The journaling assignment arrives like clockwork. Write about a patient encounter that didn’t go the way you hoped. Describe what you would do differently. Reflect. In medical training, this kind of structured self-examination has become as standard as rounds, as expected as sutures. Reflection, the field has decided, is how clinicians grow.

But a pair of medical educators — an internal medicine physician and a psychiatrist — recently asked a question that doesn’t come up often enough in teaching hospitals: What if we’re doing it wrong?

Their essay, published earlier this year in KevinMD, argued that when reflection is done poorly, or simply too much, it stops functioning as a tool for growth and starts functioning as something else entirely. It begins to resemble rumination — the repetitive, self-critical loop associated with anxiety and depression — landing on students who are already struggling and following them as they move into their careers.

A 2025 survey by Sermo found that 85% of physicians report reflecting on the quality of their care “frequently” or “all the time.” Nearly half say they’re only “somewhat” satisfied with that care. The reflection is happening, often daily, inside systems that don’t always make space for anything to change.

You see a similar mindset in elite sports programs and corporate cultures — a chronic dissatisfaction that means even a championship performance triggers an intense review. You won, but “could have been better” and “there are things to work on.”

Where’s the Line?

Bethany Teachman, PhD, runs the PACT Lab at the University of Virginia, Charlottesville, Virgina, where she studies maladaptive thinking patterns, anxiety, and cognitive bias. She’s spent her career examining when introspection helps and when it traps people.

“A key question to ask yourself is whether it feels like you’re solving problems, or getting new insights or information,” Teachman said. “If so, that tends to indicate helpful introspection and reflection. In contrast, if you’re repeating the same thoughts over and over and there isn’t forward motion — you aren’t making a decision, deciding on a next step, accepting a situation, regulating your difficult emotions — then that’s a clue that you’re ruminating in unhealthy ways.”

Psychologist Michelle G. Newman, PhD, who studies anxiety and depression at Penn State, University Park, Pennsylvania, puts the distinction more bluntly. “Healthy reflection quickly leads to constructive conclusions such as problem-solving and/or learning something about oneself that helps you move forward or change behavior,” Newman said. “Rumination and worry are repetitive thought processes that get stuck on the negative without any resolution.”

She added that worry tends to focus on the future, catastrophizing about what might go wrong, while rumination loops back to the past. The two often feed each other, sustaining negative emotion long after the triggering event has passed.

Why Physicians are Especially Vulnerable

Medical training selects for highly conscientious, self-critical people — and then amplifies those traits during residency. The students who get in are often the ones who have spent their entire academic lives turning mistakes into fuel.

Srijan Sen, MD, PhD, who directs the Eisenberg Family Depression Center at the University of Michigan, Ann Arbor, Michigan, has the research to back that up. “Incoming physicians, on average, are meaningfully different from the general population in many ways,” he said. “Some of these differences, such as higher neuroticism and higher conscientiousness, are risk factors for rumination, depression, and other negative outcomes.”

Ironically, Sen said, these are the very traits that we really want in our doctors. “We want our doctor to double-check that they prescribed the correct medication dose and are operating on the correct side of the body.”

“Worriers do tend to be highly conscientious and perfectionistic,” Newman added, though she cautions that research linking those traits directly to rumination is less settled than it sometimes appears.

What does seem clear, according to Teachman, is the role shame can play in turning reflection into something more corrosive. There’s a meaningful difference between environments that treat mistakes as normal parts of learning and those that frame them as evidence of a deeper flaw in the person making them. Medical culture has historically leaned toward the latter.

“One important piece that can differentiate whether efforts to evaluate errors are helpful vs promote rumination is to consider whether the process of reviewing mistakes is framed as a normal, healthy process that does not indicate the person is flawed,” Teachman said, “vs framed in a way that the person feels shamed or inadequate, and they become fearful. We want people to feel challenged, not threatened.”

The Control Problem

There’s a second mechanism at work that makes this particularly difficult in medicine, and it has less to do with personality than with systems.

A physician who reflects on a structural problem — inadequate staffing, an electronic health record that buries relevant information, a reimbursement model that only allows 11 minutes per patient — but has no meaningful ability to change any of it is in a psychologically precarious position. The reflection may be accurate, but there’s nowhere for it to go.

Sen’s research points directly at the environment. His Intern Health Study, one of the largest longitudinal studies of physician mental health, found that workplace conditions are the key factor in determining whether training physicians struggle psychologically, with workload ranking as the single most important variable.

“Conscientious physicians want to make sure that they are providing the best possible care for all of their patients,” Sen said. “But when physicians work excessive workloads, they are not able to spend as much time and effort as they feel is needed for each patient. I think the most important steps we can take to help both training physicians and the patients that they treat is to reduce workload and work hours.”

But for many physicians, the problem isn’t only that there’s too much work. It’s that the work keeps revealing problems they have no power to solve. “In general, it can be demoralizing to be in a situation where you feel helpless to improve a broken system,” Teachman said. “Getting stuck on repeated thoughts about how a situation should be different can become unproductive.”

Her recommendation for clinicians in that position involves a two-part shift. The first is identifying what falls within one’s control — even if it’s small — and taking some step toward it. A sense of agency, even a modest one, can interrupt the loop.

The second is acceptance, which “doesn’t mean that you view a situation as acceptable,” Teachman said. “It means you accept that this is the current reality, which ultimately enables and empowers people to decide what they do want to do about that reality.”

Newman approaches the same pattern from the perspective of coping behavior. Rumination, in her view, is not irrational — it’s the mind trying to brace for the worst before the worst arrives.

“It increases and sustains negative emotion and avoids experiencing a sharp increase in their negative emotion if the negative outcome happens,” Newman explained. “If I expect the worst, I will be emotionally prepared; I would rather be pleasantly surprised if the worst doesn’t happen than be unprepared and have the bad thing happen.”

The problem is that this strategy rarely works. The feared outcome often fails to materialize as imagined, while the rumination itself consumes time, attention, and emotional energy that could otherwise go toward problem-solving.

The Journaling Question

If reflection can become rumination, the obvious follow-up is whether the tools medicine uses to promote reflection — journaling prompts, mindfulness exercises, structured self-assessments — might be making things worse.

Teachman said the honest answer is yes, for some people. “There are no one-size-fits-all approaches,” she said. “It’s important to view interventions for mental health challenges, including rumination as trial and error and monitor progress. For instance, you might try journaling for 3 weeks and track whether rumination increases or decreases. If it increases, this may mean that journaling is not a good fit, or it may mean that you want to change how you journal.”

The content and approach matter as much as the act. Example: Writing about a negative experience from a self-compassionate stance significantly improved mood, while participants who wrote about the same event in a purely emotionally expressive way showed a worsening of mood and depressive symptoms in a study by Natasha Odou, DPsych, and Jay Brinker, PhD, at the Australian National University.

A journal prompt that asks a struggling resident to catalog everything that went wrong in a difficult case is a different intervention than one that asks what they might do differently, or what they handled well — and the research suggests that difference is not trivial.

What Educators Can Do

The experts are consistent on one point: individual coping strategies only go so far.

For Teachman, the most powerful intervention is cultural: normalize error as part of learning rather than evidence of inadequacy.

“Educators can normalize the process of making and learning from mistakes, promote a sense of belonging, encourage self-efficacy so people don’t feel shamed or flawed as a person, and recognize they can improve specific behaviors,” she said. “Teaching people basic skills in perspective-taking and ways to consider evidence and re-evaluate unhelpful thinking patterns can help build resilience.”

Newman’s approach is more behavioral. The goal isn’t to stop rumination once it’s running — by then, you’re already losing. The goal is to catch it before it builds momentum.

The brain, it turns out, is bad at keeping score. Relaxation lowers the overall stress load so there’s less kindling for triggers to ignite. Cognitive strategies can challenge how likely a feared outcome is. And simply tracking what you worried about against what happened has a way of quietly deflating the whole enterprise.

The Habit Medicine Should Relearn

The Sermo survey embedded its most important finding in a single line: “Self-reflection is a habit rooted in growth and accountability, but when time, support, or energy run low, it risks becoming an internal coping mechanism rather than a lever for improvement.”

Medicine has been slow to reckon with that distinction. The question was never whether physicians should reflect, it’s whether the reflection is going anywhere. Newman’s prescription is blunter than most institutions are comfortable with, but it may be the most honest thing said about the whole problem.

“Worry and rumination is a process looking for content,” she said. “One needs to make themselves just move on, cut it off, and focus on productive thoughts.”