McConnell, Meghan M. PhD; Eva, Kevin W. PhD
Training to become a physician involves a broad range of feelings and emotions that can influence how students learn and transfer knowledge and skills to new settings. Common emotional experiences include stress from time pressures, uncertainty, or unrealistic expectations; hopelessness from treating chronically ill patients; fear of failure or increasing responsibility; and guilt and sympathy over the death of patients or perceived poor performance.1–5 Consistent with this list, most of the literature on emotion in medical education focuses on negative emotions. Researchers justify this focus because such negative states are often associated with the high incidence of burnout among medical trainees.6,7 However, positive emotions—such as pride, excitement, gratitude, and happiness—also accompany important experiences for medical trainees.1
Given the broad range of emotional experiences associated with physician training, it is somewhat surprising that the role that emotion plays in learning remains relatively unexamined in the health care professional education literature. Because learners contribute to the creation of their learning environment through their own experiences and emotions, emotional states likely influence not only what students learn but also how readily they can transfer that learning to new situations. Therefore, it is important for medical educators to develop a deeper understanding of the effects of various emotions on learning and knowledge transfer.
What Is Emotion?
Emotion is somewhat difficult to define. Researchers have conceptualized a variety of experiential concepts, including emotion, mood, affect, attitudes, and feelings. We used the term emotion in its most general sense—to refer to affective contents, states, and experiences.
Although researchers have debated how to best define emotion, they generally agree that emotions vary along two dimensions—valence and arousal. Valence is a term borrowed from physics and chemistry8 that refers to the extent to which an emotion is perceived as being positive or negative, pleasant or unpleasant, good or bad. Although valence is often considered the defining feature of emotional states, arousal is also an important component. Arousal refers to the extent to which an emotion is experienced as activating or deactivating. For example, high arousal states (e.g., fear, anxiety, excitement) are differentiated from low arousal states (e.g., depression, calmness).
The purpose of this review is to summarize the relevant empirical research on the way in which emotions influence how individuals identify and perceive information, how they interpret it, and how they act on the information available in learning and practice situations. Our aim was to better understand these issues to establish a research agenda that might ultimately provide students, professionals, and educators with better support throughout the emotionally charged training and practice that characterize the medical profession.
Given the breadth of focus, we decided that a critical synthesis of a variety of relevant research findings was more appropriate than attempting a systematic and comprehensive review.9 Such a review is intended to provide readers with a selective summary of the literature around a broad topic rather than generating an exhaustive summary of the evidence relevant to a narrowly defined “Does it work?” type of research question. As such, we aim to offer a representative summary of the literature on emotion and the various cognitive processes associated with learning and knowledge transfer.
From September 2011 to February 2012, we searched several online databases, including Medline, PsycInfo, GoogleScholar, ERIC, and Web of Science, for articles that presented empirical evidence relevant to health care professional education and the interaction between emotion and learning or knowledge transfer. Because our accumulation of evidence was iterative and varied in focus, we cannot specify a simple list of key words. We also manually searched the reference lists and conducted citation analyses on articles that we found particularly useful. We limited our search to articles written in English and those published up to and including the early months of 2012. Although the first author (M.M.C.) primarily conducted the literature search, both authors repeatedly discussed the results of the literature search and, as a result of these discussions, sought additional articles to fill identifiable gaps in the information that they had collected.
Perception and information processing
Individuals perceive and process information in multiple ways, and emotion has been shown to have considerable influence on information processing. A plethora of research has demonstrated that, when in positive moods, individuals are more likely to see the “big picture” by focusing on the broader, more general components of the situation (e.g., global processing). On the other hand, when people are in negative moods, they are more likely to focus on specific details (e.g., local processing).10–13 In other words, positive emotions encourage people to see the forest, whereas negative emotions lead them to focus on the leaves. Whether one is better than the other depends on the level at which the most useful information is available for a particular task, but it is clear that even fairly subtle influences can have an effect.
For example, Fredrickson and Branigan14,15 induced a range of positive (e.g., joy, serenity, amusement, contentment) and negative emotions (e.g., fear, anxiety, anger, sadness) by having participants watch emotionally evocative film clips. They also included a neutral control condition by having participants watch a film intended to elicit no emotion (i.e., an abstract display of colored sticks stacking up). Using a task that dissociated the local details from the global context, the researchers were able to examine whether emotion had an influence on basic perceptual processing. To do so, they showed participants a display consisting of three geometric figures—a target and two comparison items (see Figure 1). The participants’ task was to decide which of the two comparison items was more similar to the target item. Participants experiencing positive emotions were more likely to categorize items on the basis of their global features (e.g., the triangular structure of the illustrated target, leading to a selection of comparison item 1; see Figure 1) relative to participants experiencing negative or neutral states, who were more likely to categorize items on the basis of their local features (e.g., the circles used to create the stimulus in Figure 1, leading to selection of comparison item 2). This finding suggests that positive emotions are associated with broader cognitive focus. Other researchers have shown, using the same task, that, when induced into negative emotional states, participants are more likely to categorize figures on the basis of the local details than those in neutral states.10,11
This influence of emotional states on how individuals perceive and process information can have important implications for learning and knowledge transfer. Global processing styles (i.e., focusing on the “big picture”) appear to lead to more associative and relational connections between relevant learning events, which should promote the transfer of knowledge to new situations by enabling individuals to detect analogies across novel tasks. For example, a recent set of studies conducted by Brand and colleagues16,17 examined whether positive and negative emotions have differential effects on knowledge transfer. During the learning phase of these experiments, participants learned to solve the Tower of Hanoi (ToH) puzzle by moving a pyramid consisting of different-sized disks from one peg to another with the restrictions that only one disk can be transferred per move and that each disk must be smaller than the disk underneath it. Participants solved three- and four-disk ToH puzzles until they reached a predefined mastery level. Afterwards, the researchers manipulated the participants’ mood by having them write about a “happy and positive” or “sad and negative” life event. Following the mood induction, they asked participants to solve one proximal (five-disk ToH) and two transfer tasks. All three tasks required similar cognitive strategies, although they differed in their surface features. The results showed that emotional valence is an important factor in transfer. Performance on the two transfer tasks was improved for participants induced to experience positive emotions and was impaired for those experiencing negative emotions.
The differences in processing styles for positive and negative emotions (e.g., global versus local) should not be confused with those between nonanalytic (System 1) and analytic (System 2) reasoning processes. According to most clinical decision-making models, System 1 is fast, automatic, intuitive, and energy efficient, whereas System 2 is slow, controlled, deliberate, and energy intensive. Although these two reasoning systems have been thoroughly researched in a variety of different contexts and settings, few have explored the influence of emotion on these two modes of processing.18,19 At most, researchers have hypothesized that emotional processing is specific to System 1 and that System 2 processing is free from emotional influence.20 Therefore, positive emotions likely encourage the automatic processing of global details, whereas negative emotions lead to the automatic processing of local details. Some empirical support suggests that emotional valence can influence the likelihood of committing cognitive biases, but the influence of emotion on the prevalence of this effect appears to vary. For example, anchoring biases (i.e., focusing on one trait or piece of information at the expense of understanding the whole situation) are more likely to occur when learners are in negative emotional states.21,22 On the other hand, the fundamental attribution bias (i.e., the tendency to underestimate situational forces and overestimate dispositional factors) and the just world bias (i.e., the belief that people get the outcomes they deserve) are more likely to occur when people are in positive emotional states.23,24 If researchers are able to consistently demonstrate that nonanalytically derived clinical errors (System 1) are more or less likely to occur depending on whether an individual is in a positive or negative mood, then refining our understanding of this relationship may help prevent future clinical errors.
In addition to influencing how people identify and process information, emotion affects how people understand and react to different scenarios. Specifically, emotions have been shown to influence how flexible individuals are in interpreting information and whether their interpretations are modulated by the unintentional retrieval of past emotional experiences.
Cognitive flexibility. Studies have shown that positive emotions facilitate an individual’s ability to think flexibly and discover alternative strategies and solutions.25–27 For example, Gasper28 examined whether positive and negative emotions have different influences on an individual’s ability to switch mindsets according to the context of the problem at hand. He asked participants to recall and write about “positive and happy” or “negative and sad” life events to induce them into happy or sad moods. He then asked them to complete a classic problem-solving task designed to measure the perseveration of fixed patterns of thinking. This problem-solving task required participants to form four- or five-letter words from a string of letters without rearranging the letters (e.g., FYRXOMG; answer is FROG). This task consisted of two phases. In the first phase, participants could solve all word problems using a particular strategy—Use every other letter to form the name of an animal, as illustrated in the above example. This phase served to orient participants toward a particular problem-solving strategy because the word problems could only be solved using this particular approach. The second phase of the task was intended to disrupt this strategy, whereby the correct answer could only be obtained using a much more obvious and simpler strategy (e.g., GXEVERZOE, GEEZE is wrong, but EVER is correct). Gasper found that individuals experiencing negative emotions relied on the established problem-solving strategy until they received feedback that it was inadequate. On the other hand, those experiencing positive emotions were much more likely to abandon the established strategy on their own accord. Other researchers have found that positive emotions also facilitate creativity, cognitive flexibility, explorative behavior, and openness to information, whereas negative emotions reduce the number of alternative solutions that come to mind.25
The results of Gasper’s28 study suggest that positive emotions promote problem solving by increasing the number of potential solutions that come to mind and by decreasing an individual’s reliance on old, and potentially inadequate, problem-solving strategies. According to Brand et al,16 flexible thinking “should be particularly favorable for detecting analogies between different transfer tasks with similar or dissimilar surface features with identical substructure.” Clearly, such cognitive flexibility can have important implications in a field like medicine where researchers have identified premature closure as a major challenge to diagnostic accuracy.29,30 Indeed, Estrada, Isen, and colleagues,21,31,32 studying diagnostic decision making, have reported that positive emotions are associated with increased diagnostic accuracy, greater curiosity, and enhanced integration of information. By fostering positive emotional states, educators may be able to promote not only student well-being but also transfer of clinical skills and knowledge through more flexible problem solving.
Memory retrieval. All memories are not created equal. Highly emotional experiences tend to be well remembered, which should come as no surprise to clinicians who themselves commonly report strong memories of particularly emotional experiences many years after their occurrence. Although plenty of research has shown that emotional events and experiences are retrieved more reliably from memory than neutral events,33,34 what is less recognized is why emotional experiences have such a strong impact on memory formation and what implications these mechanisms hold for learning and knowledge transfer within the medical education community.
One potential explanation for enhanced memory of emotional events is that an individual who experiences an emotional reaction is more likely to mentally rehearse or “mull over” the event.35–37 This hypothesis was supported by Ferree and Cahill35 in recent research. They examined the rate at which people involuntarily revisit emotional events relative to nonemotional events. Surprisingly, their study was one of the first to systematically examine whether unintentional retrieval of events was more likely to occur for emotional experiences than for nonemotional ones. To study this question, the researchers showed participants a series of either emotional or neutral films and asked them to subjectively rate each film for its “emotionality” using a 10-point adjectival scale ranging from “completely unemotional” to “extremely emotional.” The authors did not distinguish between positive and negative emotions. They then collected various physiological data from the participants, including saliva samples, heart rate, and galvanic skin responses. The participants returned to the laboratory two days later; instead of having more physiological data collected, as they had been told would happen, they were given a surprise memory test of the films. Participants were asked to (1) recall as many films as they could, (2) rank order the films according to how well they remembered each one, and (3) estimate the number of times scenes from each film had “spontaneously popped into their minds” since they first viewed them. Across the various measures, participants remembered more about the emotional films than the neutral films. Furthermore, participants reported nearly three times more “spontaneous intrusive recollections” (SIRs) for the emotional films than for the neutral films, and the frequency of SIRs was positively correlated with the amount of detail recalled (but only for emotional films). On the basis of these results, Ferree and Cahill concluded that SIRs promote covert retrieval of encoded versions of an event, which subsequently enhances memory for emotional experiences.
Other research has shown that negative events are spontaneously remembered more frequently than positive events.38,39 For example, Bernsten40 compared involuntary memories for highly negative and highly positive events among undergraduate students. The results demonstrated that both negative and positive events are subject to involuntary retrieval; however, the involuntary memories associated with highly negative life events were more prevalent than the involuntary recollections of highly positive ones. Such repeated retrieval of negatively arousing emotional events may help medical education researchers understand the commonly reported decline in empathy41 that occurs during medical training, as well as shed light on issues of physician burnout.6,7,42 That is, if medical trainees and professionals alike are more likely to remember and recall negative events, then their perception may be biased over time, whereby negative aspects of practice (i.e., demanding patients, imprudent clinical errors and failures, or difficult intra- or interprofessional interactions) appear to be much more common (because of the ease of recall) than positive experiences.
At the same time, these findings establish a difficult paradox in that negative events might prompt various indications of dissatisfaction with the profession while being particularly valuable for inducing learning. Although researchers have not examined, to our knowledge, a direct link between health professionals’ dissatisfaction and their recall of negative memories, the data discussed in this section may have relevance for test-enhanced learning—the finding that repeated testing enhances subsequent recall of information more than repeated studying of the same information for an equivalent amount of time.43–45 Researchers usually argue that studying and testing influence memory in different ways. Wheeler and colleagues46 have proposed that studying encourages cognitive rehearsal of information, whereas testing enhances the retrieval process itself (an individual’s ability to access and use information from memory), which improves long-term retention. Proponents often suggest that testing for learning should not be summative so as to avoid assessment fatigue, but Ferree and Cahill’s35 findings raise the question of whether or not an emotional reaction to the testing event, especially those that are negative and/or arousing, may enhance subsequent retrieval further by increasing the tendency to rehearse the tested information after the fact.
Acting on information
To this point in our report, we have focused on how emotions moderate individual perceptions and memories, but emotions also appear to influence how people act and respond to different learning events.47,48 For example, emotions appear capable of altering the extent to which individuals seek out and act appropriately in response to feedback interventions. Such factors provide another avenue through which understanding emotion can have important implications for how individuals learn and transfer knowledge to new clinical problems.
Feedback serves as an important pedagogical intervention in medical education settings.49 Providing students with the opportunity to elicit and receive performance feedback and stressing on them the importance of seeking external data to inform their perceptions of their own performance is commonly thought to promote learning and knowledge transfer. However, research on whether positive (e.g., information about success) and negative (e.g., information about failure) feedback has different effects on a learner’s motivation has suggested that both positive and negative feedback can equally increase and decrease motivation and performance.50–52
Several researchers have suggested that situationally induced regulatory focus (i.e., how individuals orient themselves to a given situation) may modulate the relationship between the emotional valence induced by feedback and an individual’s motivation to act on such feedback. Self-regulatory focus theory53,54 proposes two separate, independent regulation orientations or “states of mind”—the promotion system and the prevention system. Under the promotion system, individuals are oriented toward advancement opportunities, rewards, and accomplishments. In contrast, the prevention system orients individuals toward security, punishment, and avoiding negative outcomes. With a promotion focus, individuals are sensitive to the presence or absence of positive outcomes and, therefore, should be particularly sensitive to rewards that result from skilled performance. With a prevention focus, however, individuals are sensitive to the presence or absence of negative outcomes and, therefore, should be sensitive to punishments that accompany poor performance.55–57
Higgins53,54 suggested that under a promotion focus, success (i.e., positive feedback) produces feelings that are not only positive but are also high in emotional arousal (e.g., excitement, happiness), whereas failure (i.e., negative feedback) produces feelings that are negative but are also low in arousal (e.g., apathy, discouragement). On the other hand, success/positive feedback under a prevention focus is associated with positive feelings that are low in arousal (e.g., quiescence, relaxation), whereas failure/negative feedback produces negative feelings that are high in arousal (e.g., agitation, tension). Higgins’ theory, therefore, suggests that it is emotional arousal that leads to an individual being more receptive to feedback and more motivated to change rather than emotional valence.
The potential influence of emotional arousal on motivation inspired Van Dijk and Kluger55–57 to directly examine the interaction between feedback valence (negative versus positive) and regulatory focus and whether this interaction influences the extent to which an individual is motivated to act on the feedback that he or she has received. To test their (and Higgins’) hypothesis, they had participants imagine a scenario in which they were working at a job and their supervisor commented on their task performance.56 To manipulate regulatory focus, half the participants were told that they were working at a job that they had to keep because of financial obligations (prevention focus), whereas the other half were told that they were working at a job that they had always desired to have and wanted to advance at their position (promotion focus). To manipulate feedback valence, half of the participants in each condition were randomly told that they had failed in their task performance, whereas the other half were told that they had excelled in their performance. Van Dijk and Kluger measured motivation by directly asking participants to rate how much effort they intended to invest in their future performance, using a scale ranging from “much less” through “about the same” to “much more.” The results confirmed their predictions. Motivation ratings were higher for those who received positive feedback relative to those who received negative feedback, but only when participants were under promotion focus. The effects were reversed for those under prevention focus, with motivation being higher for those who received negative feedback relative to those who received positive feedback.
Few researchers have attempted to empirically examine the relationship between regulatory focus and emotional valence and arousal. Although most agree that feedback interventions are emotional experiences for medical students and practitioners,58 we know little about the relationship between emotions, regulatory focus, and feedback valence. For example, it remains to be determined what factors promote prevention or promotion focus, whether we can manipulate those factors, and whether feedback can be tailored optimally by attending more carefully to those factors.
Emotions and feelings are deeply interconnected with how individuals identify, perceive, and interpret information available in learning environments, as well as with how they act on the information available in learning and practice situations. Our review of the relevant literature provides several empirical examples of how emotion influences learning and knowledge transfer that represent broad and stable patterns from which we can draw several conclusions.
1. Negative emotions encourage individuals to focus on the individual details associated with a learning scenario, which may be beneficial in tasks that require a strong attention to detail. On the other hand, positive emotions encourage individuals to focus on the big picture of a learning event. This global processing style may enable learners to create associative and relational connections between relevant learning events, thereby increasing the likelihood of transferring knowledge and skills to new situations.
2. Negative emotions may increase an individual’s reliance on familiar problem-solving strategies, which may make it more difficult for him or her to adapt when such strategies are potentially inadequate. Positive emotions facilitate cognitive flexibility and openness to information, which may enable students to detect similarities between tasks, thereby enhancing the transfer of clinical skills and knowledge. Researchers believe that such flexibility is valuable for reducing the likelihood of errors attributable to premature closure.59
3. Emotional experiences, particularly negative ones, are more likely to be mulled over than nonemotional experiences. This unintentional retrieval of emotional events and reactions can increase the likelihood of an individual further retrieving his or her negative learning experiences from memory relative to positive experiences, though transfer may be impeded, and such retrieval may contribute to lowering empathy and satisfaction.
4. The difference in effects of positive and negative emotions is dependent on the feedback recipient’s state of mind. The promotion and prevention regulatory systems interact with feedback valence (negative/failure versus positive/success) to influence motivation and improvement. Under promotion focus, motivation is higher for those who receive positive feedback relative to those who receive negative feedback. Under prevention focus, motivation is higher for those who receive negative feedback relative to those who receive positive feedback.
Taken together, these results demonstrate that both positive and negative emotions play an important role in learning and knowledge transfer. These findings have important implications for medical educators regarding how best to prepare students to learn complex knowledge and skills and to transfer this knowledge into novel clinical settings. Consider the common pedagogical technique known as “pimping,” whereby attending physicians or senior residents ask junior colleagues a series of challenging questions. These pimping experiences are associated with a variety of emotions, including humiliation, embarrassment, excitement, and anxiety, and educators have theorized that these emotive states promote learning during the pimping experience.60,61 Indeed, most students recall these pimping sessions quite well—a fact that is used by some educators to promote the use of pimping as a form of teaching. However, we do not yet have a complete understanding of whether, why, or when pimping works. Are students more likely to replay these events in their heads because of their evocative nature? Are they more likely to look up relevant information in response to a particular pimping event? Does the impact of pimping on knowledge retention depend on whether students experience positive versus negative emotions or arousing versus nonarousing states? Does pimping promote or impede the transfer of knowledge and skills to new clinical cases? The literature reviewed in this article suggests that, when students perceive a learning situation as threatening or frightening, they may have better memory of the emotional event because of cognitive rehearsal and elaboration, but they may be less likely to make broader connections, thereby precluding transfer of the learned information to other clinical settings. Therefore, although pimping may enhance memory for certain situations, creating the impression of influential teaching/learning, it may actually impede the application of knowledge gained to new contexts.
Further understanding how different emotional states affect clinical decision-making skills may also facilitate medical training and practice patterns. As we discussed earlier, one of the most commonly reported causes of clinical error is premature closure,29,30 which occurs when a diagnosis is accepted before alternative diagnoses have been properly ruled out. In such cases, physicians may have paid too much attention to a specific feature or finding at the expense of understanding the whole situation. To what extent does the emotional state of the physician influence the likelihood of committing such an error? Theoretically, because negative emotions have been shown to promote focusing on specific details of a scene, individuals in negative moods may be more likely to commit errors of premature closure. If such a connection is found, students, physicians, and educators alike should be cognizant of the impact of unexamined emotions on diagnostic accuracy because understanding how these errors arise may provide important insights into how they might be prevented in the future.
Of course, for such knowledge to have an impact on training and practice, we must know whether emotion and its influence on performance can be modulated effectively. Some evidence suggests that once individuals are made aware of potential mood effects, they are able to modulate the extent to which emotion influences their performance.10,62,63 As a result, medical educators may be able to train physicians to be aware of their emotional states and how their emotions may bias perceptions, interpretations, and actions. Explicitly drawing attention to learners’ emotional states by making them components of self-reflective checklists and portfolios may be useful in this regard.64 Alternatively, the use of simulated situations may help students become aware of when and to what extent emotions regulate their decision making. By subjecting students to a series of simulations and then requiring them to continuously monitor how they are feeling, medical trainees may become better at monitoring their emotional states. By fostering the ability to identify different emotional states and their effects on learning, medical professionals and trainees will ideally develop an awareness of when they are learning and performing at their best and when they are not.
Finally, we think it is worth explicitly reinforcing just how powerful emotions can be. The mood induction procedures that we have described in this review are quite minimal. If a brief film clip has an effect, how much more dramatic might the change be after a more extreme experience, like those common in medical training and care? That being said, it is important to note that many of the studies that we discussed induced emotional states and then had participants complete emotionally neutral tasks (e.g., global/local processing tasks; ToH puzzle). It may be worth differentiating between endogenous emotional states that trainees bring into a learning environment (i.e., stress, nervousness, excitement) and the emotional states that are brought about in response to specific learning events (i.e., stress associated with performing one’s first intubation, excitement induced by observing the birth of a infant). The literature that we reviewed did not inform us about the extent to which it matters whether an individual’s emotional state is tied to the learning/transfer event. The distinction between endogenous and exogenous emotional experiences may be particularly important in the context of medical education, given the potentially high prevalence of both instances in health care settings.1
Recommendations for future research
Medical trainees are required to learn complex skills and make complicated decisions. Given that a key goal of medical education is to enable practitioners to recognize similarities between clinical problems at a deep level of understanding (i.e., to enable transfer), we should not see concerns about trainees’ emotional states as simply about individuals’ well-being (though that is clearly important). Rather, the emotions experienced not only during medical school but throughout one’s career may have a significant impact on health care professionals and trainees’ capacity to perform at a high level. As Borrell-Carrió and Epstein65 recently stated, “emotional self-awareness and self-regulation of attention can be consciously cultivated as habits to help physicians function better in clinical situations.” More research is needed in this area to understand how to effectively prepare trainees to perform under a wide range of emotional conditions.
Other disclosures: None.
Ethical approval: Not applicable.
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