Shifting the Medical Education Paradigm from Knowledge to Critical Thinking

Mark Quirk, Ed.D. Professor and Assistant DeanUniversity of Massachusetts Medical School

Harvard AcademyEducation Day

ObjectivesParticipants will be able to . . .

1. Appreciate the ‘knowledge dilemma’ in medical education

2. Identify the components of critical thinking3. Describe intuition and metacognition and their

importance to critical thinking4. Identify educational strategies that enhance

metacognition

“The phenomenal strides in every branch of scientific medicine have

tended to overload it with detail. To winnow out the wheat from the chaff and to prepare it in an easily digested shape for the tender stomachs of the first and second year students taxes

the resources of the most capable teachers.”

Osler, 1899

Second year medical students at one institution

were assigned required readings that totaled ___

hours per week.

Taylor, N Engl J Med 1992

Impact on Curriculum

62

For the bewildered student, the elemental curriculum combines the properties of both gases and of crystals: like the former, it is intangible and difficult to contain, and it expands promptly to fill whatever space is available; like the latter, it grows by continuous accretion of substance from the surrounding medium.

Taylor, N Engl J Med, 1992

Trainees in cardiac imaging reading 40 papers a day, five days a week, would take over 11 years to bring themselves up to date with the specialty.

R. Smith, BMJ, 2010;T. DeLaine, Drexel, 2004

The Proliferation of Medical Knowledge

But by the time they had completed that task, they would have to catch up on another eight years’ reading.

Any physician would have to read 150 journals/month or 7,700 articles per year to stay informed.

Excerpt from: Upon this age Edna St Vincent Millay 1939

Upon this gifted age, in its dark hour,Rains from the sky a meteoric showerOf facts ... they lie unquestioned, uncombinedWisdom enough to leech us of our illIs daily spun, but there exists no loomTo weave it into fabric

Critical Thinking

Reasonable reflective thinking focused on what to believe or do

R. Ennis, Theory into Practice, 1993

Critical Thinking Analysis; Compare and Contrast

MetacognitionIntuition

Clarify and Question; Recognize Ambiguity

Independent, Self-confident, Open-minded, Creative

Expertise

Critically Thinking about Your own or Someone Else’s Thinking

Critical thinking is best understood as the ability of thinkers to take charge of their own thinking. This requires that they develop sound criteria for analyzing and assessing their own thinking and routinely use those criteria and standards to improve its quality.

Elder and Paul, J Dev Educ, 1994

..make sense of our world by carefully examining our thinking, and the thinking of others . . .

Chafee, Thinking Critically, 1988

11

What was the story behind Flight 1549?

22 March 2005

The Event: “We had 208 seconds to plan and problem-solve” The co-pilot and I had to take on different roles than what typically would

be done according to protocol. I decided early on that we were best served by me using my greater experience in the [A320] to fly the airplane.

Additionally, I felt like I had a clear view out the left-hand and forward windows of all the important landmarks that I needed to consider. They would be easier for me to see. And ultimately the choice of where we would go and what flight path we would take would be mine.

I also thought that since it had been almost a year since I had been through our annual pilot recurrent training, and Jeff had just completed it— he was probably better suited to quickly knowing exactly which checklist would be most appropriate.

Air and Space Magazine (Smithsonian) interview with Captain ‘Sully’ Sullenberger 2.18.2009

Monitoring/regulating/self-assessing/perspective-taking

Anticipating/planning

Reflecting/checking/

Metacognition: Thinking about Thinking

Unconscious

Conscious

Rapid

Intuition

System 1

Deliberate

Metacognition

System 2

Quirk, M 2006; Croskerry, 2009

Intuition in Medicine

Aware of knowing something without having to discover or perceive it

Accomplishing the ‘routine’ Addressing complex clinical situations

that don’t have an immediate visible evidence base (NICU sepsis example)

Using advanced pattern recognition skills of Radiologists = ‘Search Superiority’

Pattern Recognition i cdnuolt blveiee taht I cluod aulaclty uesdnatnrd what I was

rdanieg. The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy

It dseno't mtaetr in waht oerdr the ltteres in a word are, the olny iproamtnt tihng is taht the frsit and lsat ltteer be in the rghit pclae. The rset can be a taotl mses.

Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Azanmig huh?

Yaeh and I awlyas tghuhot slpeling was ipmorantt!

Heuristics: Rules of Thumb

Occam’s Razor : The simplest solution to a clinical problem is most often correct

Availability: You are most likely to use recent clinical experience to guide new experience

Sutton's Law – ‘obvious’ diagnoses more often explain symptoms than ‘non-obvious’ ones

Didn’t know enough about the disease

G Bordage,Acad Med 1999

Why did you miss dx past year? Bias

Was influenced by a ‘similar’ case Was in denial of an ‘upsetting’ diagnosis Was in too much of a hurry Let the consultant convince me Didn’t reassess the situation Patient had too many problems at once

Errors

“Our propensity for certain types of error is the price we pay for the brain’s remarkable ability to think and act intuitively. Heuristics play the odds: sometimes, particularly under unusual circumstances, these rules of thumb lead to wrong decisions.”

M. Graber, Acad Med 2002

Biases

Posterior probability -- decision about this patient is unduly influenced by what has gone on before in physician’s and or patient’s past

Sutton’s slip -- dx possibilities other than the obvious are not given enough consideration

Anchoring -- tendency to ‘lock on’ to salient features in the initial presentation and failing to adjust

Croskerry, Acad Med 2003

Surgical Resident Example: Simulation Setting

50 year old man with multiple trauma (MVC) – Level 1

Excellent resident – Attendings want to work with this resident

Patient begins to crash

Power of Simulation

• Resident orders Atropine -- was perfect until this moment

185/145

(158)

HR

SpO2

HR

SpO2

Biases

Posterior probability -- decision about this patient is unduly influenced by what has gone on before in physician’s and or patient’s past

Sutton’s slip -- dx possibilities other than the obvious are not given enough consideration

Anchoring -- tendency to ‘lock on’ to salient features in the initial presentation and failing to adjust

Croskerry, Acad Med 2003

Ambulatory Care Case (Part I)• The patient presents in the office with left shoulder pain

• This doctor’s previous patient had MS and was in acute crisis - she had to be sent to the ED

• This patient with shoulder pain was lifting a motorcycle engine into place four days ago when pain developed. Doctor had a long relationship with the patient. He is young, strong, and an alcoholic.

• This patient had called earlier and another doctor on call had recommended Advil

• But the pain persisted

• At this visito Shoulder and cardiac exam 100% normalo ECG normal

(Part II)• Gave him an X-ray slip and told him not to drink until we

worked it out

• Did not admit to ED

• Next day the patient died of an MI en route to the ED

• Why didn’t the doctor send the patient to the ED?

o Two patients in a row to the ED? Never happened before

o Didn’t believe this was his heart based on what I knew about him (young, strong, alcoholic) and test results

o Also knew he would argue with me about going to the ED because ‘that’s the type of patient he was’

Unconscious

Conscious

Rapid

Intuition

Deliberate

Metacognition

M Quirk 2006

Role of the Teacher/Mentor

Help learner gain self-insight (reflective writing tasks)

Focus feedback on thinking (not just behavior) Explain strategies for learning (how you read

the literature) Model reflection and self-assessment (think

out loud) Serve as a resource (be available) Use teaching styles and strategies to promote

deliberate reflection

Deliberate Reflection Systematically think aloud through practice

and/or prompting Account (“What did you see?”) Assess (What was good/could be improved?) Analyze (Look for bias) Define Alternative(s) Act (Plan)

Companion to Deliberate Practice (Ericsson, 2007; McGaghie, 2011)

Research support

Study 1. Self-Generated Reflective Questions (Reading)If students develop and ask themselves questions

they learn best

1. Re-read only 2. Teacher Questions

3. Learner QuestionsOutcome Assessment:

a. Immediate short answer b. Immediate free recall c. Post-2 day short answer

Methods:

Results: 1. Learner Questions (most effective)** 2. Teacher Questions (2nd)

3. Re-read only (least effective)

** Took twice as long Weinstein, McDermott & Roediger, J Exp Psych Appl 2010

Study 2. Pause for Reflection (Lecture) If we talk 6 minutes less students learn more

1. Two minutes (12-18 minute intervals)2. Student dyads to reflect 3. No teacher interaction4. Control group5. Repeated two courses

Outcome Assessment:a. Immediate free recallb. Post-12 day multiple choice

Methods Pause:

Results: 1. Intervention group better on both a and b 2. Magnitude of differences = 2 letter grades

Ruhl, KL. Teach Educ, 1987,

Study 3: Self-explanation. (Computer Learning Modules)Prompting to explain thinking improves critical thinking

In a controlled experimental laboratory setting, college students solved problems (similar and structurally different) more effectively and without spending more time using self-explanation prompts.

Authors conclude: “This is a particularly important accomplishment in light of the fact that this prompting procedure— one that proved to be both effective and efficient—is a very simple and easy-to-implement feature for computer-based learning environments.”

Atkinson, RK J Educ Psych 2003

Assertive / Suggestive

Emphasis on teacher’s

knowledge & experiences (Cognition)

Reliance on Teacher Reliance on Learner

Characteristics of Teaching Styles

Emphasis on learner’s

reasoning skills and feelings

(Metacognition/Deliberate

Reflection)

Collaborative / Facilitative

Reliance on Teacher Reliance on Learner

Teaching Styles: Emphasis on Metacognition

Facilitative

Deliberate Reflection

AccountWhat happened (is

happening)?What did you want to happen?

Action Plan

Assess

Alternatives

What will you do (next time - when)?

What else could you have done? How can you do it differently?

What were (are) you thinking and feeling? What is good/bad (about the experience)?

What sense can you make of this? What were your biases/assumptions? Are they true?

Analyze

Adapted from Schon, 1983

Power of Simulation

• Resident orders Atropine -- was perfect until this moment

185/145

(158)

HR

SpO2

HR

SpO2

De-Brief Frame “Walk me through it -- Tell me what you were thinking and

feeling.” “What did you see (account)? When did you decide to act

– order Atropine?” Were you missing something? Are there other

explanations for the sudden change in the patient’s condition?

Resident clearly recognized the patient was crashing but only focused on one vital. Acted before completing the visual/mental checklist.

This is anchoring (name it).

Power of Simulation

De-Brief Frame “What would you do differently next time?” “What are the alternatives?”

Power of Simulation

Simulation Training: Team PerspectiveTrauma Bay: MVA – 70 yr old woman with

multiple trauma

De-Brief Frame “Walk me through it -- Tell me what you were thinking

and feeling.” “How did you view your role and responsibility in

relation to the more senior attending?” “How did you consider the alternative offered by the

attending?” Resident felt anxious and checked her decision-

making and clarified her role.

Avoided visceral bias (influence of affective sources of error on decision-making) by reflecting.

Power of Simulation

Summary

1. Critical thinking is reasonable reflective thinking focused on what to believe or do

2. Metacognition is critically thinking about thinking3. Teaching and practicing deliberate reflection

improve metacognition4. Positive outcomes include greater self-

awareness, fewer diagnostic errors, more effective teamwork, greater self-directed learning and improved physician-patient relations

Integrated ACGME Competency Diagram

Medical Knowledge

Patient Care

Professionalism Interpersonal and CommunicationSkills

Practice-based Learning

System-based Practice

Integrated ACGME Competency Diagram in On the Pathway to Expertise

Medical Knowledge

Patient Care

Professionalism

Interpersonal and CommunicationSkills

System-based Practice

Practice-based Learning

How to learn from experience

Yogi Berra “If you don’t know

where you are going you might end up someplace else”

Critical Thinking

Thank You!