Teaching Critical Thinking
Mike McEvoy, PhD, NRP, RN, CCRN
Saratoga County EMS
Albany Medical Center
What is “Critical Thinking”?
1. Higher ordered thinking
2. Question assumptions
3. Decide whether a theory is:
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True
False
Partly true and partly false
Sometimes true and sometimes false
4. Requisite for “street ready” graduates
Teaching “how to think” versus “what to think”
Why Johnny Can’t Read Google
• Critical thinking problematic everywhere
On Line Research Skills
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Google used for 47.3% of all searches
Are users savvy to results relevance?
16 Charleston College students (20 yo)
Google results randomly swapped or
reversed
Pang B et al. In Google We Trust: Users Decisions on Rank, Position and
Relevance. J Comp-Mediated Comm. 2007:12(3), article 3.
http://jcmc.indiana.edu/vol12/issue3/pan.html
Students consistently used (falsely)
top-ranked pages
Dreyfus Model of Skill Acquisition:
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Novice
Advanced Beginner
Competent
Proficient
Expert
The Dreyfus Model
NOVICE:
• Cookbook approach (rule governed behavior)
– Everything is B & W
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Limited and inflexible (sloooow)
Lack contextual knowledge
Unable to relate training to real events
No ability to prioritize tasks
Unconsciously Incompetent
The Dreyfus Model
ADVANCED BEGINNER (1-2 yrs):
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Marginally acceptable performance
Beginning to link knowledge with experience
Beginning to know when to apply and break rules
Patterns emerge – “aspects of the situation”
Moves from rules to guidelines
– Problems arise when guidelines conflict
• Cannot prioritize – needs competent partner to
assure important tasks don’t go undone
Consciously Incompetent
The Dreyfus Model
COMPETENT (2-3 yrs)*:
• Conscious, deliberate, planning ability (knows
what to do, when, why and how to do it)
• Can determine what is and is not important
• Has a model that can be used as a starting
point in most situations
• Not yet fast, fluid, efficient, or flexible
• Feels mastery and ability to cope
• Learn best from simulation
* Best preceptors
Consciously Competent
The Dreyfus Model
PROFICIENT (3-5 yrs):
• Experienced based ability to see whole situations
– uses “maxims”
• Readily formulates plans for action
• Anticipates “most likely” occurrences
• Recognizes departures from the expected course
and modifies plans accordingly
• Intuitive pattern recognition
• Learn best from case studies
Unconsciously Competent
The Dreyfus Model
EXPERT:
• Zeroes in on problems without wasteful
considerations of alternatives
• Anticipates the unusual
• Has knowledge not easily available in textbooks
• Difficult to capture descriptions of behaviors
Reflective EMS Provider
The Critical Thinking Process
Concept Formation
• Info gathered to form general impression
• Includes:
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Scene assessment
Chief complaint
History
Affect
Initial assessment
Physical exam
Diagnostic tests
Data Interpretation
• Data gathered
• Knowledge
– Anatomy and
physiology
– Pathophysiology
• Attitude
• Experience
Application of Principle
• Field impression/working diagnosis
• Protocols/standing orders
• Treatment/intervention
Evaluation
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Patient reassessment
Reflection on care given
Revision of impression
Protocol/standing orders
Revision of treatment/intervention
Reflection on Action
• Run critique
• Addition to/modification
of student experience
base
Critical Thinking Detractors:
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Protocols
SOGs
PSE
Tendency to test at
lower thought levels
• Faculty not in
clinical practice
Critical Thinking Enhancers
• Simulation
• Story telling
• Case reviews
(experienced providers)
When is Critical Thinking Important?
• Rare EMS call = life threat
• Minor trauma/medical calls require little
critical thinking (easy decisions)
• Obvious life threats also not very
challenging (fit standard treatments)
• Patients between minor and lifethreatening are critical thinking
challenges!
So, how do I teach critical
thinking to newbies?
Mental checklists
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Stop and think
Scan the situation
Decide and act
Maintain control
Reevaluate
Performance Characteristics of
People Under Stress:
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Reduced awareness of environmental clues
Increased sensitivity to signs of anxiety
Decreased tolerance for pain and frustration
Increased emphasis on performance error
Decreased efficiency in mental processing
Increased mistakes and injuries
Critical Thought Checklist:
1. Read the scene
– Environment/dangers
– Immediate surroundings/clues
– MOI
2. Read the Patient
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Observe (LOC, appearance, position…)
Touch (skin, pulse)
Talk (CC, new or preexisting…)
Assess (Listen, VS…)
Identify life threats
Critical Thought Checklist:
3. React
– Address life threats
– Pick most likely cause
– Decide the most serious condition present
4. Reevaluate
– Detailed assessment
– Response to initial management
– Any less obvious problems?
5. Revise your plan
6. Review your performance after the call
Bloom’s Taxonomy: Modern
Day Critical Thinking?
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Knowledge
Comprehension
Application
Analysis
Synthesis
Evaluation
Memorization or Critical Thinking?
1. The skin layer ______ is composed largely of fat.
a.
b.
c.
d.
Subcutaneous tissue
Subdermis
Epidermis
Dermis
2. A skateboarder has sustained a “road rash” following a
fall. The two external skin layers have been destroyed,
leaving a layer largely composed of fat. What is the
name of this remaining layer that you see?
a.
b.
c.
d.
Subcutaneous tissue
Subdermis
Epidermis
Dermis
Bloom’s Taxonomy: Modern
Day Critical Thinking?
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Knowledge
Comprehension
Application
Analysis
Synthesis
Evaluation
A patient asks the EMT what
the term, “MCI” means. The
EMT knows that MCI stands
for _______________.
Bloom’s Taxonomy: Modern
Day Critical Thinking?
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Knowledge
Comprehension
Application
Analysis
Synthesis
Evaluation
You respond to an MCI.
The crew chief of the
first arriving ambulance
assumes the role of the
__________________.
Bloom’s Taxonomy: Modern
Day Critical Thinking?
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Knowledge
Comprehension
Application
Analysis
Synthesis
Evaluation
The triage officer at an MCI
finds seven patients. Four are
tagged “red.” Which of the
following would have the
highest acuity and therefore
require immediate transport?
Bloom’s Taxonomy: Modern
Day Critical Thinking?
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Knowledge
Comprehension
Application
Analysis
Synthesis
Evaluation
The EMT at the scene of an MCI must utilize
resources efficiently. Of the following
patients, which would the EMT elect to not
transport first?
1) A 6 year-old with a pulse of 190, a
fractured femur, and a rigid
abdomen
2) A 73 year-old with a closed head
injury and a heart rate of 48
3) A 35 year-old unconscious 38 week
gestation pregnant female
4) A 55 year-old firefighter with chest
pain and EKG changes
Bloom’s Taxonomy: Modern
Day Critical Thinking?
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Knowledge
Comprehension
Application
Analysis
Synthesis
Evaluation
You transport a patient from the scene of an
MVC. On arrival at the ED , the nurse
replaces your non-rebreather mask with a
nasal cannula. The physician removes the
patient from the long backboard. Defend
their actions using published evidence.
One Last Thought: Internet
• Are we fostering evidence based practice?
• Introduce credible sources
• Teach analysis
– Who put it there and why
• Academic, advocacy group or hobbyist
– Currency (date)
– Scientific sources cited
– Author qualifications and contact info
– Reputable third party certification/links
– Etc…
First year med students
Second/third year med students
Summary
• Critical Thinking is higher ordered thought
• Necessary for “Street Ready” providers
• Difficult to teach/foster:
– Beginners seek black & white, not gray
– EMS design very protocol driven
• Can be promoted with attention to stories,
simulation, case based teaching, better
testing
• Savvy internet use will promote future
evidence based practice in EMS