Objectives

1.

2. Objectives Participants will be able to . . . Appreciate the �knowledge dilemma� in medical education Identify the components of critical thinking Describe intuition and metacognition and their importance to critical thinking Identify educational strategies that enhance metacognition

3. �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.�

4. Second year medical students at one institution were assigned required readings that totaled ___ hours per week.Taylor,N Engl J Med 1992

7. Excerpt from: Upon this ageEdna St Vincent Millay 1939 Upon this gifted age, in its dark hour, Rains from the sky a meteoric shower Of facts ... they lie unquestioned, uncombined Wisdom enough to leech us of our ill Is daily spun, but there exists no loom To weave it into fabric

8. Critical Thinking Reasonable reflective thinking focused on what to believe or do

10. 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 11

12. 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.

16. 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�

17. 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! 

18. Heuristics: Rulesof 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

19. Didn�t know enough about the disease

20. 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.�

21. 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

22. Surgical Resident Example: Simulation Setting 50 year old man with multiple trauma (MVC) � Level 1 Excellent resident � Attendingswantto work with this resident Patient begins to crash

24. 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

26. (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?

28. 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

29. 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

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

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

33. 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

38. 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).

39. De-Brief Frame �What would you do differently next time?� �What are the alternatives?�

40. Simulation Training: Team PerspectiveTrauma Bay: MVA � 70 yr old woman with multiple trauma

41. 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.

42. Summary Critical thinking is reasonable reflective thinking focused on what to believe or do Metacognition is critically thinking about thinking Teaching and practicing deliberate reflection improve metacognition Positive outcomes include greater self-awareness, fewer diagnostic errors, more effective teamwork, greater self-directed learning and improved physician-patient relations

43. Integrated ACGME Competency Diagram

44. Integrated ACGME Competency Diagram in On the Pathway to Expertise

45. Yogi Berra �If you don�t know where you are going you might end up someplace else�

46. References Swenssen, RG, Hessel, SJ, and Herman, PG (1982) Radiograph interpretation with and without search. Investigative Radiology. 161;145-151. Norman, GR, et.al. (1992) Visual perception in medical practice. In Innovations in Medical Education. Springer-Verlag. 204-217. Weed, L (1997) New connections between medical knowledge and patient care. BMJ. 315:231�5. Smith, R. Strategies for coping with information overload. BMJ 2010;341:c7126. Taylor, CR (1992) Great Expectations. The reading habits of year II medical students. N Engl J Med 326(21): 1436-40. Osler, SW (1899) �After 25 years.� Address to McGill University. Millay, ESV Upon This Age From Huntsman, What Quarry? (1939) Osler, SW (1897) Influence of Louis on American Medicine. Johns Hopkins Medical Bulletin 8 161 Croskerry, p. (2003) Cognitive Forcing Strategies in Clinical Decision making Ann Emerg Med. 2003;41:110-120.] Russell. I.J., Hendricson, W.D., & Herbert, R.J. (November, 1984). Effects of lecture information density on medical student achievement. Journal of Medical Education, 59, 881-889. Berardi-Coletta, B., Buyer, L. S., Dominowski, R. L., &Rellinger, E. R. (1995). Metacognition and problem solving: A process-oriented approach. Journal of Experimental Psychology: Learning, Memory, & Cognition, 2 1, 205�223. Chamberlaine, M. et.al. The influence of medical students� self-explanations on diagnostic performanceMedical Education 2011: 45: 688�695 Atkinson, RK. 2003 Transitioning From Studying Examples to Solving Problems: Effects of Self-Explanation Prompts and Fading Worked-Out Steps J of Educ Psychology, Vol. 95, No. 4, 774�783

47. References Croskerry, P. (2003) The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them Acad. Med. 78:775�780. Bordage, G. (1999) Why did I miss the diagnosis? Acad Med 74: s138-143 Scho�n DA. (1983) The Reflective Practitioner. How Professionals Think in Action. London: Temple Smith. Crandall, B & Getchell-Reiter, K. (1993) Critical decision method: A technique for eliciting concrete assessment indicators from the intuition of NICU nurses Adv Nurs Science 16(1) 42-51 Ennis, RH. Critical thinking assessment. Theory into Practice. 32(3):179-186 Elder, L., & Paul, R. (1994, Fall). Critical thinking: Why we must transform our teaching. Journal of Developmental Education 18(1), 34-35. Chaffee J. (1988) Thinking Critically. Boston, Ma Houghton Mifflin Ericsson, KA. (2007) An expert-performance perspective of research on medical expertise: the study of clinical performance. Med Educ. 41: 1124-1130 Croskerry, P. A Universal Model of Diagnostic Reasoning Acad Med. 2009; 84:1022�1028. Bond, WF et al. (2006) Cognitive versus Technical Debriefing after Simulation Training AcadEmerg Med; 13:276�283 McGaghie W, Issenberg, SB, Cohen, E, Barsuk, J, and Wayne, D. Does Simulation Based Medical Education with Deliberate Practice yoeld better results than traditional clinical education? Acad Med, 2011;86:706-711. Cheshire, A., Ball, L. J. & Lewis, C. N. (2005) Self-explanation, feedback and the development of analogical reasoning skills: Microgenetic evidence for a metacognitive processing account. In: Proceedings of the Twenty-Second Annual Conference of the Cognitive Science Society, ed. B. G. Bara, L. Barsalou& M. Bucciarelli, pp. 435�41. Erlbaum. [

48. References Davison G, Navarre S, Vogel R. The articulated thoughts in simulated situations paradigm: A thinkaloud approach to cognitive assessment. Curr Dir Psychol Sci. 1995; 4:29�33. Ruhl, K. L., Hughes, C. A., and Schloss, P. J. (1987). "Using the pause procedure to enhance lecture recall", Teacher Education and Special Education, 10, 14. Davison G, Robins C, Johnson M. Articulated thoughts during simulate situations: a paradigm for studying cognition in emotion and behavior. CognitTher Res. 1983; 7:17�39. Petranek C. Written debriefing: the next vital step in learning with simulations. SimulGam. 2000; 31:109�18.