Presentation on theme: "Critical Thinking Richard M. Schwartzstein, MD"— Presentation transcript:
1 Critical Thinking Richard M. Schwartzstein, MD Executive Director, Carl J. Shapiro Institute for Education and ResearchFaculty Associate Dean for Medical EducationProfessor of MedicineHarvard Medical School
10 CaseA 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.
11 Case, cont.PH: asthma since childhood, hypertension for 30 years, mild diabetes, 30 pack year smokerPE: obese. BP 160/90, HR 92, RR 16Mild 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?
12 Case, cont. Walk the patient: After 50 yards, breathing starts to become labored, patient appears diaphoretic, chest exam: wheezes.Diagnosis?
14 Diastolic Dysfunction 1/3 of cases of CHF are due primarily to diastolic dysfunctionFailure of LV to accommodate increased volume loadSymptoms often isolated to exercise
15 QUESTIONIs the patient an example to be learned or a problem to be solved?
16 QUESTIONIs the patient an example to be learned or a problem to be solved?Pattern recognition = experience-based, non analytical reasoningNorman G, Young M, Brooks L. Med Ed 2007
17 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.
18 Critical Thinking Plan of Attack Define the elements of critical thinkingDistinguish critical thinking from clinical reasoningDelineate strategies for developing critical thinking in our learners.
19 Critical Thinking Plan of Attack Define the elements of critical thinkingDistinguish critical thinking from clinical reasoningDelineate strategies for developing critical thinking in our learners.Caveat: this is a work in progress…
20 Hierarchy of Knowledge Bloom’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?
21 Revision of Bloom’s Taxonomy Anderson LW, Krathwohl DR (eds), 2001 Revision of Bloom’s Taxonomy Anderson LW, Krathwohl DR (eds), A taxonomy for learning, teaching and assessing: A revision of Bloom’s taxonomy of educational objectives. New York, Longman.
22 What is an expert? Mylopoulos M, Regehr G. Med Ed 2007 Expertise = Knowledge + ExperienceExperts 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.”
23 Routine vs. Adaptive Expert Mylopoulos M, Regehr G. Med Ed 2007 Routine ExpertNovel problem adapt problem to the solution with which they are comfortableCharacterized by speed, accuracy, automaticityAdaptive ExpertUse a new problem as a point of departure for exploration; expand knowledge and understandingCharacterized by innovation, creativity
24 Critical Thinking Is the KSA model appropriate? Are there specific:Knowledge/factsSkillsAttitudes…that must be acquired in order for the learner to become a critical thinker?
25 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?Content learned in a conceptual framework
26 Knowledge Content learned in a conceptual framework Judge credibility of sourcesFrom primary sources to “Google it…”Primary sourcesStudy designAppropriate populationStatisticsSecondary sourcesTextbooksReview articlesEvidence-based medicine
27 Knowledge Content learned in a conceptual framework Judge credibility of sourcesBias and cognitive dispositions to respondAvailability bias- probability assigned based on ease of recall of specific examplesConfirmation bias - selectively accepting or ignoring data
29 Skills Formulation of hypotheses How to pose questions Going from the particular to the generalAre they testable?Revising with new dataIdentifying the key issuesFormulation of hypotheses
30 SkillsSymptoms link with physical findings? Lab data with symptoms and signs?Finding common mechanismsFormulation of hypothesesMaking logical connections between ideas
31 Skills Formulation of hypotheses Making logical connections between ideasUtilization of dataSensitivity and specificity of testsPre and post-test probabilitiesRed flags
32 Skills Formulation of hypotheses Cultural Gender Making logical connections between ideasUtilization of dataIdentify assumptionsCulturalGenderContextual, e.g., in our ED, upper lobe infiltrates are all TB
33 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?
35 The Clinical Reasoning Paradigm What do “experts” (routine experts?) do?Content knowledge vs thought processMental representations of disease processesIllness 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”)
36 How often do we need critical thinking in the clinical setting? Bowen J, NEJM, 2006:355;Pattern recognition (non-analytical thinking) is “essential to diagnostic expertise”“Deliberative analytic reasoning is primary strategy when a case is complex…”
38 Clinical Reasoning My bias… The 80/20 rule80% 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.
40 Critical Thinking in College, Council for Learning Assessment (CLA), courtesy of Richard Hersh, EdD, lecture at HMS, Jan. 19, 2007
41 Some Strategies for Teaching Critical Thinking Go back to the knowledge, skills, attributesBe explicit that we are teaching critical thinkingWoven into teaching contentSeparate teaching modulesBeware the hidden curriculum!!A few thoughts from the literature (and my experience).
42 Concept Maps Guerrero, Acad Med 2001;76:385 Torre et al Concept Maps Guerrero, Acad Med 2001;76:385 Torre et al., Am J Med 2006;119:903Graphic devices to represent relationships between multiple conceptsReinforce mechanistic thinkingMake links explicit
43 Higher Order Concepts Auclair F, BMC Medical Education 2007;7:16 32 third year students given complex CPC case (endocarditis) to analyze12/32 made correct dxDiagnostic accuracy use of higher order concepts. Students who missed dx reported factual observations19/25 students: given problem formulation (i.e, concept links) made dxProblem not knowledge but moving from fact to concept
44 Case Conference Traditional 65 year old homeless man back pain Hep C, spinal lymphomaLater abn CXRMACDiscuss: tests, meds, each disease in isolation
45 Case Conference Traditional 65 year old homeless man back pain Hep C, spinal lymphomaLater abn CXRMACDiscuss: tests, meds, each disease in isolationCritical thinking65 year old homeless man back painHep C, spinal lymphomaUnifying mechs?Abn CXRMACDiscuss: make links -immune problemHIV
46 Model the Process Think out loud Discourage quick jumps to the dx Force the student to assess her own thought processGive frequent feedbackTest them on the process as well as the content
47 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.