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Critical Thinking

MEDICINE: AN “UNCERTAIN SCIENCE”? Here's Where Critical Clinical Thinking Comes in...

"The profusion of facts obscured a deeper and more significant problem: the reconciliation between knowledge (certain, fixed, perfect, concrete) and clinical wisdom (uncertain, fluid, imperfect, abstract)."

Those were the words of Dr. Mukherjee (Mukherjee, 2015) as he reflected on his didactic and clinical training in medicine.  He reflects on the seemingly constant “greyness” of decision-making in the real medical world, even with the best diagnostic tools. He also reflects on the fundamental deficiencies of his formal training in preparing him for some of the uncertainty.  If the training of M.D.’s is so “uncertain,” do we, in veterinary medicine, dare to think differently about our clinical practices?  If so much is about using good judgment when facts are missing or inconclusive, and much is also about self-reflection and correction, then what is called for is “critical clinical thinking,” “clinical reasoning,” or “clinical problem-solving.”

Often, this skill is considered the “magic” that somehow passes from a clinical year or residency mentor. Why does this have to be some deep dark secret?   Indeed, it has always been accepted that those in training would just get better at this as they were immersed in the clinic. But why should we postpone giving practice at such skills of self-reflective thinking?

I generally don’t make a practice of touting my own work, preferring to note that of others.  However, as first author of the attached manuscript in J. Vet. Med. Education (jvme.0216-032r1pub), I have the privilege of sharing this document as a whole, as we’ve tried to add to the prior works of veterinary educators like Herron et al. (1990), Ramaekers et al. (2011), and Buur et al. (2012) who have sought to tackle this subject in the context of veterinary education.

Herron and colleagues noted that the standard 3 years of basic science led to no improvement in overall performance on the Watson-Glaser Critical Thinking Appraisal, but, of great concern, found a regression  in the “the ability to determine the strength of an argument.” In that publication, it was first proposed that problem-solving might best be taught in a discipline-specific context, and starting in the first year.

More recently, Ramaekers and colleagues (2011) described the art of pattern recognition that is typical of expert diagnosticians, called “illness scripts.” Furthermore, that these are necessary to move a novice clinician to an expert.  Buur and colleagues (2012) showed that overall veterinary student performance on a general critical thinking skills tests (California Critical Thinking Skills Test) did not improve following a 2 year problem-based curriculum.  Our study of first year veterinary students also showed no overall improvement in student performance on a third general critical thinking skills test (Cornell Critical Thinking Test X) following a year-long series of practice case analyses, but did show improvement in pre-developed rubric scores associated with attributes of critical clinical thinking.

So, critical thinking is best taught and evaluated within the context of the constructs of one’s professional domain. Therefore, as veterinary educators, we should be concerned about providing appropriate practice with clinical problem-solving from the very beginning of the curriculum, ideally maintaining the effort until they graduate.   And one more thing…it’s a team sport.

As always, please share your experiences and thoughts on this topic.

References

Buur JL, Schmidt P, Smylie D, et al. Validation of a scenario-based assessment of critical thinking using an externally validated tool. J Vet Med Educ.2012;39(3):276–82. Medline:22951463 http://dx.doi.org/10.3138/jvme.0112-009R .

Herron MA, Wolf A, DiBrito W. Faculty and student attitudes toward problem solving and independent learning in the veterinary medical curriculum. J Vet Med Educ. 1990;17(1):19–21.

Ferguson DC, McNeil LK, Schaeffer DJ, Mills EM (2017) Encouraging Critical Clinical Thinking (CCT) Skills in First-Year Veterinary Students, J. Vet. Med. Ed. 44(3):531-540. Published online, Sept. 1, 2017, http://jvme.utpjournals.press/doi/pdf/10.3138/jvme.0216-032R1

Mukherjee S. The laws of medicine: field notes from an uncertain science. New York: Simon and Schuster; 2015. http://www.simonandschuster.com/books/The-Laws-of-Medicine/Siddhartha-Mukherjee/TED-Books/9781476784847

Ramaekers SPJ, van Beukelen P, Kremer WDJ, et al. An instructional model for training competence in solving clinical problems. J Vet Med Educ. 2011;38(4):360–72. Medline:22130412 http://dx.doi.org/10.3138/jvme.38.4.360 .