factors such as gender (being female:
Another 5 logs recounted instances of gender bias where the physician was not properly recognized as such, due to being female or non-White. One student wrote: “[…] Specifically, while rounding with the team (female attending staff and male residents), I noted that the patient preferentially responded to the male resident when asked questions by the female staff. […] It seemed that the patient felt that the male, despite being a resident, was in a position of higher authority and decision-making capacity due to his gender” (ID: 37).
Additionally, 9 logs recounted bias towards various other patient populations. This included bias toward patients with HIV (
Communication barriers related to language or low health literacy were described in 5 logs. One student wrote: “The patient was primarily Russian-speaking. […] [The attending physician's] frustration seemed to almost jump out of the page at me. He noted that the patient was a poor historian” (ID: 38). Issues related to decreased access to care appeared in 4 logs, including barriers based on race (
Other singularly coded themes included structural or cultural issues such as ableism, racism from patients, misattributed relationships, and catastrophe bias.
Thematic analysis (student logs)
In the second phase of analysis, logs were coded into thematic categories. Each log could be placed into multiple categories depending on its content. Of the 46 logs, 34 (77.3%) reflected some form of bias, most commonly at the patient level (
Students often recognized these issues and questioned their role in addressing them. One student reflected: “[…] I found it unfortunate that patient bias played a role in her care, but also am unsure of what more I could have done […]” (ID: 15). These types of reflections highlight not only awareness of systemic issues, but also internal grappling with professional responsibilities.
Social determinants of health were described in 6 logs (13.6%), most often in relation to economic hardship (
Health inequities were identified in 9 logs (20.5%). Specifically, disparities in access to care were described in 5 logs (55.6%), and 4 logs (44.4%) referenced health outcomes linked to patient demographics. Figure 1A details the broad categories of observations noted by students.
Themes and emotional tone identified in neurology clerkship student logs. (A) Percentage of logs tagged with key content categories, including bias, social determinants of health, health inequities, healthcare system challenges, and quality improvement opportunities. (B) Emotional tone expressed in student narratives. Logs could be coded into multiple categories for data included in both graphs.
Emotional tone and reflection outcomes
Emotional tone of each log was also analyzed (Figure 1B). The majority of logs conveyed frustration or distress (
Other tones included empathy or compassion (
While students frequently described moments of inequity, distress, or discomfort, the structured reflection process prompted meaningful engagement with professional identity formation. Twenty-two logs (55.0%) described a lesson in professional identity. For example, after witnessing a patient disrespect members of the care team while being courteous towards the attending physician, 1 student wrote, “It's also important for me as a future doctor to address this kind of behavior or not condone the disrespect when I see it directly” (ID: 7). Another student felt conflicted with the way the attending physician acknowledged a patient with substance abuse disorder and wrote that they “hope to have the bravery to be an advocate in discussion for patients like this as a physician” (ID: 20). Lastly, after witnessing a physician deliver a terminal diagnosis, a student reflected, “The demands of being a physician often require that we play a particular role in the dying process as a caring guide/partner, yes, but also as a source of truth, predictability, and impartiality” (ID: 42).
Nineteen logs (47.5%) focused on grappling with ethical dilemmas (Figure 2). “This situation forced me to really consider the challenge that medical providers face in trying to balance patient comfort and autonomy with the reality of the resources available” 1 student reflected (ID: 21). Eleven logs (27.5%) noted increased self-awareness. One student mentioned: “it is impossible to get rid of our biases, but by becoming aware of them, it would be more likely that the patient would receive higher quality care” (ID: 33).
Themes of personal and professional growth in student logs. Distribution of logs highlighting different aspects of personal and professional development noted in student logs.
Most logs involved patient-physician dynamics (
These encounters suggest that even brief reflective assignments, when coupled with structured guidance and faculty feedback, can support students’ development as humanistic, ethically engaged physicians.
Clerkship director responses
Clerkship directors’ responses were overwhelmingly supportive. Most responses (97.8%) included validation of the student's experience, making comments such as: “you showed remarkable self-reflection and insight into your preconceived concepts of patients and the impacts of those beliefs on patient care” (Response to ID: 24). 71.7% served as teaching moments by expanding on issues such as health disparities. 17.4% (
Discussion
Our analysis shows that students commonly see instances of bias and health inequities during their clinical rotations. Every student submitted at least 1 log reflecting on such experiences, underscoring how prevalent these issues are in the clinical learning environment. In addition, every log contained some type of thoughtful discussion either on the situation itself or on some takeaway lessons that the student had made. These reflections revealed not just the challenges encountered, but also students’ emotional responses, including frustration, empathy, and a desire to improve. Many logs also demonstrated self-awareness, ethical reasoning, and an emerging sense of professional identity. This suggests that providing students with space to reflect on these experiences could potentially be a powerful tool.
The specific content of these reflections revealed exposure to patient-level and system-level bias, communication barriers, assumptions based on race or gender, and disparities in access to care, highlighting the complex realities that students are navigating in real time. Most commonly, students appear to see instances of bias against others based on race and/or gender. One student even noted an instance where the student themselves had racially charged comments directed towards them from a patient. It is possible that without having this avenue to communicate these experiences, these incidences may not have ever come to light. Previous studies have shown that this kind of behavior is often directed towards trainees and can cause an emotional toll and perpetuate moral distress.20-22 Additionally, students report uncertainty in how to deal with these encounters.21,22 Ideally, students would be able to debrief with a more senior member of the clinical team, such as a resident or attending physician. However, depending on the nature of the relationship between the student and the rest of their team or the overall team dynamic, the student may feel uncomfortable sharing with the team or asking to reflect on the incident. Thus, these logs allow another avenue of communication with mentors and clerkship directors to further debrief on these instances.
These experiences reflect a key component of the hidden curriculum, a set of implicit messages and lessons students learn through observation and informal interactions, often outside the scope of formal teaching. 23 Students are witnessing how structural inequities and interpersonal dynamics shape patient care and professional behavior. 24 Without dedicated space to process and contextualize these observations, students may internalize harmful norms or feel disillusioned.25,26 For example, if students witness bias against certain patient populations during their core clerkship rotations, which is supposed to be the foundation of the students’ clinical experiences, they may be less likely to advocate against this behavior later in their medical career.21,27 Along these lines, a previous survey based study found that students often reported dissatisfaction with their ethical development during clerkships with over 60% of students feeling that they acted unethically for a good evaluation or to fit in with the team. 5 Specifically, 98% of students heard physicians make derogatory remarks about patients, 61% observed unethical behavior by other members of the medical team, and 54% of those students felt complicit in these actions. 5 Encouraging reflection through structured logs offers a counterbalance to this component of the hidden curriculum, prompting students to think critically about what they are learning and what kind of physicians they hope to become. The responses by clerkship directors also helped promote healthy ways for students to learn from this incident by validating students’ experiences and providing some teaching points and key takeaways for the student to understand from this incident. In addition, structuring the clerkship experience to incorporate numerous opportunities for students to debrief, either with their clinical team, with the clerkship directors, or with their peers, gives students the ability to hear different perspectives.28,29 In our curricular program, this took the form of a weekly meeting with a few peers and both clerkship directors, which created a space for students to freely discuss any topics they wanted. Rather than normalizing certain implicit biases, this would allow students to gain new perspectives on the incident and gain takeaway lessons that would help students learn how best to react to these situations in the future.30,31
Additionally, the goal of this reflective log, especially when coupled with faculty review and feedback, was to provide a structured opportunity for students to process these observations, make sense of their emotional responses, and articulate lessons learned. While the primary focus of this log was not professional identity formation, reflection on clinical encounters may spontaneously contribute to the development of professional values and physician self-concept. Prior literature has shown that such reflective processes, especially those prompted by emotionally charged clinical situations, can contribute to professional identity formation by fostering self-awareness, insight into personal values, and adaptive coping strategies.1,12,32-35 By reflecting on challenging encounters, students may gain a deeper understanding of their own needs, limitations, and professional ideals, aiding in the internalization of norms and values that define the medical profession.1,12,33,34 Furthermore, structured approaches to reflection, including narrative writing and facilitated discussion, have specifically been shown to enhance emotional processing, “meaning-making,” and resilience, thereby promoting professional identity development.12,32,34 In our analysis, many students spontaneously articulated how these clinical experiences shaped their vision of themselves as future physicians, supporting this notion that reflective writing, though designed primarily as a tool for critical thinking and debriefing, may also facilitate aspects of professional identity development.
Incorporating reflective writing into clerkships not only gives students a voice but also provides educators with insight into the learning climate. 12 It helps identify patterns in the hidden curriculum and create opportunities for meaningful discussion, mentorship, and curricular change. 36 Although students did not directly identify or suggest changes to the curriculum in their logs, a greater sample size throughout multiple years may reveal areas for improvement. In addition, faculty who regularly work with students may benefit from targeted training on how to facilitate debriefing conversations and support learners as they navigate challenging or ethically complex clinical encounters. Such training could empower faculty to more effectively respond to students’ reflections and foster a more open, supportive learning environment.
This study had several limitations that should be acknowledged. First, this was a single-institution study, and findings may not generalize to other institutions with different curricula or clerkship structures. Second, reflections were written as part of a required assignment, which may have influenced the content or tone due to perceived expectations from faculty reviewers. Finally, because the reflections were de-identified prior to analysis, we were unable to examine differences across student demographics or follow up with participants for additional clarification or depth. These limitations may influence the transferability of our findings and should be considered when interpreting the results.
Conclusions
In conclusion, our study shows that there are significant and complex challenges that students regularly witness in the clinical environment, including bias, health inequities, and systemic barriers to care. Given how frequently students encounter inequity in clinical settings, it is essential to support them in making sense of these moments and developing the tools to address them thoughtfully in their future practice. Structured opportunities for reflection, combined with guidance from trained faculty, can help students process difficult experiences and contribute to a more just and empathetic healthcare system. We encourage other institutions and clerkships to adopt similar reflective practices to create space for open dialogue, promote critical thinking, and foster a learning environment that prioritizes equity and compassion.
Supplemental Material
sj-docx-1-mde-10.1177_23821205251374897 - Supplemental material for Implementing a Curricular Model for Structured Reflection in a Neurology Clinical Clerkship
Supplemental material, sj-docx-1-mde-10.1177_23821205251374897 for Implementing a Curricular Model for Structured Reflection in a Neurology Clinical Clerkship by Nitesh Mohan, Mackaleigh Levine BA, Chen Yan and Robert G. Wilson in Journal of Medical Education and Curricular Development
Footnotes
Acknowledgments
ORCID iD
Ethical Approval
Funding
Declaration of Conflicting Interests
Data Availability
Supplemental Material
References
Supplementary Material
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