“Education is not the learning of facts but the training of the mind to think”- Albert Einstein”
A few years ago I moved from a research laboratory to the classroom. Until then, I had been accustomed to examine ideas and try to find solutions by experimenting and challenging the current knowledge in certain areas. However, in the classroom setting, the students seemed to only want to learn facts with no room for alternative explanations, or challenges. This is not the way a clinician should be trained- I thought, and I started looking in text books, teaching seminars and workshops for alternative teaching methods. I quickly learned that teaching critical thinking skills is the preferred method for higher education to develop highly-qualified professionals.
Why critical thinking? Critical thinking is one of the most important attributes we expect from students in postsecondary education, especially highly qualified professionals in Health Care, where critical thinking will provide the tools to solve unconventional problems that may result. I teach Pathophysiology in Optometry and as in other health professions, not all the clinical cases are identical, therefore the application and adaptation of the accumulated body of knowledge in different scenarios is crucial to develop clinical skills. Because critical thinking is considered essential for patient care, it is fostered in many health sciences educational programs and integrated in the Health Professions Standards for Accreditation.
But what is critical thinking? It is accepted that critical thinking is a process that encompasses conceptualization, application, analysis, synthesis, evaluation, and reflection. What we expect from a critical thinker is to:
- Formulate clear and precise vital questions and problems;
- Gather, assess, and interpret relevant information;
- Reach relevant well-reasoned conclusions and solutions;
- Think open-mindedly, recognizing their own assumptions;
- Communicate effectively with others on solutions to complex problems.
However, some educators emphasize the reasoning process, while others focus on the outcomes of critical thinking. Thus, one of the biggest obstacles to proper teaching of critical thinking is the lack of a clear definition, as observed by Allen et al (1) when teaching clinical critical thinking skills. Faculty need to define first what they consider critical thinking to be before they attempt to teach it or evaluate student learning outcomes. But keep in mind that not all students will be good at critical thinking and not all teachers are able to teach students critical thinking skills.
The experts in the field have classically agreed that critical thinking includes not only cognitive skills but also an affective disposition (2). I consider that it mostly relies on the use of known facts in a way that enables analysis and reflection of conventional and unconventional cases for the future. I have recently experimented with reflection in pathophysiological concepts and I have come to realize that reflection is an integral part of the health professions. We cannot convey just pieces of information based on accumulated experience, we have to reflect on it. Some studies have demonstrated that reflective thinking positively predicted achievement to a higher extent than habitual action. However, those may not be the key elements of critical thinking that you choose to focus on.
How do we achieve critical thinking in higher education and Health Professions? Once we have defined what critical thinking means to us, it must be present at all times when designing a course, from learning objectives to assignments. We cannot expect to contribute to development of critical thinking skills if the course is not designed to support it. According to the Delphi study conducted by the American Philosophical Association (3), the essential elements of lessons designed to promote critical thinking are the following:
- “Ill structured problems” are those that don’t have a single right answer they are based on reflective judgment and leave conclusions open to future information.
- “Criteria for assessment of thinking” include clarity, accuracy, precision, relevance, depth, breadth, logic, significance, and fairness (Paul & Elder, 2001).
- “Student meaningful and valid assessment of their own thinking”, as they are held accountable for it.
- “Improving the outcomes of thinking” such as in writing, speaking, reading, listening, and creating.
There are a variety of examples that serve as a model to know if the course contains critical thinking elements and to help design the learning objectives of a course. However, it can be summarized in the statement that “thinking is driven by questions”. We need to ask questions that generate further questions to develop the thinking process (4). By giving questions with thought-stopping answers we are not building a foundation for critical thinking. We can examine a subject by just asking students to generate a list of questions that they have regarding the subject provided, including questions generated by their first set of questions. Questions should be deep to foster dealing with complexity, to challenge assumptions, points of view and the sources of information. Those thought-stimulating types of questions should include questions of purpose, of information, of interpretation, of assumption, of implication, of point of view, of accuracy and precision, of consistency, of logic etc.
However, how many of you just get the question: “Is this going to be on the test?”. Students do not want to think. They want everything to be already thought-out for them and teachers may not be the best in generating thoughtful questions.
As an inexperienced research educator, trying to survive in this new environment, I fought against the urge of helping the students to be critical thinkers, and provided answers rather than promoting questions. I thought I just wanted to do traditional lectures. However, unconsciously I was including critical thinking during lectures by using clicker questions and asking about scenarios with more than one possible answer. Students were not very happy, but the fact that those questions were not graded but instead used as interactive tools minimized the resistance to these questions. The most competitive students would try to answer them right and generate additional questions, while the most traditional students would just answer, no questions asked. I implanted this method in all my courses, and I started to give critical thinking assignments. The students would have to address a topic and to promote critical thinking, a series of questions were included as a guide in the rubric. The answers were not easily found in textbooks and it generated plenty of additional questions. As always, it did not work for every student, and only a portion of the class probably benefited from them, but all students had exposure to it. Another critical thinking component was the presentation of a research article. Students had a limited time to present a portion of the article, thus requiring analysis, summary and reflection. This is still a work in progress and I keep inserting additional elements as I see the need.
How does critical thinking impact student performance? Assessment
Despite the push for critical thinking in Health Professions, there is no agreement on whether critical thinking positively impacts student performance. The curriculum design is focused on content rather than critical thinking, which makes it difficult to evaluate the learning outcomes (5). In addition, the type of assessment used for the evaluation of critical thinking may not reflect these outcomes.
There is a growing trend for measuring learning outcomes, and some tests are used to assess critical thinking, such as the Classroom Assessment Techniques (CAT), which evaluate information, creative thinking, learning and problem solving, and communication. However, the key elements in the assessment of student thinking are purpose, question at issue, assumptions, inferences, implications, points of view, concepts and evidence (6). Thus, without a clear understanding of this process and despite the available tests, the proper assessment becomes rather challenging.
Another issue that arises when evaluating students critical thinking performance is that they are very resistant to this unconventional model of learning and possibly the absence of clear positive results may be due to the short exposure to this learning approach in addition to the inappropriate assessment tools. Whether or not there is a long term beneficial effect of critical thinking on clinical reasoning skills remains to be elucidated.
I tried to implement critical thinking in alignment with my view of Physiology. Since, I taught several courses to the same cohort of students within the curriculum, I decided to try different teaching techniques, assessments and approaches at different times during the curriculum. This was ideal because I could do this without a large time commitment and without compromising large sections of the curriculum. However, after evaluating the benefits, proper implementation and assessment of critical thinking, I came to the conclusion that we sacrifice contact hours of traditional lecture content for a deeper analysis of a limited section of the subject matter. However, the board exams in health professions are mostly based on traditional teaching rather than critical thinking. Thus, I decided to only partly implement critical thinking in my courses to avoid a negative impact in board certification, but include it somehow as I still believe it is vital for their clinical skills.
- Allen GD, Rubenfeld MG, Scheffer BK. Reliability of assessment of critical thinking. J Prof Nurs. 2004 Jan-Feb;20(1):15-22.
- Facione PA. Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction: Research findings and recommendations [Internet]. Newark: American Philosophical Association; 1990[cited 2016 Dec 27]. Available from: https://eric.ed.gov/?id=ED315423
- Facione NC, Facione PA. Critical thinking assessment in nursing education programs: An aggregate data analysis. Millbrae: California Academic Press; 1997[cited 2016 Dec 27].
- Paul WH, Elder L. Critical thinking handbook: Basic theory and instructional structures. 2nd Dillon Beach: Foundation for Critical Thinking; 2000[cited 2016 Dec 27].
- Not sure which one
- Facione PA. Critical thinking what it is and why it counts. San Jose: California Academic Press; 2011 [cited 2016 Dec 27]. Available from: https://blogs.city.ac.uk/cturkoglu/files/2015/03/Critical-Thinking-Articles-w6xywo.pdf
Lourdes Alarcon Fortepiani is an Associate professor at Rosenberg School of Optometry (RSO) at the University of the Incarnate Word in San Antonio, Texas. Lourdes received her M.D. and Ph.D. in Physiology at the University of Murcia, Spain. She is a renal physiologist by training, who has worked on hypertension, sexual dimorphism and aging. Following her postdoctoral fellowship, she joined RSO and has been teaching Physiology, Immunology, and Pathology amongst other courses. Her main professional interest is medical science education. She has been active in outreach programs including PhUn week activities for APS, career day, and summer research activities, where she enjoys reaching K-12 ad unraveling different aspects of science. Her recent area of interest includes improving student critical thinking.