Shifting the Medical Education Paradigm from Knowledge to Critical Thinking

1. Harvard Academy Education Day Shifting the Medical Education Paradigm from Knowledge to Critical Thinking Mark Quirk, Ed.D. Professor and Assistant Dean University of Massachusetts Medical School

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.” Osler, 1899

4. Impact on Curriculum Second year medical students at one institution were assigned required readings that totaled ___ hours per week.Taylor,N Engl J Med 1992 62

5. 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

6. The Proliferation of Medical Knowledge 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. 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. R. Smith, BMJ, 2010; T. DeLaine, Drexel, 2004

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 R. Ennis, Theory into Practice, 1993

9. Critical Thinking Analysis; Compare and Contrast Expertise Clarify and Question; Recognize Ambiguity Metacognition Intuition Independent, Self-confident, Open-minded, Creative

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

13. Metacognition: Thinking about Thinking Anticipating/planning Reflecting/checking/ Monitoring/regulating/self-assessing/perspective-taking

15. Deliberate Metacognition System 2 Intuition System 1 Rapid Conscious Unconscious Quirk, M 2006;Croskerry, 2009

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. Bias Why did you miss dx past year? • 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 Didn’t know enough about the disease G Bordage,Acad Med 1999

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.” M. Graber, AcadMed 2002

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 Croskerry, Acad Med 2003

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

23. Power of Simulation HR HR SpO2 SpO2 185/145 (158) • Resident orders Atropine -- was perfect until this moment

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 Croskerry, Acad Med 2003

25. 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 andanotherdoctor on call had recommended Advil • But the pain persisted • At this visit • Shoulder and cardiac exam 100% normal • ECG normal

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? • Two patients in a row to the ED? Never happened before • Didn’t believe this was his heart based on what I knew about him (young, strong, alcoholic) and test results • Also knew he would argue with me about going to the ED because ‘that’s the type of patient he was’

27. Deliberate Metacognition Intuition Rapid Conscious Unconscious M Quirk 2006

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 Methods: • 1. Re-read only • 2. Teacher Questions • 3. Learner Questions • Outcome Assessment: • a. Immediate short answer • b. Immediate free recall • c. Post-2 day short answer 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

32. Study 2. Pause for Reflection (Lecture)If we talk 6 minutes less students learn more Methods Pause: • Two minutes (12-18 minute intervals) • Student dyads to reflect • 3. No teacher interaction • 4. Control group • 5. Repeated two courses • Outcome Assessment: • Immediate free recall • Post-12 day multiple choice Results: 1. Intervention group better on both a and b 2. Magnitude of differences = 2 letter grades Ruhl, KL. Teach Educ, 1987,

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

34. Characteristics of Teaching Styles Reliance on Teacher Reliance on Learner Assertive / Suggestive Collaborative / Facilitative Emphasis on teacher’s knowledge & experiences (Cognition) Emphasis on learner’s reasoning skills and feelings (Metacognition/Deliberate Reflection)

35. Teaching Styles: Emphasis onMetacognition Reliance on Teacher Reliance on Learner Facilitative

36. Deliberate Reflection Account What happened (is happening)? What did you want to happen? Action Plan Assess What were (are) you thinking and feeling? What is good/bad (about the experience)? What will you do (next time - when)? Alternatives Analyze What sense can you make of this? What were your biases/assumptions? Are they true? What else could you have done? How can you do it differently? Adapted from Schon, 1983

37. Power of Simulation HR HR SpO2 SpO2 185/145 (158) • Resident orders Atropine -- was perfect until this moment

38. De-Brief Frame Power of Simulation • “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 Power of Simulation • “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 Power of Simulation • “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 Patient Care Medical Knowledge Professionalism Interpersonal and Communication Skills System-based Practice Practice-based Learning

44. Integrated ACGME Competency Diagram in On the Pathway to Expertise Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-based Learning How to learn from experience Professionalism System-based Practice

45. Yogi Berra “If you don’t know where you are going you might end up someplace else” Critical Thinking Thank You!