Teaching Critical Thinking in Medical Education

Teaching Critical Thinking in Medical Education John Epling, MD, MSEdSUNY-Upstate Medical University Tiffany A. Koszalka, PhD Syracuse University C o l l e g e s o f : M e d i c i n e  G r a d u a t e S c h o o l s  H e a l t h P r o f e s s i o n s  N u r s i n g  U n i v e r s i t y H o s p i t a l Improving the health of the communities we serve through education, biomedical research, and health care

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Before we start… • Let’s think about our teaching… – What types of teaching strategies do you use?– How well do these strategies actively engage your students?– What type of thinking and learning responses do these strategies evoke in your students? • Please take a few minutes to record your responses to these questions on page 1 of the session handout … Department of Family Medicine 2 Instructional Design, Development & Evaluation

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Today • Critical thinking definitions and dimensions• Critical thinking in medical education• Technology and teaching critical thinking• Examples of critical thinking activities• Discussion on integrating critical thinking activities• Summary Department of Family Medicine 3 Instructional Design, Development & Evaluation

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What is critical thinking? • How do you define critical thinking?• Please take a few minutes to record your response on the bottom of page 1 of the session handout … Department of Family Medicine 4 Instructional Design, Development & Evaluation

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What is critical thinking? • 70′s/80′s – reaction to “reproductive” learning• Ennis (’89) – “reflective thinking focused on deciding what to believe or do” • Paul (’92) – question, goal, point of view, assumptions, central concepts, principles/theories, data, reasoning, consequences Department of Family Medicine 5 Instructional Design, Development & Evaluation

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What is critical thinking? • Dimensions of critical thinking – Ennis logical – judges relationships between termscritical – knows criteria for judging statementspragmatic – statement good enough for goal • But there’s more… Department of Family Medicine 6 Instructional Design, Development & Evaluation

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What is critical thinking? • Walters – above + creativity, imagination, insight, intuition • Litecky (’92) – “the active mental effort to make meaning of our world by carefully examining thought in order to better understand content” Department of Family Medicine 7 Instructional Design, Development & Evaluation

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What is critical thinking? • Resnick and Klopfer (’87) – non-algorithmic – self-regulation of thinking – complex process – yields multiple solutions – imposing meaning – nuanced judgement and – effortful interpretation – multiple criteria Department of Family Medicine 8 Instructional Design, Development & Evaluation

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What is critical thinking? • William Graham Sumner (1906) – …the examination and test of propositions of any kind which are offered for acceptance, in order to find out whether they correspond to reality or not…It is a mental habit and power…It is our only guarantee against delusion, deception, superstition, and misapprehension of ourselves and our earthly circumstances. Department of Family Medicine 9 Instructional Design, Development & Evaluation

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What is a critical thinker? • A well-cultivated critical thinker: – Raises vital questions and problems, formulating them clearly and precisely; – Gathers and assesses relevant information, using abstract ideas to interpret it effectively; – Comes to well-reasoned conclusions and solutions, testing them against relevant criteria and standards; – Thinks openmindedly within alternative systems of thought, recognizing and assessing, as need be, their assumptions, implications, and practical consequences; and – Communicates effectively with others in figuring out solutions to complex problems. (from CriticalThinking.org) Department of Family Medicine 10 Instructional Design, Development & Evaluation

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“Complex” Thinking Process Content/Basic Thinking accepted knowledgemetacognition Creative Thinking generated knowledge Critical Thinking reorganized knowledge Department of Family Medicine 11 Instructional Design, Development & Evaluation

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Is critical thinking different than other thinking? Critical thinking can be seen as having two components: – a set of skills to process and generate information and beliefs, and – the habit, based on intellectual commitment, of using those skills to guide behavior. It is thus to be contrasted with: – the mere acquisition and retention of information alone, (because it involves a particular way in which information is sought and treated,) – the mere possession of a set of skills, (because it involves the continual use of them,) and – the mere use of those skills ("as an exercise") without acceptance of their results. From: http://www.criticalthinking.org/University/univclass/Defining.html Department of Family Medicine 12 Instructional Design, Development & Evaluation

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What is the purpose of critical thinking? • "The purpose of critical thinking is, therefore, to achieve understanding, evaluate view points, and solve problems. Since all three areas involve the asking of questions, we can say that critical thinking is the questioning or inquiry we engage in when we seek to understand, evaluate, or resolve." Maiorana, Victor P. Critical Thinking Across the Curriculum: Building the Analytical Classroom. 1992. Department of Family Medicine 13 Instructional Design, Development & Evaluation

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What are the dimensions of critical thinking? 35 dimensions of critical thought • Affect … – Independence, feelings, perspective, intellect, confidence, etc. • Cognitive Macro abilities … – Generalizing, clarifying, questioning, connecting • Cognitive Micro skills … – Compare and contrast, infer, predict, distinguish See page 2 of session handout .. Review the list and Circle the dimensions you believe that you prompt in your students during your teaching Department of Family Medicine 14 Instructional Design, Development & Evaluation

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Activities that prompt critical thinking • What types of instructional activities do you think prompt critical thinking? Department of Family Medicine 15 Instructional Design, Development & Evaluation

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Activities that prompt critical thinking • embedded questions • selecting and evaluating resources • simulations • creating checklists or evaluation • case studies, problem-based schema learning • creating a model • metacognitive strategies (guided • conducting an interview note-taking) e.g. creating own • creating an ‘expert’ lecture study guide placing new • taking sides, becoming the expert, knowledge into a 3D model of the defending position ‘world’ • taking a journey through a new • putting collected data into a environment and exploring all personal ‘scrapbook’ aspects • developing a student portfolio • working collaboratively to socially negotiate tasks Department of Family Medicine 16 Instructional Design, Development & Evaluation

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Critical Thinking and Med Ed • Not much on “critical thinking” – more in nursing/health professions lit. • West, JAMA 2000;284:1105-1110 – concept mapping exercise – peds residents– found “expected” change in maps pre and post educational intervention Department of Family Medicine 17 Instructional Design, Development & Evaluation

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Critical Thinking and Med Ed • Jane Scott – Watson-Glaser Critical Thinking Assessment– pre-MS1, end-MS3– CT increased over 2 years.– could not predict clerkship performance Department of Family Medicine 18 Instructional Design, Development & Evaluation

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Critical Thinking and Med Ed • Critical Appraisal and Critical Thinking – Kee, QJM 2004; 97:609– argument analysis, logical fallacy • Simulation-based Med Ed – Ziv, Medical Teacher 2005;27(3):193– “learning from mistakes” Department of Family Medicine 19 Instructional Design, Development & Evaluation

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Technology and Critical Thinking • “using computers as mindtools”• What types of computer software stimulate critical thinking? Department of Family Medicine 20 Instructional Design, Development & Evaluation

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Learning with computers (mindtools) • Learning with computers (mindtools) requires … – Mindtools Thinking harder about a subject Active (Computer matter domain Engagement tools – Thinking deeply about the domain Teacher/System Passive – Engaging in meaningful learning Control Student • Active – manipulative Presentation Creation • Constructive – articulative / Generativity reflective (From: Jonassen, p. 11) • Intentional – purposive• Authentic – complex / contextual• Collaborative – socially negotiated Department of Family Medicine 21 Instructional Design, Development & Evaluation

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Common Mindtools …and how may they help students engage in critical thinking • Databases (Semantic Organizing Tool)• Concept maps (Semantic Organizing Tool)• Intentional search tools (Interpretation Tool)• Visualization tools (Interpretation Tool)• Spreadsheets (Dynamic Modeling Tool)• Microworlds / Simulations (Dynamic Modeling Tool)• Expert Systems (Dynamic Modeling Tool)• Systems Modeling tools (Dynamic Modeling Tool)• Presentation/Hypermedia tools (Knowledge Construction Tool)• Live conversation environments (Social Collaboration Tool) Department of Family Medicine 22 Instructional Design, Development & Evaluation

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Example 1 • Epidemiology Simulation engages learners in … – Analyzing and recognizing patterns– Hypothesizing, planning, and predicting– Identifying causal relationships– Generating alternatives and evaluating choices– Elaborating explanations– Designing and problem solving Department of Family Medicine 23 Instructional Design, Development & Evaluation

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Example 2 • Concept mapping engages learners in … – Connecting, comparing and contrasting information – Recognizing patterns– Classifying and sequencing information– Identifying causal relationships– Summarizing and visualizing information West, Pomeroy, Park, Gerstenberger, & Sandoval (2000, JAMA) Critical thinking in graduate medical education: The role of concept mapping in assessment Department of Family Medicine 32 Instructional Design, Development & Evaluation

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Example 2 First year med students pre-instruction Department of Family Medicine 33 Instructional Design, Development & Evaluation

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Example 2 second/third year med students post-instruction Department of Family Medicine 34 Instructional Design, Development & Evaluation

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Example 3 • EBM WebQuests – not DOING one…– CREATING one… engages learners in … Prioritizing, classifying, verifying, and assessing information Identifying main ideas and finding / defining content sequencesIdentifying patterns, organizing information, describing contentComparing and contrasting information Department of Family Medicine 35 Instructional Design, Development & Evaluation

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CT and Med Ed – Ideas • What do we ALREADY do that promotes critical thinking? • Use page 3 of the session handout to describe critical thinking activities that you already use in 2 or 3 of your teaching areas • And .. think about how can we make teaching and learning better for medical students through integration of critical thinking activities … Department of Family Medicine 39 Instructional Design, Development & Evaluation

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Commonly used activities that prompt critical thinking at Upstate Which do you use and How? • embedded questions • selecting and evaluating resources • simulations • creating checklists or evaluation schema • case studies, problem-based • creating a model learning • conducting an interview • metacognitive strategies (guided • creating an ‘expert’ lecture note-taking) e.g. creating own • taking sides, becoming the expert, study guide placing new defending position knowledge into a 3D model of • taking a journey through a new the ‘world’ environment and exploring all • putting collected data into a aspects personal ‘scrapbook’ • working collaboratively to socially negotiate tasks • developing a student portfolio Department of Family Medicine 40 Instructional Design, Development & Evaluation

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Discussion • Break into two teams based on your interests – Pre-clinical teaching– Clinical teaching • In your team identify a topic • Discuss how critical thinking activities can be integrated into teaching this topic and consider … – How practical is it to integrate these types of activities– What barriers (personal / system) may prevent this integration– How can this activity be evaluated • Record your responses on page 4 of the session handout and prepare to share your ideas Department of Family Medicine 41 Instructional Design, Development & Evaluation

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Summary • Was critical thinking prompted during this session? – If yes, in what ways?– If no, how could it have been? Reflection questions, embedded questions, classifying teaching activities, summarizing, self-evaluation, collaborating on a problem, engaging with content from multiple perspectives . . . Department of Family Medicine 42 Instructional Design, Development & Evaluation

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