Critical Thinking in Medicine: All You Wanted To Know
by [email protected] | Jan 15, 2020 | critical thinking | 0 comments
Critical Thinking in Medicine: All You Wanted To Know
We’ve often come across the importance of possessing critical thinking into our lives. From being trained at coaching institutes to getting listed as one of the requisites in job descriptions, the quality of critical thinking is regarded as important everywhere. It can be an art, science, and a miracle, all at the same time! Let’s dig deeper and discover more about this art, science, and miracle of the human brain.
What is critical thinking?
Starting with its meaning and definition, over time, the clarity of critical thinking has evolved with multiple understandings about the subject. Most definitions of it can be fairly complex and best taught and understood by philosophy majors or psychologists.
Beyer (1995), provides the most basic definition of Critical Thinking as “making reasoned judgments”.
In another understanding, it is the ability to think clearly and rationally about what to do and/or what to believe. It also includes the ability to engage in reflective and independent thinking. A person with critical thinking skills is capable of the following:
- Having an understanding of logical connections between multiple ideas
- Identify, construct, and evaluate arguments
- Detect loopholes and common mistakes in reasoning
- Reflect on the justification of one’s own values and beliefs
- Identify the relevance and importance of ideas
What are its characteristics?
According to experts, to think critically involves asking questions, defining a problem, analyzing evidence, examining assumptions and biases, overlooking emotional reasoning, avoiding oversimplification, and tolerating ambiguity.
Besides, considering other interpretations and dealing with ambiguity also constitute critical thinking. Other characteristics include:
- Disposition – People who think critically are skeptical, open-minded, respect clarity and precision, look at different points of view, and respect evidence and reasoning.
- Criteria – An individual must apply specific criteria along with conditions that must be met for something to be reasoned as believable.
- Reasoning – The ability to arrive at a conclusion from one or more premises, using logical relationships among statements or data.
What are the steps involved in critical thinking?
It is a common misconception that it limits creativity as it involves the rules of rationality and logic, however, creativity requires breaking rules, unlike to think critically. Cognitive steps in thinking critically include:
- Gathering information from all sources i.e. verbal and/or written expressions, reflections, experience, and observation
- Gathering and assessing relevant information
- Deriving well-reasoned conclusions and solutions
- Testing outcomes against relevant criteria
- Evaluating all assumptions, implications, and practical consequences
How critical thinking is helpful to medical students?
In the healthcare industry, medical professionals are known to use critical thinking, especially when they derive knowledge from other interdisciplinary subject areas to provide a holistic approach to their patients. Medical students can utilize their ability to think critically for the following:
- Avoiding medical/clinical errors
- Identifying better alternatives for diagnosis and treatment
- Better ability to make clinical decisions
- Working in a resource-limited environment
- Quality thinking, quality work output, and increased productivity
Can it be taught?
To an extent, critical thinking can not only be taught but also developed and enhanced by experts through technology. As massive information is available in the present times, students only need a befitting trainer to guide them through the information and inculcate it the right way.
Students need to develop and apply critical thinking skills effectively to complex problems and to critical choices they are forced to face, as a result of the information explosion and other dynamic technological changes. Since questioning is one of the important aspects of critical thinking, it is essential to teach students how to ask good, relevant, and logical questions to think critically and succeed.
The Takeaway
Every new or established medical professional should understand their psychological foibles so as to be much clearer about every aspect of their lives and to make the best decisions. Some worthwhile quotes for every medical practitioner:
- “Knowledge of bias should contribute to your humility, not your confidence”
- “When beliefs are based on emotions, facts alone stand little chance”
- “Reason evolved primarily to win arguments, not to solve problems”
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Medical Student Guide For Critical Thinking
Critical thinking is an essential cognitive skill for every individual but is a crucial component for healthcare professionals such as doctors, nurses and dentists. It is a skill that should be developed and trained, not just during your career as a doctor, but before that when you are still a medical student.
To be more effective in their studies, students must think their way through abstract problems, work in teams and separate high quality from low quality information. These are the same qualities that today's medical students are supposed to possess regardless of whether they graduate in the UK or study medicine in Europe .
In both well-defined and ill-defined medical emergencies, doctors are expected to make competent decisions. Critical thinking can help medical students and doctors achieve improved productivity, better clinical decision making, higher grades and much more.
This article will explain why critical thinking is a must for people in the medical field.
Definition of Critical Thinking
You can find a variety of definitions of Critical Thinking (CT). It is a term that goes back to the Ancient Greek philosopher Socrates and his teaching practice and vision. Critical thinking and its meaning have changed over the years, but at its core always will be the pursuit of proper judgment.
We can agree on one thing. Critical thinkers question every idea, assumption, and possibility rather than accepting them at once.
The most basic definition of CT is provided by Beyer (1995):
"Critical thinking means making reasoned judgements."
In other words, it is the ability to think logically about what to do and/or believe. It also includes the ability to think critically and independently. CT is the process of identifying, analysing, and then making decisions about a particular topic, advice, opinion or challenge that we are facing.
Steps to critical thinking
There is no universal standard for becoming a critical thinker. It is more like a unique journey for each individual. But as a medical student, you have already so much going on in your academic and personal life. This is why we created a list with 6 steps that will help you develop the necessary skills for critical thinking.
1. Determine the issue or question
The first step is to answer the following questions:
- What is the problem?
- Why is it important?
- Why do we need to find a solution?
- Who is involved?
By answering them, you will define the situation and acquire a deeper understanding of the problem and of any factors that may impact it.
Only after you have a clear picture of the issue and people involved can you start to dive deeper into the problem and search for a solution.
2. Research
Nowadays, we are flooded with information. We have an unlimited source of knowledge – the Internet.
Before choosing which medical schools to apply to, most applicants researched their desired schools online. Some of the areas you might have researched include:
- If the degree is recognised worldwide
- Tuition fees
- Living costs
- Entry requirements
- Competition for entry
- Number of exams
- Programme style
Having done the research, you were able to make an informed decision about your medical future based on the gathered information. Our list may be a little different to yours but that's okay. You know what factors are most important and relevant to you as a person.
The process you followed when choosing which medical school to apply to also applies to step 2 of critical thinking. As a medical student and doctor, you will face situations when you have to compare different arguments and opinions about an issue. Independent research is the key to the right clinical decisions. Medical and dentistry students have to be especially careful when learning from online sources. You shouldn't believe everything you read and take it as the absolute truth. So, here is what you need to do when facing a medical/study argument:
- Gather relevant information from all available reputable sources
- Pay attention to the salient points
- Evaluate the quality of the information and the level of evidence (is it just an opinion, or is it based upon a clinical trial?)
Once you have all the information needed, you can start the process of analysing it. It’s helpful to write down the strong and weak points of the various recommendations and identify the most evidence-based approach.
Here is an example of a comparison between two online course platforms , which shows their respective strengths and weaknesses.
When recommendations or conclusions are contradictory, you will need to make a judgement call on which point of view has the strongest level of evidence to back it up. You should leave aside your feelings and analyse the problem from every angle possible. In the end, you should aim to make your decision based on the available evidence, not assumptions or bias.
4. Be careful about confirmation bias
It is in our nature to want to confirm our existing ideas rather than challenge them. You should try your best to strive for objectivity while evaluating information.
Often, you may find yourself reading articles that support your ideas, but why not broaden your horizons by learning about the other viewpoint?
By doing so, you will have the opportunity to get closer to the truth and may even find unexpected support and evidence for your conclusion.
Curiosity will keep you on the right path. However, if you find yourself searching for information or confirmation that aligns only with your opinion, then it’s important to take a step back. Take a short break, acknowledge your bias, clear your mind and start researching all over.
5. Synthesis
As we have already mentioned a couple of times, medical students are preoccupied with their studies. Therefore, you have to learn how to synthesise information. This is where you take information from multiple sources and bring the information together. Learning how to do this effectively will save you time and help you make better decisions faster.
You will have already located and evaluated your sources in the previous steps. You now have to organise the data into a logical argument that backs up your position on the problem under consideration.
6. Make a decision
Once you have gathered and evaluated all the available evidence, your last step is to make a logical and well-reasoned conclusion.
By following this process you will ensure that whatever decision you make can be backed up if challenged
Why is critical thinking so important for medical students?
The first and most important reason for mastering critical thinking is that it will help you to avoid medical and clinical errors during your studies and future medical career.
Another good reason is that you will be able to identify better alternative options for diagnoses and treatments. You will be able to find the best solution for the patient as a whole which may be different to generic advice specific to the disease.
Furthermore, thinking critically as a medical student will boost your confidence and improve your knowledge and understanding of subjects.
In conclusion, critical thinking is a skill that can be learned and improved. It will encourage you to be the best version of yourself and teach you to take responsibility for your actions.
Critical thinking has become an essential for future health care professionals and you will find it an invaluable skill throughout your career.
We’ll keep you updated
Science-Based Medicine
Exploring issues and controversies in the relationship between science and medicine
Critical Thinking in Medicine
Cognitive Errors and Diagnostic Mistakes is a superb new guide to critical thinking in medicine written by Jonathan Howard. It explains how our psychological foibles regularly bias and betray us, leading to diagnostic mistakes. Learning critical thinking skills is essential but difficult. Every known cognitive error is illustrated with memorable patient stories.
Rodin’s Thinker is doing his best to think but if he hasn’t learned critical thinking skills, he is likely to make mistakes. The human brain is prone to a multitude of cognitive errors.
Critical thinking in medicine is what the Science-Based Medicine ( SBM ) blog is all about. Jonathan Howard has written a superb book, Cognitive Errors and Diagnostic Mistakes: A Case-Based Guide to Critical Thinking in Medicine , that epitomizes the message of SBM . In fact, in the Acknowledgements, he credits the entire team at SBM for teaching him “an enormous amount about skepticism and critical thinking”, and he specifically thanks Steven Novella, Harriet Hall (moi!), and David Gorski.
Dr. Howard is a neurologist and psychiatrist at NYU and Bellevue Hospital. The book is a passionate defense of science and a devastating critique of Complementary and Alternative Medicine ( CAM ) and pseudoscience. Its case-based approach is a stroke of genius. We humans are story-tellers; we are far more impressed by stories than by studies or by textbook definitions of a disease. Dr. Howard points out that “Anecdotes are part of the very cognition that allows us to derive meaning from experience and turn noise into signal.” They are incredibly powerful from an emotional standpoint. That’s why he chose to begin every discussion of a cognitive error with a patient’s case, an anecdote.
CAM knows how effective this can be; that’s why it relies so heavily on anecdotes. When doctors think of a disease, they are likely to think of a memorable patient they treated with that disease, and that patient’s case is likely to bias their thinking about other patients with the same disease. If there is a bad outcome with a treatment, they will remember that and may reject that treatment for the next patient even if it is the most appropriate one. Dr. Howard uses patient stories to great advantage, first providing the bare facts of the case and then letting the patient’s doctors explain their thought processes so we can understand exactly where and why they went wrong. Then he goes on to explain the psychology behind the cognitive error, with study findings, other examples, and plentiful references. If readers remember these cases, they might avoid similar mishaps.
An encyclopedia of cognitive errors
The book is encyclopedic, running to 30 chapters and 588 pages. I can’t think of anything he failed to mention, and whenever an example or a quotation occurred to me, he had thought of it first and included it in the text. I couldn’t begin to list all the cognitive errors he covers, but they fall roughly into these six categories:
- Errors of overattachment to a particular diagnosis
- Errors due to failure to consider alternative diagnoses.
- Errors due to inheriting someone else’s thinking.
- Errors in prevalence perception or estimation.
- Errors involving patient characteristics or presentation context.
- Errors associated with physician affect, personality, or decision style.
A smattering of examples
There is so much information and wisdom in this book! I’ll try to whet your appetite with a few excerpts that particularly struck me.
- Discussing an issue with others who disagree can help us avoid confirmation bias and groupthink.
- Negative panic: when a group of people witness an emergency and fail to respond, thinking someone else will.
- Reactance bias: doctors who object to conventional practices and want to feel independent may reject science and embrace pseudoscience.
- Cyberchondria: using the Internet to interpret mundane symptoms as dire diagnoses.
- Motivated reasoning: People who “know” they have chronic Lyme disease will fail to believe 10 negative Lyme tests in a row and then believe the 11 th test if it is positive.
- The backfire effect: “encountering contradictory information can have the paradoxical effect of strengthening our initial belief rather than causing us to question it.”
- Biases are easy to see in others but nearly impossible to detect in oneself.
- Checklists for fake diseases take advantage of the Forer effect . As with horoscopes and cold readings, vague, nonspecific statements convince people that a specific truth about them is being revealed. Fake diseases are unfalsifiable: there is no way to rule them out.
- When presenting risk/benefit data to patients, don’t present risk data first; it will act as an “anchor” to make them fixate on risk.
- The doctor’s opinion of the patient will affect the quality of care.
- Randomness is difficult to grasp. The hot hand and the gambler’s fallacy can both fool doctors. If the last two patients had disease X and this patient has similar symptoms, the doctor will think he probably has disease X too. Or if the doctor has just seen two cases of a rare disease, it will seem unlikely that the next patient with similar symptoms will have it too.
- Apophenia : the tendency to perceive meaningful patterns with random information, like seeing the face on Mars.
- Information bias: doctors tend to think the more information, the better. But tests are indicated only if they will help establish a diagnosis or alter management. They should not be ordered out of curiosity or to make the clinician feel better. Sometimes doctors don’t know what to do with the information from a test. This should be a lesson for doctors who practice so-called functional medicine : they order all kinds of nonstandard tests whose questionable results give no evidence-based guidance for treating the patient. Doctors should ask “How will this test alter my management?” and if they can’t answer, they shouldn’t order the test.
- Once a treatment is started, it can be exceedingly difficult to stop. A study showed that 58% of medications could be stopped in elderly patients and only 2% had to be re-started.
- Doctors feel obligated to “do something” for the patient, but sometimes the best course is to do nothing. “Just don’t do something, stand there.” At the end of their own life, 90% of doctors would refuse the treatments they routinely give to patients with terminal illnesses.
- Incidentalomas: when a test reveals an unsuspected finding, it’s important to remember that abnormality doesn’t necessarily mean pathology or require treatment.
- Fear of possible unknown long-term consequences may lead doctors to reject a treatment, but that should be weighed carefully against the well-known consequences of the disease itself.
- It’s good for doctors to inform patients and let them participate in decisions, but too much information can overwhelm patients. He gives the example of a patient with multiple sclerosis whose doctor describes the effectiveness and risks of 8 injectables, 3 pills, and 4 infusions. The patient can’t choose; she misses the follow-up appointment and returns a year later with visual loss that might have been prevented.
- Most patients don’t benefit from drugs; the NNT tells us the Number of patients who will Need to be Treated for one person to benefit.
- Overconfidence bias: in the Dunning-Kruger effect, people think they know more than the experts about things like climate change, vaccines and evolution. Yet somehow these same people never question that experts know how to predict eclipses.
- Patient satisfaction does not measure effectiveness of treatment. A study showed that the most satisfied patients were 12% more likely to be admitted to the hospital, had 9% higher prescription costs, and were 26% more likely to die.
- The availability heuristic and the frequency illusion: “Clinicians should be aware that their experience is distorted by recent or memorable [cases], the experiences of their colleagues, and the news.” He repeats Mark Crislip’s aphorism that the three most dangerous words in medicine are “in my experience”.
- Illusory truth: people are likely to believe a statement simply because they have heard it many times.
- What makes an effective screening test? He covers concepts like lead time bias, length bias, and selection bias. Screening tests may do more harm than good. The PSA test is hardly better than a coin toss.
- Blind spot bias: Everyone has blind spots; we recognize them in others but can’t see our own. Most doctors believe they won’t be influenced by gifts from drug companies, but they believe others are unconsciously biased by such gifts. Books like this can make things worse: they give us false confidence. “Being inclined to think that you can avoid a bias because you [are] aware of it is a bias in itself.”
- He quotes from Contrived Platitudes: “Everything happens for a reason except when it doesn’t. But even then you can in hindsight fabricate a reason that will satisfy your belief system.” This is the essence of what CAM does, especially the versions that attribute all diseases to a single cause.
Some juicy quotes
Knowledge of bias should contribute to your humility, not your confidence.
Only by studying treatments in large, randomized, blinded, controlled trials can the efficacy of a treatment truly be measured.
When beliefs are based in emotion, facts alone stand little chance.
CAM , when not outright fraudulent, is nothing more than the triumph of cognitive biases over rationality and science.
Reason evolved primarily to win arguments, not to solve problems.
He includes a thorough discussion of the pros and cons of limiting doctors’ work hours, with factors most people have never considered, and a thorough discussion of financial motivations.
The book is profusely illustrated with pictures, diagrams, posters, and images from the Internet like “The Red Flags of Quackery” from sci-ence.org. Many famous quotations are presented with pictures of the person quoted, like Christopher Hitchens and his “What can be asserted without evidence can be dismissed without evidence”.
He never goes beyond the evidence. Rather than just giving study results, he tells the reader when other researchers have failed to replicate the findings.
We rely on scientific evidence, but researchers are not immune from bias. He describes the many ways research can go astray: 235 biases have been identified that can lead to erroneous results. As Ioannidis said, most published research findings are wrong. But all is not lost: people who understand statistics and the methodologies of science can usually distinguish a good study from a bad one.
He tells the infamous N-ray story. He covers the file drawer effect, publication bias, conflicts of interest, predatory journals, ghostwriting, citation plagiarism, retractions, measuring poor surrogates instead of meaningful clinical outcomes, and outright fraud. Andrew Wakefield features prominently. Dr. Howard’s discussions of p-hacking, multiple variables, random chance, and effect size are particularly valuable. HARKing is Hypothesizing After the Results are Known. It can be exploited to create erroneous results.
He tells a funny story that was new to me. Two scientists wrote a paper consisting entirely of the repeated sentence “Get me off your fucking mailing list” complete with diagrams of that sentence. It was rated as excellent and was accepted for publication!
Conclusion: Well worth reading for doctors and for everyone else
As the book explains, “The brain is a self-affirming spin-doctor with a bottomless bag of tricks…” Our brains are “pattern-seeking machines that fill in the gaps in our perception and knowledge consistent with our expectations, beliefs, and wishes”. This book is a textbook explaining our cognitive errors. Its theme is medicine but the same errors occur everywhere. We all need to understand our psychological foibles in order to think clearly about every aspect of our lives and to make the best decisions. Every doctor would benefit from reading this book, and I wish it could be required reading in medical schools. I wish everyone who considers trying CAM would read it first. I wish patients would ask doctors to explain why they ordered a test.
The book is not inexpensive. The price on Amazon is $56.99 for both softcover and Kindle versions. But it might be a good investment: you might save much more money that that by applying the principles it teaches, and critical thinking skills might even save your life. Well-written, important, timely, easy, and entertaining to read, lots of illustrations, packed with good stuff. Highly recommended.
Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so), and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel. In 2008 she published her memoirs, Women Aren't Supposed to Fly .
- Posted in: Book & movie reviews , Critical Thinking , Neuroscience/Mental Health , Science and Medicine
- Tagged in: bias , CAM , cognitive errors , diagnostic mistakes , Jonathan Howard
Posted by Harriet Hall
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Cultivating Critical Thinking in Healthcare
Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).
Given this, it's necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught , assessed and integrated into the design and development of staff and nurse education and training programs (Papp et al. 2014).
So, what exactly is critical thinking and how can healthcare educators cultivate it amongst their staff?
What is Critical Thinking?
In general terms, ‘ critical thinking ’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills .
In practice, however, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions .
Several formal definitions of critical thinking can be found in literature, but in the view of Kahlke and Eva (2018), most of these definitions have limitations. That said, Papp et al. (2014) offer a useful starting point, suggesting that critical thinking is:
‘The ability to apply higher order cognitive skills and the disposition to be deliberate about thinking that leads to action that is logical and appropriate.’
The Foundation for Critical Thinking (2017) expands on this and suggests that:
‘Critical thinking is that mode of thinking, about any subject, content, or problem, in which the thinker improves the quality of his or her thinking by skillfully analysing, assessing, and reconstructing it.’
They go on to suggest that critical thinking is:
- Self-directed
- Self-disciplined
- Self-monitored
- Self-corrective.
Key Qualities and Characteristics of a Critical Thinker
Given that critical thinking is a process that encompasses conceptualisation , application , analysis , synthesis , evaluation and reflection , what qualities should be expected from a critical thinker?
In answering this question, Fortepiani (2018) suggests that critical thinkers should be able to:
- Formulate clear and precise questions
- Gather, assess and interpret relevant information
- Reach relevant well-reasoned conclusions and solutions
- Think open-mindedly, recognising their own assumptions
- Communicate effectively with others on solutions to complex problems.
All of these qualities are important, however, good communication skills are generally considered to be the bedrock of critical thinking. Why? Because they help to create a dialogue that invites questions, reflections and an open-minded approach, as well as generating a positive learning environment needed to support all forms of communication.
Lippincott Solutions (2018) outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:
- Inquisitiveness with regard to a wide range of issues
- A concern to become and remain well-informed
- Alertness to opportunities to use critical thinking
- Self-confidence in one’s own abilities to reason
- Open mindedness regarding divergent world views
- Flexibility in considering alternatives and opinions
- Understanding the opinions of other people
- Fair-mindedness in appraising reasoning
- Honesty in facing one’s own biases, prejudices, stereotypes or egocentric tendencies
- A willingness to reconsider and revise views where honest reflection suggests that change is warranted.
Papp et al. (2014) also helpfully suggest that the following five milestones can be used as a guide to help develop competency in critical thinking:
Stage 1: Unreflective Thinker
At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.
Stage 2: Beginning Critical Thinker
Here, the learner begins to think critically and starts to recognise cognitive differences in other people. However, external motivation is needed to sustain reflection on the learners’ own thought processes.
Stage 3: Practicing Critical Thinker
By now, the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.
Stage 4: Advanced Critical Thinker
As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.
Stage 5: Accomplished Critical Thinker
At this stage, the skilled critical thinker can take charge of their thinking and habitually monitors, revises and rethinks approaches for continual improvement of their cognitive strategies.
Facilitating Critical Thinking in Healthcare
A common challenge for many educators and facilitators in healthcare is encouraging students to move away from passive learning towards active learning situations that require critical thinking skills.
Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are also several generally recognised hallmarks of teaching for critical thinking . These include:
- Promoting interaction among students as they learn
- Asking open ended questions that do not assume one right answer
- Allowing sufficient time to reflect on the questions asked or problems posed
- Teaching for transfer - helping learners to see how a newly acquired skill can apply to other situations and experiences.
(Lippincott Solutions 2018)
Snyder and Snyder (2008) also make the point that it’s helpful for educators and facilitators to be aware of any initial resistance that learners may have and try to guide them through the process. They should aim to create a learning environment where learners can feel comfortable thinking through an answer rather than simply having an answer given to them.
Examples include using peer coaching techniques , mentoring or preceptorship to engage students in active learning and critical thinking skills, or integrating project-based learning activities that require students to apply their knowledge in a realistic healthcare environment.
Carvalhoa et al. (2017) also advocate problem-based learning as a widely used and successful way of stimulating critical thinking skills in the learner. This view is echoed by Tsui-Mei (2015), who notes that critical thinking, systematic analysis and curiosity significantly improve after practice-based learning .
Integrating Critical Thinking Skills Into Curriculum Design
Most educators agree that critical thinking can’t easily be developed if the program curriculum is not designed to support it. This means that a deep understanding of the nature and value of critical thinking skills needs to be present from the outset of the curriculum design process , and not just bolted on as an afterthought.
In the view of Fortepiani (2018), critical thinking skills can be summarised by the statement that 'thinking is driven by questions', which means that teaching materials need to be designed in such a way as to encourage students to expand their learning by asking questions that generate further questions and stimulate the thinking process. Ideal questions are those that:
- Embrace complexity
- Challenge assumptions and points of view
- Question the source of information
- Explore variable interpretations and potential implications of information.
To put it another way, asking questions with limiting, thought-stopping answers inhibits the development of critical thinking. This means that educators must ideally be critical thinkers themselves .
Drawing these threads together, The Foundation for Critical Thinking (2017) offers us a simple reminder that even though it’s human nature to be ‘thinking’ most of the time, most thoughts, if not guided and structured, tend to be biased, distorted, partial, uninformed or even prejudiced.
They also note that the quality of work depends precisely on the quality of the practitioners’ thought processes. Given that practitioners are being asked to meet the challenge of ever more complex care, the importance of cultivating critical thinking skills, alongside advanced problem-solving skills , seems to be taking on new importance.
Additional Resources
- The Emotionally Intelligent Nurse | Ausmed Article
- Refining Competency-Based Assessment | Ausmed Article
- Socratic Questioning in Healthcare | Ausmed Article
- Carvalhoa, D P S R P et al. 2017, 'Strategies Used for the Promotion of Critical Thinking in Nursing Undergraduate Education: A Systematic Review', Nurse Education Today , vol. 57, pp. 103-10, viewed 7 December 2018, https://www.sciencedirect.com/science/article/abs/pii/S0260691717301715
- Fortepiani, L A 2017, 'Critical Thinking or Traditional Teaching For Health Professionals', PECOP Blog , 16 January, viewed 7 December 2018, https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/
- Jacob, E, Duffield, C & Jacob, D 2017, 'A Protocol For the Development of a Critical Thinking Assessment Tool for Nurses Using a Delphi Technique', Journal of Advanced Nursing, vol. 73, no. 8, pp. 1982-1988, viewed 7 December 2018, https://onlinelibrary.wiley.com/doi/10.1111/jan.13306
- Kahlke, R & Eva, K 2018, 'Constructing Critical Thinking in Health Professional Education', Perspectives on Medical Education , vol. 7, no. 3, pp. 156-165, viewed 7 December 2018, https://link.springer.com/article/10.1007/s40037-018-0415-z
- Lippincott Solutions 2018, 'Turning New Nurses Into Critical Thinkers', Lippincott Solutions , viewed 10 December 2018, https://www.wolterskluwer.com/en/expert-insights/turning-new-nurses-into-critical-thinkers
- Papp, K K 2014, 'Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing', Academic Medicine , vol. 89, no. 5, pp. 715-720, https://journals.lww.com/academicmedicine/Fulltext/2014/05000/Milestones_of_Critical_Thinking___A_Developmental.14.aspx
- Snyder, L G & Snyder, M J 2008, 'Teaching Critical Thinking and Problem Solving Skills', The Delta Pi Epsilon Journal , vol. L, no. 2, pp. 90-99, viewed 7 December 2018, https://dme.childrenshospital.org/wp-content/uploads/2019/02/Optional-_Teaching-Critical-Thinking-and-Problem-Solving-Skills.pdf
- The Foundation for Critical Thinking 2017, Defining Critical Thinking , The Foundation for Critical Thinking, viewed 7 December 2018, https://www.criticalthinking.org/pages/our-conception-of-critical-thinking/411
- Tsui-Mei, H, Lee-Chun, H & Chen-Ju MSN, K 2015, 'How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning', Journal for Nurses in Professional Development , vol. 31, no. 3, pp. 170-175, viewed 7 December 2018, https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx
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Critical thinking in healthcare and education
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- Peer review
- Jonathan M Sharples , professor 1 ,
- Andrew D Oxman , research director 2 ,
- Kamal R Mahtani , clinical lecturer 3 ,
- Iain Chalmers , coordinator 4 ,
- Sandy Oliver , professor 1 ,
- Kevan Collins , chief executive 5 ,
- Astrid Austvoll-Dahlgren , senior researcher 2 ,
- Tammy Hoffmann , professor 6
- 1 EPPI-Centre, UCL Department of Social Science, London, UK
- 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
- 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
- 4 James Lind Initiative, Oxford, UK
- 5 Education Endowment Foundation, London, UK
- 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
- Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk
Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration
Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.
Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2
Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.
Essential skills for doctors and patients
Critical thinking is not a new concept in education: at the beginning of the last century the US educational reformer John Dewey identified the need to help students “to think well.” 3 Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (such as analysis, inference, and self regulation); approaches to specific questions or problems (orderliness, diligence, and reasonableness); and approaches to life in general (inquisitiveness, concern with being well informed, and open mindedness). 4
An increasing body of evidence highlights that developing critical thinking skills can benefit academic outcomes as well as wider reasoning and problem solving capabilities. 5 For example, the Thinking, Doing, Talking Science programme trains teachers in a repertoire of strategies that encourage pupils to use critical thinking skills in primary school science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on pupils’ science attainment, with signs that it was particularly beneficial for pupils from poorer families. 6
In medicine, increasing attention has been paid to “critical appraisal” in the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions. 7 8 9 The need for critical appraisal in medicine was recognised at least 75 years ago, 10 and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. 11 The General Medical Council’s Good Medical Practice guidance includes the need for doctors to be able to “provide effective treatments based on the best available evidence.” 12
If patients and the public are to make well informed health choices, they must also be able to assess the reliability of health claims and information. This is something that most people struggle to do, and it is becoming increasingly important because patients are taking on a bigger role in managing their health and making healthcare decisions, 13 while needing to cope with more and more health information, much of which is not reliable. 14 15 16 17
Teaching critical thinking
Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curriculums for primary and secondary schools in many countries. 18 Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking. 19 20 This matters because the ability to think critically is an essential life skill relevant to decision making in many circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for pupils who live in homes where they are encouraged to think and talk about what they are doing. This, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the “critical thinking gap” between children from disadvantaged communities and their more advantaged peers requires attention as early as possible.
Although it is possible to teach critical thinking to adults, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, starting in primary school. Erroneous beliefs, attitudes, and behaviours developed during childhood may be difficult to change later. 21 22 This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on and adequate time to learn them.
Strategies for teaching students to think critically have been evaluated in health and medical education; in science, technology, engineering, and maths; and in other subjects. 23 These studies suggest that critical thinking skills can be taught and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students to make sound judgments. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically , and the ability to think critically is correlated with academic success. 24 25
Evaluations of strategies for teaching critical thinking in medicine have focused primarily on critical appraisal skills as part of evidence based healthcare. An overview of systematic reviews of these studies suggests that improving evidence based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment. 26
Cross sector collaboration
Informed Health Choices, an international project aiming to improve decision making, shows the opportunities and benefits of cross sector collaboration between education and health. 27 This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health. It aims to develop, identify, and promote the use of effective learning resources, beginning at primary school, to help people to make well informed choices as patients and health professionals, and well informed decisions as citizens and policy makers.
The project has drawn on several approaches used in education, including the development of a “spiral curriculum,” measurement tools, and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals. The basic ideas are revisited repeatedly, building on them until the student has grasped a deep understanding of the concepts. 28 29 The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. 30 31 32 The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games. 33 34 35 It has also built on the traditions of clinical epidemiology and evidence based medicine to identify the key concepts required to assess health claims. 29
It is difficult to teach critical thinking abstractly, so focusing on health may have advantages beyond the public health benefits of increasing health literacy. 36 Nearly everyone is interested in health, including children, making it easy to engage learners. It is also immediately relevant to students. As reported by one 10 year old in a school that piloted primary school resources, this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget.” Although the current evaluation of the project is focusing on outcomes relating to appraisal of treatment claims, if the intervention shows promise the next step could be to explore how these skills translate to wider educational contexts and outcomes.
Beyond critical thinking
Exciting opportunities for cross sector collaboration are emerging between healthcare and education. Although critical thinking is a useful example of this, other themes cross the education and healthcare domains, including nutrition, exercise, educational neuroscience, learning disabilities and special education needs, and mental health.
In addition to shared topics, several common methodological and conceptual issues also provide opportunities for sharing ideas and innovations and learning from mistakes and successes. For example, the Education Endowment Foundation is the UK government’s What Works Centre for education, aiming to improve evidence based decision making. Discussions hosted by the foundation are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors.
Similarly, the foundation’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted, and applied in healthcare. Since the development and evaluation of educational interventions are separated, evaluators have no vested interested in the results of the assessment, all results are published, and bias and spin in how results are analysed and presented are reduced. By contrast, industry sponsorship of drug and device studies consistently produces results that favour the manufacturer. 37
Another example of joint working between educators and health is the Best Evidence Medical Education Collaboration, an international collaboration focused on improving education of health professionals. 38 And in the UK, the Centre for Evidence Based Medicine coordinates Evidence in School Teaching (Einstein), a project that supports introducing evidence based medicine as part of wider science activities in schools. 39 It aims to engage students, teachers, and the public in evidence based medicine and develop critical thinking to assess health claims and make better choices.
Collaboration has also been important in the development of the Critical Thinking and Appraisal Resource Library (CARL), 40 a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently under way at the Education Endowment Foundation. On 22 May 2017, the foundation is also cohosting an event with the Royal College of Paediatrics and Child Health that will focus on their shared interest in critical thinking and appraisal skills.
Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners, and the public can all benefit from working together to help people to think critically about the choices they make. Events such as the global evidence summit in September 2017 ( https://globalevidencesummit.org ) can help bring people together and build on current international experience.
Contributors and sources: This article reflects conclusions from discussions during 2016 among education and health service researchers exploring opportunities for cross sector collaboration and learning. This group includes people with a longstanding interest in evidence informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation, and critical thinking and appraisal.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.
Provenance and peer review: Not commissioned; externally peer reviewed.
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- ↵ National Research Council. Taking science to school: learning and teaching science in grades K-8. National Academies Press, 2007 .
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- ↵ Vosniadou S. International handbook of research on conceptual change. 2nd ed . Routledge, 2013 .
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Evidence and its uses in health care and research: The role of critical thinking
Milos jenicek, pat croskerry, david l hitchcock.
- Author information
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Milos Jenicek, Department of Clinical Epidemiology & Biostatistics, Michael G. de Groote School of Medicine, McMaster University, Hamilton, Ontario, Canada. e-mail: [email protected]
Received 2010 Sep 14; Accepted 2010 Oct 15; Collection date 2011.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.
Obtaining and critically appraising evidence is clearly not enough to make better decisions in clinical care. The evidence should be linked to the clinician’s expertise, the patient’s individual circumstances (including values and preferences), and clinical context and settings. We propose critical thinking and decision-making as the tools for making that link.
Critical thinking is also called for in medical research and medical writing, especially where pre-canned methodologies are not enough. It is also involved in our exchanges of ideas at floor rounds, grand rounds and case discussions; our communications with patients and lay stakeholders in health care; and our writing of research papers, grant applications and grant reviews.
Critical thinking is a learned process which benefits from teaching and guided practice like any discipline in health sciences. Training in critical thinking should be a part or a pre-requisite of the medical curriculum.
Keywords: critical thinking and decision making in medicine, patient safety, quality of care, clinical reasoning and argumentation, logic of medicine, using evidence
Sackett et al. originally defined evidence based medicine (EBM) as ‘… the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’, and its integration with individual clinical expertise [ 1 ].’ In the nearly two decades that have intervened, there has been significant uptake of the idea that clinical care should be based upon sound, systematically researched evidence. There has been less emphasis on how clinical expertise itself might be improved, perhaps because the concept is more amorphous and difficult to define.
Clinical expertise is an amalgam of several things: there must be a solid knowledge base, some considerable clinical experience, and an ability to think, reason, and decide in a competent and well-calibrated fashion. Our focus here is on this last component: the faculties of thinking, reasoning and decision making. Clinicians must be able to integrate the best available critically appraised evidence with insights into their patients, the clinical context, and themselves [ 2 ]. To accomplish this integration, physicians need to develop their critical thinking skills. Yet historically this need has not received explicit attention in medical training. We believe that it should.
As an illustration of the use of critical thinking in clinical care, consider the following clinical scenario from emergency medicine : A 52-year-old male presents to the emergency department of a community centre with a complaint of constipation and is triaged with a low level acuity score to a ‘minors’ area. The department is extremely busy and several hours elapse before he is seen by the emergency physician. His principal complaint is constipation; he hasn’t had a bowel movement for 4 days. His abdomen is soft and non-tender. A large amount of firm stool is evident on rectal examination. He recalls a minor back strain a few days earlier. The physician orders a soapsuds enema and continues seeing other patients. After about 30 minutes he finds the nurse who administered the enema; she reports that it was ineffective. He orders a fleet enema which again proves ineffective. The nurse expresses her opinion that the patient is taking up too much time and suggests he be given an oral laxative and another fleet enema to take home with him. She is clearly unwilling to continue investing her effort in a patient with a trivial complaint. Nevertheless, the physician decides to administer a third enema himself. The third enema is only marginally effective and he then decides to disimpact the patient. The physician notes poor rectal tone and enquires further about the patient’s urination. He says he has been unable to urinate that day. On catheterisation he is found to have 1200cc. Neurological findings are equivocal: reflexes are present in both legs and there is some subjective diminished sensation.
A diagnosis of cauda equina syndrome is made and the emergency physician calls the neurosurgery service at a tertiary care hospital. It is now late in the evening. The neurosurgeon is reluctant to accept the working diagnosis. He suggests that the loss of sphincter tone might be due to the disimpaction, and argues that there was no significant history of back injury or convincing neurological findings. When the ED physician persists, the neurosurgeon suggests transferring the patient to the tertiary hospital ED for further evaluation and asks for a CT investigation of the patient’s lower spine before seeing him. The CT reveals only some minor abnormalities and the patient is kept overnight. An MRI is done in the morning. It shows extensive disc herniation with compression of nerve roots. The patient subsequently undergoes prolonged back surgery.
This case had a good outcome, although things might have been dramatically different. The patient might have suffered permanent neurological injury requiring lifelong catheterisation for urination.
Our scenario illustrates some key points about clinical decision making. At the outset, the patient presents with an apparently benign condition – constipation. The impression of a benign condition is incorporated at triage and results in a low-level acuity score and prolonged wait. The patient’s nurse also incorporates this diagnosis and exerts coercive pressure on the physician to discharge the patient. The neurosurgeon is dismissive of a physician’s assessment in a community centre ED, creating considerable inertia against referral. Thus the ED physician faces a variety of obstacles to ensure optimal patient care. These have little to do with EBM. He must resist and overcome a variety of cognitive, affective and systemic biases, his own as well as others’, and various contextual constraints. He must continue to think critically and persist in a course that has become increasingly challenging.
Our scenario also illustrates some key points about critical thinking. The initial impression of a benign condition of constipation is not the only diagnosis compatible with the patient’s symptoms. A health care professional reaching a preliminary diagnosis must be aware of the danger of fixing prematurely on this diagnosis and ignoring (or failing to look for) subsequent evidence that tells against it, as the nurse in our scenario was inclined to do. Observational and textual studies both indicate that the most common source of errors in reasoning is to close prematurely on a favoured conclusion and then ignore evidence that argues against that conclusion [ 3 ]. It is also important to keep in mind that a patient’s signs or symptoms may have more than one cause. Data that may confirm one of the causes does not necessarily rule out all the others. Attentive listening to the patient and careful looking in the data-gathering stage are essential to good medical practice, as Groopman has recently pointed out [ 4 ]. From a logical point of view, the physician’s diagnostic task is to gather data that will determine which one (or ones) of the possible causes is (or are) responsible for the patient’s problem. This goal will guide the selection of data and of additional tests. ‘Parallel’ or ‘lateral’ thinking [ 5 ] will help with the differential diagnosis.
Critical Thinking
Dewey’s original conceptualization [ 6 ] of what he called “reflective thinking” has spawned in the intervening century a variety of definitions of critical thinking, most notably that of Ennis as “ reasonable reflective thinking that is focused on deciding what to believe or what to do” [ 7 ] . Scriven and Paul have elaborated this definition as “… the intellectually disciplined process of actively and skilfully conceptualizing, applying, synthesizing or evaluating information gathered from, or generated by observation, experience, reflection, reasoning, or communication as a guide to belief or action ” [ 8 ].
The consensus of 48 specialists in critical thinking from the fields of education, philosophy and psychology was that it should be defined as ‘ purposeful self-regulatory judgment which results in interpretation, analysis, evaluation and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgement is based ’ [ 9 ]. The list of additional definitions remains impressive [ 10 , 11 ].
Even more useful than these definitions are various lists of dispositions and skills characteristic of a “critical thinker” [ 7 , 9 , 12 ]. More useful still are criteria and standards for measuring possession of those skills and dispositions [ 13 ], criteria that have been used to develop standardized tests of critical thinking skills and dispositions [ 14 – 17 ] including some with specific reference to health sciences [ 18 ].
The elements of critical thinking subsume what has variously been described as clinical judgment [ 19 ] , logic of medicine [ 20 , 21 ] , logic in medicine [ 22 ] , philosophy of medicine [ 23 ] , causal inference [ 24 ] , medical decision making [ 25 ], clinical decision making [ 26 ], clinical decision analysis [ 27 ], and clinical reasoning [ 28 ]. An increasing number of monographs on logic and critical thinking in general have appeared [ 29 – 34 ] and their content is being adapted for medicine [ 35 – 37 ].
Everyday medical practice, whether in physicians’ offices or emergency departments or hospital wards, clearly involves “ reasonable reflective thinking that is focused on deciding what to believe (meaning the understanding of the problem) and/or what to do (i.e. deciding what to do to solve the problem)” [ 7 , 38 ]. Table 1 lists specific abilities underlying critical thinking in medical practice.
Specific abilities underlying critical thinking in medical practice.
Critical thinking is also called for in medical research and medical writing. Editors of leading medical journals have called for it. Edward Huth [ 39 , 40 ], former editor of Annals of Internal Medicine, has urged that medical articles reflect better and more organized ways of reasoning. Richard Horton [ 41 , 42 ], former editor of The Lancet , has proposed the use in medical writing of a contemporary approach to argument along the lines used by the philosopher Toulmin [ 40 , 41 ]. Subsequently, two of us have developed this approach in detail for medicine [ 43 , 44 ]. Dickinson [ 45 ] has called for an argumentative approach in medical problem solving and brought it to the attention to the world of medical informatics and beyond.
Dual Process Theory
An important component of critical thinking is being aware of one’s own thinking processes. In recent years, two general modes of thinking have been described under an approach described as dual process theory. The model is universal and has been directly applied to medicine [ 46 – 48 ] and nursing [ 49 ]. One mode is fast, reflexive, autonomous, and generally referred to as intuitive or System 1 thinking. The other is slow, deliberate, rule-based, and referred to as analytical or System 2 thinking. The mechanisms that underlie System 1 thinking are based on associative learning and innate dispositions: the latter are hard-wired, as a result of the evolutionary history of our species, to respond reflexively to certain cues in the environment. We have discrete, functionally-specialized mental programs that were selected when the brain was undergoing significant development especially spanning the last 6 million years of hominid evolution [ 50 ]. Although these programs may have served us well in our ancestral past, they may not be appropriate in some aspects of modern living. Some of this System 1 substrate also underlies various heuristics and biases in our thinking – the tendency to take mental short-cuts, or demonstrate reflexive responses in certain situations, often on the basis of past experience. Not surprisingly, most error occurs in System 1 thinking.
Contemplative , or fully reflective thinking, is System 2 thinking. It suits any practice of medicine or medical research activity where there is time to utilise the best critically appraised evidence in a step-by-step process of reasoning and argument. Contemplative, fully reflective thinking is appropriate, for example, in internal medicine, psychiatry, public health, and other specialties, in etiological research and clinical trials, and in writing up the results of such research [ 35 ].
In contrast, a shortcut or heuristic approach [ 51 ] with somehow truncated thinking is often dictated by the realities of emergency medicine, surgery, obstetrics or any situation where there is incomplete information, bounded rationality, and insufficient time to be fully reflective. The extant findings and the decision maker’s experience are all that is available. The quintessential challenge for well-calibrated decision making is to optimise performance in System 1. Hogarth [ 52 ] sees this challenge as educating our intuitive processes and has delineated a variety of strategies through which this might be accomplished.
No responsible physician would engage in reflective thinking on every occasion when a decision has to be made. Such acute emergencies as sudden complications of labour and delivery, ruptured aneurysms, multiple trauma victims and other immediately life-threatening situations generally leave no time for fully reflective thinking. A shortcut or heuristic approach is required [ 51 ], involving pattern recognition, steepest ascent reasoning, or algorithmic paths [ 21 , 53 ]. There is of course a place for reflective thinking before and after such time-constrained emergency decisions. More generally, reflective thinking is called for in any aspect of medical practice where there is time and reason for it.
The distinction should be made between the involuntary autonomous nature of System 1 thinking and a deliberate decision to use a shortcut for expediency, which is System 2 thinking. There is normally an override function of System 2 over System 1 but this may be deliberately lifted under extreme conditions.
Future Direction
Critical thinking is a learned process which benefits from teaching and guided practice like any other discipline in health sciences. It was already proposed as part of an early medical curriculum [ 54 ]. If we are to train future generations of health professionals as critical thinkers, we should do so in the spirit of critical thinking as it stands today. Clinical teachers should know how to run a Socratic discourse, and in which situations it is appropriate. They should be aware of contemporary models of argument. Clinical teachers should be trained and experienced in engaging with their interns and residents in meaningful discourse while presenting and discussing morning reports, at floor and other rounds, in morbidity and mortality conferences, or at less informal ‘hallway’, ‘elevator’ or ‘coffee-maker/drinking fountain’ teaching sites for busy clinicians. Such discourse is better than so-called “pimping”, i.e. quizzing of juniors with objectives ranging from knowledge acquisition to embarrassment and humiliation [ 37 , 55 ].
Also, somebody should point out to trainees the relevance to the health context of some basics of informal logic, critical thinking and argumentation, if those basics have been acquired as the result of studying for their first undergraduate degree.
Unquestionably, the appropriate critically appraised best evidence should be used as a foundation for reasoning and argument about how to care for patients. But, if we want to link the best available evidence to a patient’s biology, the patient’s values and preferences, the clinical or community setting, and other circumstances, we should take all these factors into account in using the best available evidence to get to the beliefs and decisions that have the best possible support.
Such a reflective integration cannot be mastered by mere exposure. A learning experience is required. Trainees in medicine need to learn how to think critically [ 56 ], just as they need to learn contemporary approaches to ‘rational’ medical decision making: how to use Bayes’ theorem in the diagnostic process, how to determine the sample size in a clinical trial, how to analyze survival curves in prognosis and outcomes studies, and how to calculate odds ratios in case control research. To understand each other, the teacher and the learner should both know the fundamentals of reasoning and argument in medicine. To achieve this understanding, we can either offer separate and distinct courses on critical thinking and decision making in medicine; or spread learning, practice and experience in critical thinking and decision making across various specialties; or do both. Only the future will show which of the alternatives is better. The integrated approach seems more promising, but harder to implement. Given the limitations on the current medical undergraduate curriculum, we might be hard-pressed to persuade a curriculum committee that precious space and time should be allocated to such concepts. The overriding rationale, however, should be that the knowledge of critical and reflective thinking is declarative knowledge (knowing how) and not simply an addition of procedural knowledge (know-how) or explicit knowledge. The old adage about it being preferable to teach someone how to fish rather than giving them fish applies. Any new additions will need to be streamlined and practical. A teaching module on critical thinking might for example include attention to how we reason and make decisions, factors that may impair decision making, the concept of critical thinking, situations where critical thinking is appropriate, some basic principles of logic and some logical fallacies. However the teaching, learning and practice of critical thinking is incorporated in the medical curriculum, it will need to include not only the contemplative, fully reflective thinking on hospital floors and in clinics but also the shortcut thinking [ 57 ] in such heuristic environments as operating theatres or emergency departments [ 46 , 48 , 58 – 60 ].
Similar education is required as a basis for framing grant applications and research reports as reasoned arguments, especially in the discussion section [ 61 , 62 ]. We may see a day when most medical journals are what Paton [ 63 ] terms “reflective journals”. If an application for a research grant, a research proposal, or a group of research findings (systematically reviewed or not) presented in a medical article are all exercises in argumentation and critical thinking, their authors, readers, and editors should find a common language for all these types of scientific and professional communication.
Almost four decades ago Feinstein [ 64 ] asked what kind of basic science clinical medicine needs. At that time, he had mostly clinical biostatistics and epidemiology in mind. Recently, Redelmeier et al. [ 65 ] proposed to add cognitive psychology as one more basic science. It is time, we think, to add critical thinking to that list.
Competing interests
None declared.
Source of support: None. Departmental support to produce the manuscript is acknowledged and appreciated
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Critical Thinking in Medicine is a dedicated online platform committed to advancing evidence-based medicine teaching. Our goal is to provide medical professionals with the necessary resources to navigate research studies effectively, fostering critical thinking skills and promoting unbiased practices in medicine in general, and particularly in ...