Self-Reflection Through a Glass, Darkly

By Josh Hopps

It is the end of the USMLE Step 1 exam season in undergraduate medical education.  If UME is a solar system, Step 1 is the sun, irradiating and superheating some, leaving others cold and frozen out, and supporting life for those who thrive in intense and constrained circumstances.  Its enormous gravity pulls students toward it at the cost of medical school grades, well-being, and finances1, and impinging on medical schools’ autonomy in determining their UME curricula.  Students whose single-minded purpose for years was getting into medical school very quickly shift their focus to the Step 1 exam because of its outsized emphasis in the residency selection process2.   In years past the Step 1 conversation began at the beginning of the second year of medical school or at the end of the first year for an ambitions few.  Students now ask about First Aid for Step 1 before they’ve even matriculated…

At the end of each Step 1 season, we pause to survey the outcomes and give what succor we can to students who need it (they all need it, even those score very highly) and to reassess how to more effectively address the needs of those who weren’t as successful as they could have been.   Every year there are students who begin Step 1 season in similar situations from a numbers perspective who diverge greatly based on how well they respond to the anxiety of the situation.  Some are able to step back and make effective judgments and changes to their cognitive, affective, and behavioral approaches to Step 1 whereas others are consumed by mistakes which are escalated to failures and turned into evidence of inadequacy.  The self-reflection paradox in the cognitive psychology literature holds that for many, reflecting on work, emotions, etc., is productive and leads to benefits in overall well-being, while others become caught in a more ruminative cycle that leads to an increase in negative affect3.  How can reflection be a bad thing?

Humans are great meaning-makers, but the evidence we use to construct meaning is fraught with subjectivity, biases, and outright errors.  The literature on self-assessment in medical education is perhaps best characterized as equivocal4, with initial literature reviews demonstrating that merely asking people to reflect on their performance and engage in self-assessment was insufficient due to biases and inconsistency5.  Learners in the health sciences tend to be unstable self-assessors: over confident, under confident, static in spite of objective improvement, and out of sync with outside observers.  It was quickly established that merely prompting self-assessment was insufficient and effective interventions designed to guide reflection emerged6.  Establishing clear criteria and allowing for guided reconciliation of self-assessments with those of others resulted in improved outcomes related to reflection4,5.  Perhaps one aspect contributing to the difficulty in finding consistent, clear effects in the self-assessment literature in medical education is related to the self-reflection paradox that propels some and paralyzes others.

Self-distancing is a straightforward evidence-based strategy to neutralize the self-assessment paradox, by reducing subjectivity (self-immersing) in favor of objectivity (self-distancing).  This essentially involves perspective taking during self-reflection, moving away from first-person (“why did I feel that way?”) to the third person (“Why did Josh feel that way?”).  This simple shift has been shown to increase adaptive self-reflection (net reduction in distress) on challenging experiences related to anger and sadness, in adults and children, and across cultures3.  Working with students preparing for Step 1 reveals a minefield of negative automatic thoughts and self-assessments mired in overly subjective reasoning and many succumb.  Each year, medical schools think deeply about how to prepare their students for Step 1 from curricular and co-curricular perspectives, usually focusing on the “easiest” and most objective of medical school competencies, medical knowledge.  Perhaps it’s time to focus on the “softer” competencies by leveraging the best of reflective practice to better empower our students for the most momentous and stressful exam of their lives.

Josh Hopps, PhD, MS, is the Director of the Academic Center for Excellence and Accessibility and an Assistant Professor in the Ralph P.Leischner, Jr., MD, Department of Medical Education, Loyola University Chicago Stritch School of Medicine



  1. London, Daniel A.; Kwon, Regina; Atluru, Anupama. (2016). More on How USMLE Step 1 Scores Are Challenging Academic Medicine. Academic Medicine 91, 5 609-610.
  2. Prober, Charles G. MD; Kolars, Joseph C. MD; First, Lewis R. MD; Melnick, Donald E. MD. (2016). A Plea to Reassess the Role of United States Medical Licensing Examination Step 1 Scores in Residency Selection. Academic Medicine 91,1 pp. 12-15.
  3. Kross, Ethan; Ayduk, Ozlem. (2011. )Making Meaning out of Negative Experiences by Self-Distancing. Current Directions in Psychological Science 20: pp. 187-191.
  4. Eva, Kevin W.; Regehr, Glenn. (2005). Self-Assessment in the Health Professions: A Reformulation and Research Agenda. Academic Medicine 80, 10 pp. S46-S54.
  5. Gordon MJ. (1991). A review of the validity and accuracy of self-assessments in health professions training. Academic Medicine, 66:762–69.
  6. Gordon MJ. (1992). A review of the validity and accuracy of self-assessments in health professions training. Academic Medicine, 67:672–679.

One thought on “Self-Reflection Through a Glass, Darkly

  1. Thanks you Dr. Hopps for this reflective piece on adaptive self-reflection. It highlights the need for promoting reflective practice competency for our trainees and for ourselves as educators, a meaningful topic for me academically (within scholarship) and practically (in the “trenches” as an educator)…Within professionalizing medical education, we can apprentice educators and trainees in reflective practice, and in doing so, perspectives may shift and such a skill set then regarded as a core competency rather than a “soft skill”. Equipping our learners with coping skills for Step 1 and many other future challenging “steps” is part of our mandate. Appreciate your underlining these topics for us!

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