Reflective Practice and Leadership in Medicine and Medical Education Component 1: Presentation of a Challenging Case and Framing the Question

Physicians routinely work in charged situations. In addition to addressing complex medical problems, the physician must also manage patients’ and sometimes their own fears, anger, and grief as well as sympathy and gratitude. The educational, administrative, and research contexts of the physician’s role (e.g., frustration about changing regulatory requirements, strain due to shortages of skilled staff, or anxiety over grant funding) also carry emotional hurdles. The ability to manage emotions deliberately is a crucial factor for physicians, particularly for those in leadership positions. Although we have seen no systematic research in this area, our experience illustrates that:

  • Strong, often negative, emotions are inherent in complex situations
  • Almost all the people involved in a complex situation experience these strong emotions
  • Strong emotions can impair reasoning and decision-making
  • Physicians do not, as a rule, have opportunities to learn how to methodically incorporate and reason through situations involving strong emotions
  • Opportunities to discuss challenging cases, rather than pre-determined topics, are more likely to generate cases with strong emotions, evoke relevant, analogous experiences, and engage other participants

We designed our seminar to elicit discussions of complex dilemmas from the participants’ current experiences. This typically includes non-biomedical aspects of patient care, difficulties in research projects, and problems with the training program, etc (See Example Challenges from a variety of roles). If the dilemma is truly challenging, a participant’s initial description is normally jumbled – reflecting frustration, confusion, and concern – and often has ethical implications. Such multifaceted dilemmas are ideal for RP&L – there is no established protocol, no clear evidence base, and no easy answer.1

Because the dilemmas presented are often complex, they may generate multiple topics that could diffuse the discussion. Thus, after they are described, faculty help the presenter clarify a single problem as the main challenge. And, they help the participant frame a specific question that clearly describes the problem in a way that all participants can understand. To ensure a shared understanding of the problem, the faculty should conclude this component by summarizing the question and asking the presenter to confirm.

Keeping the clarified question in mind can be more difficult than it sounds. However, a clear question allows the faculty to guide a structured analysis of the problem, maintaining the focus on inquiry, hypothesis generation, and planning. The Example Facilitative Responses for each component provide examples of question clarification.


  1. Heifetz RS. Leadership Without Easy Answers. New York: Belknap; 1994.

Image credit: 5 Cell by Jason Hise 2007