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Critical Thinking. Richard M. Schwartzstein, MD Executive Director, Carl J. Shapiro Institute for Education and Research Faculty Associate Dean for Medical Education Professor of Medicine Harvard Medical School. Critical Thinking. Do you do it?. Critical Thinking. Do you do it?

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critical thinking

Critical Thinking

Richard M. Schwartzstein, MD

Executive Director, Carl J. Shapiro Institute for Education and Research

Faculty Associate Dean for Medical Education

Professor of Medicine

Harvard Medical School

critical thinking2
Critical Thinking
  • Do you do it?
critical thinking3
Critical Thinking
  • Do you do it?
  • Do you teach it?
critical thinking4
Critical Thinking
  • Do you do it?
  • Do you teach it?
  • What is it?
critical thinking5
Critical Thinking
  • Do you do it?
  • Do you teach it?
  • What is it?
  • What is the relationship between “critical thinking” and “clinical reasoning?”
who is this how do you know8
Who is this?(How do you know?)
  • Political leader of the 20th century.
  • Mother was American, father was British
  • Lost election after leading his country to victory in war
  • Fancied whiskey
slide10
Case
  • A 60 year old man presents with a complaint of shortness of breath that has gradually worsened over 2 years. Now can only walk for 50 yards at which time he stops with a sensation of “suffocating” and “urge to breathe.” His wife notes “wheezing” when this happens.
case cont
Case, cont.
  • PH: asthma since childhood, hypertension for 30 years, mild diabetes, 30 pack year smoker
  • PE: obese. BP 160/90, HR 92, RR 16

Mild increase in AP diameter of chest. Lungs with mild decrease in air movement, I/E=1/1.5; JVP=10 cm. +S4. Abdomen benign. No edema.

Thoughts? What next?

case cont12
Case, cont.
  • Walk the patient:

After 50 yards, breathing starts to become labored, patient appears diaphoretic, chest exam: wheezes.

Diagnosis?

cardiac asthma
Cardiac Asthma
  • Increased PCWP  interstitial edema,
  • Dyspnea
    • Mechanical load
    • Hypoxemia
    • J-receptors
    • Vascular receptors
    • “urge to breathe,” “suffocating”
diastolic dysfunction
Diastolic Dysfunction
  • 1/3 of cases of CHF are due primarily to diastolic dysfunction
  • Failure of LV to accommodate increased volume load
  • Symptoms often isolated to exercise
question
QUESTION

Is the patient an example to be learned or a problem to be solved?

question16
QUESTION

Is the patient an example to be learned or a problem to be solved?

Pattern recognition = experience-based, non analytical reasoning

Norman G, Young M, Brooks L. Med Ed 2007

primacy of teaching objectives
Primacy of Teaching Objectives

If “critical thinking” is one of our objectives, we have to understand what implications that has for our interactions with students and residents.

critical thinking plan of attack
Critical ThinkingPlan of Attack
  • Define the elements of critical thinking
  • Distinguish critical thinking from clinical reasoning
  • Delineate strategies for developing critical thinking in our learners.
critical thinking plan of attack19
Critical ThinkingPlan of Attack
  • Define the elements of critical thinking
  • Distinguish critical thinking from clinical reasoning
  • Delineate strategies for developing critical thinking in our learners.

Caveat: this is a work in progress…

hierarchy of knowledge bloom staxonomy 1956
Hierarchy of KnowledgeBloom’sTaxonomy, 1956
  • Knowledge - What is the most common cause of...?
  • Understand - If you see this, what must you consider…?
  • Application - In this patient, what is causing…?
  • Analysis,synthesis,evaluation - critical thinking?
slide21

Revision of Bloom’s TaxonomyAnderson LW, Krathwohl DR (eds), 2001. A taxonomy for learning, teaching and assessing: A revision of Bloom’s taxonomy of educational objectives. New York, Longman.

what is an expert mylopoulos m regehr g med ed 2007
What is an expert?Mylopoulos M, Regehr G. Med Ed 2007
  • Expertise = Knowledge + Experience
  • Experts develop “rich and well organized resources…to effectively and efficiently solve routine problems of practice.”
  • “Only some experts go beyond routine competencies and display flexible, innovative abilities…in a process of extending their knowledge rather than applying it.”
routine vs adaptive expert mylopoulos m regehr g med ed 2007
Routine vs. Adaptive ExpertMylopoulos M, Regehr G. Med Ed 2007
  • Routine Expert
    • Novel problem adapt problem to the solution with which they are comfortable
    • Characterized by speed, accuracy, automaticity
  • Adaptive Expert
    • Use a new problem as a point of departure for exploration; expand knowledge and understanding
    • Characterized by innovation, creativity
critical thinking is the ksa model appropriate
Critical ThinkingIs the KSA model appropriate?
  • Are there specific:
    • Knowledge/facts
    • Skills
    • Attitudes

…that must be acquired in order for the learner to become a critical thinker?

knowledge
Content learned in a conceptual framework

How do the facts fit together?

What are the underlying mechanisms?

What do you do when the patterns break down?

Knowledge
knowledge26
Content learned in a conceptual framework

Judge credibility of sources

From primary sources to “Google it…”

Primary sources

Study design

Appropriate population

Statistics

Secondary sources

Textbooks

Review articles

Evidence-based medicine

Knowledge
knowledge27
Content learned in a conceptual framework

Judge credibility of sources

Bias and cognitive dispositions to respond

Availability bias- probability assigned based on ease of recall of specific examples

Confirmation bias - selectively accepting or ignoring data

Knowledge
cognitive dispositions to respond croskerry p acad med 2003 78 775 780
Cognitive Dispositions to RespondCroskerry P, Acad Med, 2003, 78:775-780
  • Fatigue
  • Team factors
  • Affective state
  • Ambient conditions
  • Past experience
  • Patient factors
skills
Formulation of hypotheses

How to pose questions

Going from the particular to the general

Are they testable?

Revising with new data

Identifying the key issues

Skills
skills30
Formulation of hypotheses

Making logical connections between ideas

Symptoms link with physical findings? Lab data with symptoms and signs?

Finding common mechanisms

Skills
skills31
Formulation of hypotheses

Making logical connections between ideas

Utilization of data

Sensitivity and specificity of tests

Pre and post-test probabilities

Red flags

Skills
skills32
Formulation of hypotheses

Making logical connections between ideas

Utilization of data

Identify assumptions

Cultural

Gender

Contextual, e.g., in our ED, upper lobe infiltrates are all TB

Skills
attitudes
Attitudes
  • Open mind - willingness to consider alternative explanations
  • Awareness of one’s own cognitive processes - what type of reasoning was I using? (metacognition)
  • Reflection - how did we go wrong? Where did we make a mistake?
the clinical reasoning paradigm
The Clinical Reasoning Paradigm
  • What do “experts” (routine experts?) do?
    • Content knowledge vs thought process
    • Mental representations of disease processes
      • Illness scripts (mini-patterns)
      • Semantic qualifiers (e.g., acute vs chronic, proximal vs distal)
      • Encapsulated knowledge (one type of knowledge embedded in other knowledge - basic mechs within clinical examples - example: “sepsis”)
how often do we need critical thinking in the clinical setting
How often do we need critical thinking in the clinical setting?
  • Bowen J, NEJM, 2006:355;2217-2225
    • Pattern recognition (non-analytical thinking) is “essential to diagnostic expertise”
    • “Deliberative analytic reasoning is primary strategy when a case is complex…”
clinical reasoning my bias
Clinical ReasoningMy bias…
  • The 80/20 rule
    • 80% of clinical medicine, pattern recognition works well.
    • 20% of clinical medicine, to get it right, you need to apply the knowledge, skills, and attitudes of critical thinking.
  • The key - knowing into which group your patient fits.
slide40
Critical Thinking in College, Council for Learning Assessment (CLA), courtesy of Richard Hersh, EdD, lecture at HMS, Jan. 19, 2007
some strategies for teaching critical thinking
Some Strategies for Teaching Critical Thinking
  • Go back to the knowledge, skills, attributes
    • Be explicit that we are teaching critical thinking
    • Woven into teaching content
    • Separate teaching modules
    • Beware the hidden curriculum!!
  • A few thoughts from the literature (and my experience).
concept maps guerrero acad med 2001 76 385 torre et al am j med 2006 119 903
Concept MapsGuerrero, Acad Med 2001;76:385Torre et al., Am J Med 2006;119:903
  • Graphic devices to represent relationships between multiple concepts
  • Reinforce mechanistic thinking
  • Make links explicit
higher order concepts auclair f bmc medical education 2007 7 16
Higher Order ConceptsAuclair F, BMC Medical Education 2007;7:16
  • 32 third year students given complex CPC case (endocarditis) to analyze
    • 12/32 made correct dx
    • Diagnostic accuracy  use of higher order concepts. Students who missed dx reported factual observations
  • 19/25 students: given problem formulation (i.e, concept links) made dx
  • Problem not knowledge but moving from fact to concept
case conference
Traditional

65 year old homeless man back pain

Hep C, spinal lymphoma

Later abn CXRMAC

Discuss: tests, meds, each disease in isolation

Case Conference
case conference45
Traditional

65 year old homeless man back pain

Hep C, spinal lymphoma

Later abn CXRMAC

Discuss: tests, meds, each disease in isolation

Critical thinking

65 year old homeless man back pain

Hep C, spinal lymphoma

Unifying mechs?

Abn CXRMAC

Discuss: make links -immune problemHIV

Case Conference
model the process
Model the Process
  • Think out loud
  • Discourage quick jumps to the dx
  • Force the student to assess her own thought process
  • Give frequent feedback
  • Test them on the process as well as the content
final thoughts
Final Thoughts…
  • There is more to be done to understand the elements of critical thinking.
  • If we are serious about this, we need to explicitly teach the process.
  • Critical thinking and clinical reasoning (as presently defined) are not the same.
  • Faculty development will be key.