A Critical Thinking Q & A

What is critical thinking and how does it improve care for patients?

Danica Erickson - 12 May 2020

What is critical thinking?

David Ross: In three words, it’s purposeful, reflective judgement.  For the purpose of this particular study we defined it based on the work of Peter Facione, which was published in the Delphi Report in 1990.

Michelle Morros: According to Oxford online, it is the objective analysis and evaluation of an issue.

DR: The six elements of critical thinking are, analysis, inference, interpretation, evaluation, self-regulation and explanation.  It also includes inductive and deductive reasoning.


Can you give an example of critical thinking?

DR: Firstly, it has to be context specific so let’s reference it to medicine. Seeing patients as a doctor is about gathering information which you then evaluate for completeness and validity to start.

MM: You gather it and then you have to know how to organize it, synthesize it and be selective. Critical thinking is the basis for clinical reasoning, which is the medically contextualized version of critical thinking. Critical thinking is what anybody does when they have a problem to solve. Faced with an undifferentiated patient, it’s the skill that allows a physician to determine information coming in, what to do with that information, and come up with an answer.

DR: Right. I would say an example is a doctor sees a patient with an undifferentiated problem so you make use of the six elements of critical thinking to draw a valid conclusion or differential diagnosis and create a treatment plan.


Why research this? Don’t medical learners think critically already?

DR: People peak out in their mid- 20’s mentally, physically, and cognitively. Physically we peak at about 26. It’s the same with your brain: critical thinking skills peak in the mid-20’s and then decline from that point on. By age 60, those skills really drop off, as confirmed in our research. Some residents come into the program with strong critical thinking skills, some do not.

MM: It’s hard to teach critical thinking after that point in time. I was interested in joining David in this research because there are learners in their senior years, meaning they’re in their residency, having already done undergraduate school, graduate school and medical school but haven’t developed critical thinking skills. Or perhaps have stalled in their skills. We’ve assumed if learners have gotten as far as residency, they have those skills. We want to assess learners, to understand if some residents have low skills and what we can do to help them. 

And, as David said, those skills will eventually start to decline. We’re all going to lose our critical thinking skills, so for those starting with weaker skills, that drop-off later life could be dangerous for patients.

DR: Unfortunately not everyone has strong critical thinking skills. And yes, sometimes we have residents with weak critical thinking skills. This is part of the reason we undertook this research: to understand why some residents are low and what can we do for them. 

MM: So it’s a tool to help us assess: we can assess residents and if their skill level is low, can we teach it or find a way to help them compensate? 


Now you are measuring with practicing physicians? Why now? Isn’t it a bit too late for them?

DR: We’ve already measured this in residents so we have data to compare. What we have never had, because no one has researched the topic, is similar data from practicing physicians to compare to. That’s what’s new.

MM: When we researched critical thinking for practicing doctors, we discovered that nobody has actually measured critical thinking skills in practicing family physicians.

DR: It has been studied in health professionals, but not specifically family doctors in practice, so this is a unique study.

DR: Our ultimate goal is to be graduating clinically competent physicians who have strong critical thinking skills which protect them against all of the bias they’ll face throughout their career. The whole point of critical thinking is to minimize bias and therefore minimize diagnostic error. That, in turn, means better clinicians.

The results of this research could potentially be used at the provincial or national family physician college level to identify supports to put in place so physicians can practice a bit longer. This hopefully will be the next phase: measuring and assessing critical thinking in practicing doctors over time and finding ways to support longitudinal competency at the College of Family Physicians of Canada  (CFPC) level through Mainpro.

MM: That will be part two, after we’ve tackled residency.

MM: And also at the college level, if we can assess practicing physicians and they are found in need of improved critical thinking skills, that doesn’t necessarily mean they shouldn’t be practicing physicians because we have other skills to rely on. But that could mean there are also supports in place to help a physician practice a bit longer. I don’t think every physician should have to retire at age 60 or 63!

DR: We all make mistakes; that will never go away. But if we have strong critical thinking skills, it minimizes diagnostic error and makes us better physicians.


How will the results of your research be used?

DR: We’ll use them for assessment. To go back to Michelle’s comment, the results will continue to be used and enhanced in the assessment process and CaRMS (the application process for residency programs across Canada) selection process.

MM: Yes, in the selection process if those involved agree to it. 

DR: And throughout residency we’ll expand on it, so after assessment the task will be teaching it or improving it if we can. 

DR: Then it would ideally be infused into our resident curriculum, which we don’t formally do right now as part of academic days (monthly classroom-based education sessions). We do our day-to-day clinical teaching, but everyone does it at different levels.

This is an important concept and we should be working toward a more formalized part of our curriculum in our residency program. The development of critical thinking skills should be included in the undergraduate medical education (UME) and continue on following UME. It’s a bit like behavioural medicine: until it started being taught in UME, we had to do it all in residency. Ideally, if critical thinking development started in UME, teaching it would be redundant at residency level.


Click here for more information about the California Critical Thinking Skills Test
Click here for more information about Peter Facione