Within the competencies espoused by the PA and NP professions, critical thinking is a paramount issue. In fact, the scope of practice for NPs and PAs is defined by an educational program’s competency standards and by state requirements for licensure—all of which demand critical thinking.
Despite these good intentions, medical errors remain prevalent. Even after the 1999 Institute of Medicine report To Err Is Human, there are concerns that our health care system lacks a firm commitment to patient safety. State regulatory boards are questioning the critical-thinking skills of clinicians in both ethical and medical problem solving. While medical science has been successful in extending life expectancy, our patients present with more severe illness than ever before, requiring the use of multiple medications, procedures, and treatments—all of which makes critical thinking more critical than ever.
In the face of this complexity, we find younger NP and PA students with less health care and life experience than their mentors had. Those who are accepted into highly competitive PA or NP programs have demonstrated an ability to retain and recall information, especially with multiple-choice questions that have a single correct answer. Anecdotally, however, many educators say that one of the biggest obstacles facing today’s students is learning how to be a critical thinker. I too have concerns about students who are passing all of their courses, including clinical rotations, when I hear comments such as “but they can’t think for themselves.”
Clearly, not all PA and NP students are equipped with the critical-thinking skills needed in today’s complicated health care system. Even evidence-based medicine must be coupled with an equally rigorous argumentation process. As Jerome Groopman, MD, points out in How Doctors Think, “today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.”
Critical thinking in modern medicine is not something that can be instantly mastered; it must be learned though experience. According to Scott Weber, EdD, MSN, RN, FACHE, FHIMSS, in his article “Promoting Critical Thinking in Students” in the Journal of the American Academy of Nurse Practitioners, “the focus during clinicals should be on critical thinking (clinical reasoning) first and foremost…. A student should be a good entry-level critical thinker by the end of clinical education—for example, clear, accurate, precise, and relevant in his or her approach to practice, and able to link theory and practice in decision making, intervention planning, and even spontaneous modification of ongoing intervention processes.”
Weber adds that “a clinical student who is striving to become a good clinical thinker will:
“1. raise relevant, precise questions during clinical education, demonstrating the use of past experiences blended with knowledge;
“2. analyze and interpret clinical experiences from the assessment of relevant information;
“3. provide reasoned conclusions and intervention recommendations based on practice frames of reference and standards for professional performance;
“4. modify thinking based on practical implications that demonstrate self-correction of thinking in atypical or unique situations; and
“5. communicate effectively with others in negotiating complex problems.”
The most concise definition of critical thinking may be that of Dr. Richard Paul, Chair of the National Council for Excellence in Critical Thinking, who suggested that it is “the art of thinking about your thinking while you are thinking, in order to make your thinking better: more clear, more accurate, or more defensible.”
The pressing need to promote critical thinking among our students requires us to reevaluate our curricula and teaching methods. Critical thinking cannot be taught by lecturing. The relevant intellectual skills (analysis, synthesis, and reflection) must be learned through use. However, these skills can be cultivated through:
Clinical examinations. Students inevitably practice critical thinking with objective structured clinical examinations (or practical laboratories) developed to address the identified medical and behavioral problems.
Reflective papers. Reflective thinking refers to the processes of analyzing and making judgments about what has happened, then writing them down. It is increasingly important to prompt reflective thinking during learning to help students develop strategies to apply new knowledge to the complex situations they will confront in their day-to-day activities. Reflective thinking helps students develop higher-order thinking skills by prompting them to relate new knowledge to prior understanding, to think in both abstract and conceptual terms, to apply specific strategies in novel tasks, and to understand their own thinking and learning strategies.
Journal clubs. The journal club, an established teaching modality in many educational programs, improves students’ reading habits, knowledge of epidemiology and biostatistics, and critical appraisal skills.
Clinical case studies. Small-group interactions in which clinical cases are presented and discussed promote analysis and critical thinking.
Simulation. The best predictor of future performance is practicing in a simulated situation. Today’s sophisticated computer-based simulations of clinical problems can test a wide range of competencies.
If we require NP and PA students to learn critical thinking, then how do we assess it? How can we know that our students have acquired this important skill?
Several standardized tests are available to assess critical thinking skills. The California Critical Thinking Skills Test (CCTST) is a challenging, discipline-neutral measure of actual cognitive skills used in critical thinking. The standardized and validated 34-item multiple-choice test targets the core skills considered essential in a college education. An older but frequently used test is the Watson-Glaser Critical Thinking Appraisal. It too is a multiple-choice tool with text-based questions; however, it uses a more limited response format than the CCTST.
No consensus exists, however, concerning the best test. And an individual’s results on one test cannot be assumed to indicate what he or she would score on a different test.
Discipline-specific national board examinations are another option for assessing critical thinking. Today’s computerized multiple-choice tests comprise questions that assess basic medical and surgical knowledge. Some testing of reasoning skills should be required of these high-stakes examinations.
NPs and PAs need to analyze, evaluate, and synthesize information from many sources in order to make appropriate decisions about a patient’s diagnosis and treatment plan. A lack of critical thinking can be dangerous—and perhaps even fatal.
I invite your responses on best practices for teaching and assessing critical thinking. Please e-mail me at PAeditor@qhc.com.