Do Medical Student On-call Reflective Reports Show Their Expressions of Emotional Intelligence? – A Qualitative Study

Introduction : In addition to cognitive intelligence, emotional intelligence (EI) is known to play a major role in producing better doctors. When medical students are exposed to critical incidents in the hospital, it can be emotionally disturbing and such occurrences may be captured in their reflective reports. A series of reflective reports written by third year medical students, soon after exposure to such incidents, in a private medical school in Malaysia, was analysed to determine whether one could capture expression of any of the 25 competencies, inclusive of several social skills or soft skills given in the framework of Mixed Model of EI by Daniel Goleman. Methods : A convenient sample of 148 reflective reports were analysed, using grounded theory approach and discourse analysis. Expression of emotions in these reports were thematically separated into different emotional competencies which were then matched with the framework of Mixed Model of EI. Results : Reflective writing manifesting all five major divisions emotional competencies in Goleman’s framework, namely; self-awareness, self-regulation, motivation, empathy, and social skills were found in many of the reports. Excerpts from of five different reflective reports (only the contextual component without the students’ reflection) manifesting each of these five major divisions of emotional competencies were given as triggers for focus group discussions and three out of the five showed close triangulation. Conclusion : Reflective reports seem to be useful to detect expression of EI. In addition, reflective reports seem to have a potential use as a tool to nurture EI in medical students.


Social skills-Communication skills:
'In the hospital doctors and medical students examine patients with the curtains drawn and chaperons by their sides. However, I feel that drawing curtains might be just enough to prevent exposure of patient's bodies but the conversations can be overheard by others as the distances between beds are within an earshot. Hence, if sensitive issues were to be discussed, it is better to conduct the conversation within a closed room' (#72), Student realises that patient's confidentiality needs to be respected as most of the communications can be considered as 'privileged information'. The focus group that was given the truncated scenario #72, echoed the same sentiments. Studies have shown that confidentially breaches occur due poor infrastructure facilities, as in this situation (Beltran-Aroca et al., 2016). What is more important to note is that the student realizes that there is a lapse in communications; and such cognizance can be considered to be driven by EI.

Discussion
The level of emotional competence varies depending on the task, individual and the context, and it is hard to quantify. Students' reflections on critical incidents that were captured in writing are on some incidents they have experienced when interacting with patients and their carers. Reporting and reflecting on critical incidents seems to have an educational value for medical students (Branch, 2005). These are useful for developing positive attitudes and behaviours as well as values that are essential to be a good professional. How students feel about critical incidents can be in written as reflective reports which can be nascent and unpolished accounts of their experience and perceptions without being diluted by afterthoughts or opinions. In addition, such reflective reports embody a component of experiential learning (Kolb, 1984). Such reflective reports also represent sensitivity and recognition of moral issues as well as indications to stand-up regarding one's own beliefs.
As most adults, medical students too need to walk through new experiences and learn by reflection. 'Reflection' is a metacognitive process and has been defined by Boud et al., (1985) as 'a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation'. Reflective practice occurs when students exercise reflection in the context of working with ill-defined experiences or problems in professional practice (Sanders, 2009). Reflective practice seems to facilitate development of EI.

Limitations
There are few limitations to the study.
1. Single authorship: Whether an element of subjectivity and bias may have occurred as the study was done only by one person is debatable, as appraisers of qualitative research increasingly seek to assess the competence and reflexivity of a single researcher than confirm that the findings were checked by someone else (Greenhalgh, 2010). As discourse analysis focuses not only on the text but also on its construction within a contextwith inclusion of both historical and political connotationssingle author reflexivity becomes more meaningful. The author has 45 years of experience as a doctor and 35 years of teaching experience in Internal Medicine for medical undergraduates and postgraduates and this background helped to enrich his meticulous ethnographical approach and reflexivity, when data were analysed.

Reflective reports were limited to 500
words. This may have hindered documentation of emotional engagement due to lack of fluency in expressing such situations in a more explicit and detailed manner.
3. There is some variation with regards to training and maturity of students at the time the reflective report was written, depending on whether Internal Medicine posting was placed first, second or last in the clinical rotation during the Semester; and it might have contributed to intra-sample variation.

Conclusion
The emotional experience students go through during exposure to critical incidents can condition the way they would perceive and respond when they face similar clinical scenarios during their practice as doctors in the future (Brady, 2002). According to the transformative learning theory, adult learning can be triggered by disturbing dilemmas such as those gone through by students in this study.

Ariyananda, 2020
South-East Asian Journal of Medical Education 38 Vol. 14, no. 1, 2020 Transformational learning that is seen in this study involves change in existing beliefs and thought patterns through the use of discourse and critical reflection (Mezirow, 1994).
The study revealed that students have been exposed to a variety of clinical situations which made them react either with positive or negative emotions. In the foregoing account, many of them have pledged to change their behaviour; and this seems to be an adaptive response to suit their future careers as doctors. Such expressions can be considered as evidence of expression of EI that would help them to function as better doctors in years to come. As these reflective reports do not contribute to student assessment, their reflections can be considered to be genuine expression of what goes through their mind, invoking the power of EI to rationalise emotionally disturbing dilemmas, that they come across in the clinical learning environment.

Implications of this work
Reflective reports seem to have a potential to detect expression of EI with acquisition of emotional competence, and a prospect to nurture EI with the help of mentor feedback. Therefore, reflective reports should be exploited for its scope as a teaching/learning tool in EI. In this study, the fact that a 'thick description' is available shows the potential for transferability of this hypothesis for training of other healthcare workers. Similarity in learning environment across different healthcare professions makes it even easier to recontextualize, such teaching/learning situations.

Conflict of Interest
The authors declare no conflict of interest.