Evidence-Based Education:
Promoting Critical Thinking
Skills in Dental Education
American Dental Education Association | March 15, 2014
Sophia Saeed, DMD
Associate Clinical Professor
UCSF School of Dentistry
Mark Dellinges, DDS, FACP
Division Chair, Pre-Clinical Simulation
Clinical Professor
UCSF School of Dentistry
Sunday, March 9, 14
(Saeed):
Welcome to our workshop called evidence-based education: promoting critical thinking skills in dental education.
My name is Sophia Saeed, I’m an Associate Clinical Professor at the University of California, San Francisco.
In the past 10 years, I’ve seen dentistry incorporate more evidence-based practice.
What we’re starting to see in dental schools is evidence-based education...that is, using the literature and research available in the field of education to inform our
educational philosophies, methodologies, and assessments.
We’re going to talk today about critical thinking: why it’s important and how we can promote it in our teaching settings.
(Dellinges):
Hi, I’m Mark Dellinges. I’m a clinical professor at UCSF and my specialty is prosthodontics. In addition to teaching full-time, I’m enrolled as a student in the
Masters of Education program at UC Berkeley. I’m devoted to improving teaching and learning in dental education and my personal goal is to help to insure that
each and every dental student has the knowledge and skills necessary to enjoy a productive and happy life in their chosen profession.
Objectives
1. Describe the role of critical thinking skills in
patient care as an expert clinician.
2. Discuss how critical thinking skills increase
depth of learning.
3. Demonstrate practical ways to incorporate
facilitation of critical thinking skills in the preclinical and clinical setting.
Sunday, March 9, 14
(Dellinges):
By the end of this workshop, we hope you will feel comfortable in…
Describing the role of critical thinking skills in patient care as an expert clinician.
Discussing how critical thinking skills increase depth of learning.
Demonstrating practical ways to incorporate the facilitation of critical thinking skills in the pre-clinical and clinical settings.
Sunday, March 9, 14
(Saeed):
Let’s start off with a case...
A 17 year-old young man presents to your faculty practice for an initial exam. He fell a few months ago and chipped #9. He comes with his mother to inquire
about replacing tooth #8 and fixing #9. This is him biting in his “normal bite.”
What would you want to do for this patient to address his CC? (audience responds)
- We would probably want more information about the HPI, the nature of fall, his medical history... we’d want additional diagnostic information, including
radiographs, periodontal exam, maybe endodontic testing...
- But, most of us are already thinking about implant vs. fixed vs. removable for replacing #8. We’re questioning the restorability of #9. We can’t help but focus on
the poor oral hygiene, the malocclusion, and the short clinical crowns.
- We’ve already judged the pros and cons of each option in our own mind so that when mom asks, “well, what would you do, doc?” we can share our expertise in
an organized fashion.
- As expert clinicians, we use PATTERN RECOGNITION and previous patient experiences in our clinical reasoning. This is distinct from a novice clinician, who
tends to rely on didactic knowledge.
Getting students from where THEY are to where WE are is part of our task as educators.
Definition
“Purposeful, self-regulatory judgment which
results in interpretation, analysis, evaluation
and inference, as well as explanation of the
evidential, conceptual, methodological,
criteriological, or contextual considerations
upon which judgement is based.”
Facione PA. Critical Thinking: a statement of expert consensus for purposes of educational assessment and instruction. Millbrae, CA.
The California Academic Press, 1990: 2.
Sunday, March 9, 14
(Saeed) :
So, what is critical thinking and what role does it play? There are a lot of definitions.
This one from Facione is pretty comprehensive, but it’s also a mouthful...and a lot to process.
Information
Judgment
Interpret
Analyze
Evaluate
Infer
Sunday, March 9, 14
(Saeed) :
Ultimately, information is presented to us, we make a judgment about that information, and then decide what to do with that information.
We might interpret, analyze, evaluate, or infer.
Then we decide:
Do we accept it? Is it conceptually sound? Does it apply in this situation?
Parallels to Clinical Reasoning
Subjective information gathering
Open ➞ close-ended questions
Objective findings
Clinical & Radiographic findings, focused exam
Assessment
Diagnosis
Plan
Treatment Plan
Sunday, March 9, 14
(Saeed):
Critical thinking is so parallel to clinical reasoning that these two terms are often used interchangably. If we need critical thinking skills to be a good clinician, we
need to foster it in our trainees.
In the clinical case we saw earlier...
- We start off by asking open-ended questions, judging that information, then asking more focused questions.
- We then gather objective clinical and radiographic findings. We might focus our diagnostic tests based on the information we’ve judged and assessed from the
patient interview.
- We would judge the subjective and objective findings together and formulate a diagnosis
- And that leads us to treatment options.
Every time we make a judgment about information entering our minds, we are using critical thinking skills.
New CODA Standards
2-9: Graduates must be competent in the
use of critical thinking and problemsolving, including their use in comprehensive
care of patients, scientific inquiry and
research methodology
Sunday, March 9, 14
(Dellinges):
If you need an official answer of why this should matter to you as a dental educator, CODA has adopted a standard that requires us to incorporate critical thinking
into our curricula. And with that, we’ll have to find ways to assess how well our students are grasping this concept from our teaching interventions.
Parallels to Evidence-Based Dentistry
Assess
Information
Judging
Information
Sources
Applying
Knowledge to
Clinical Care
Sunday, March 9, 14
(Dellinges):
Similarly, when we think about evidence-based dentistry, we read, judge, and decide if we should apply certain evidence to a specific clinical situation.
Say I read an article about implant-supported fixed prostheses in the esthetic zone. It talks about single-unit versus splinted restorations. It makes some
conclusions about achieving the best functional and esthetic solution for patients.
I judge the information source. It was JADA, a reputable journal.
I judge the study, it looks like they had a good sample size, a mix of men and women patients, various ethnic backgrounds.
The methods used were consistent with my clinical protocol for implant restorations.
The implant system used is the same one I use.
The conclusions they’ve drawn are consistent with their data and make sense to me.
So far, things look good.
- But then I realize that my patient is still growing, he’s only 17 years old. The study was conducted on 30-65 year-olds.
- I realize all the patients were in class I or II occlusion. My patient is not.
And so now I don’t know if this evidence can be applied to my clinical situation.
Again, I am assessing the information, judging the information source, and deciding if I can apply the knowledge to my specific clinical case.
Clinical Reasoning
NOVICE:
Biomedical/
Didactic
Knowledge
INTERMEDIATE:
Biomedical/
Didactic
Knowledge
+
Clinical
Experience
EXPERT:
Pattern
Recognition
De Bruin ABH, Schmidt HG, Rikers RMJP. The Role of Basic Science Knowledge and Clinical Knowledge in Diagnostic Reasoning: A Structural Equation Modeling Approach.
Academic Medicine. 80(3): Aug 2004.
Sunday, March 9, 14
(Saeed):
We’re going to talk a little bit more about difference in clinical reasoning between us (the expert clinicians), and those earlier in their clinical careers.
Clinical Reasoning
Novice = Biomedical/Didactic Knowledge
didactic
De Bruin ABH, Schmidt HG, Rikers RMJP. The Role of Basic Science Knowledge and Clinical Knowledge in Diagnostic Reasoning: A Structural Equation Modeling Approach.
Academic Medicine. 80(3): Aug 2004.
Adapted from Ambrose SA, et al. How Learning Works. San Francisco: Jossey-Bass, 2010. Print.
Sunday, March 9, 14
(Saeed):
We’ll start off with the novice clinician.
Flashback to dental school, seeing your first patient for a comprehensive exam. If you can’t remember that long ago, think of a student you’ve supervised who is
new to the clinical setting. Does everyone have someone in mind?
The student interviews his patient, but he is not as good as you in honing in on a differential diagnosis because he doesn’t have the same clinical experience. He
asks a lot of questions, but doesn’t yet have the ability to make judgements about the answers. So, he gathers a lot of data that may or may not be useful.
He has the radiographs taken, completes the clinical exam, and then he sits down and thinks long and hard about all the information he’s gathered. He struggles
with formulating a diagnosis and treatment plan.
Most of the information the student is retrieving is didactic knowledge about pathophysiology of caries and periodontal disease, the rules of interpreting
radiographs, deciding... is that really caries I see on the radiograph or is that a radiolucent cp, or cervical burnout. The student becomes overwhelmed with
information, because he is relying so heavily on that.
The knowledge organization in his brain looks like dots that may be connected in small linear patterns or in little clusters. All of it is didactic, none of it is clinical
experience. And it’s not well-organized or richly connected.
Clinical Reasoning
Intermediate = Biomedical/Didactic
Knowledge + Clinical Knowledge
didactic
+
clinical
De Bruin ABH, Schmidt HG, Rikers RMJP. The Role of Basic Science Knowledge and Clinical Knowledge in Diagnostic Reasoning: A Structural Equation Modeling Approach.
Academic Medicine. 80(3): Aug 2004.
Adapted from Ambrose SA, et al. How Learning Works. San Francisco: Jossey-Bass, 2010. Print.
Sunday, March 9, 14
(Saeed):
The intermediate clinician- perhaps a D4 in the last 6 months of training- has presumably made some progress.
This student now has some clinical experiences under his belt, which allows him to start incorporating clinical experience, along with didactic knowledge, into his
knowledge “dots.”
He also starts building more elaborate networks between these PREVIOUSLY isolated bits of knowledge.
He starts seeing how diagnosis is related to treatment planning. He starts seeing how oral home care and xerostomia are related to caries risk. He starts seeing
how patients with diabetes often have root caries.
Clinical Reasoning
Expert = Pattern Recognition
clinical
patterns
De Bruin ABH, Schmidt HG, Rikers RMJP. The Role of Basic Science Knowledge and Clinical Knowledge in Diagnostic Reasoning: A Structural Equation Modeling Approach.
Academic Medicine. 80(3): Aug 2004.
Adapted from Ambrose SA, et al. How Learning Works. San Francisco: Jossey-Bass, 2010. Print.
Sunday, March 9, 14
(Saeed):
The expert clinician has organized information into schemas or patterns. The expert relies much more heavily on pattern recognition and the knowledge networks
she’s created based on her clinical experiences. The expert tends to forget the basic science knowledge because it becomes less relevant in her day-to-day
practice.
Why is this important to understand the differences in knowledge networks? As expert clinicians who are training novices, if we do not maintain some current
knowledge of basic sciences, dental materials, etc, we will have a hard time helping our students wrap the clinical experiences into their knowledge “dots” and
enrich the networks between them.
One of the ways we get the students from where they are to where we are is by promoting critical thinking.
So how do we identify which students already have this skill set?
Critical Thinking Abilities
1. Focus on a question
2. Analyze arguments
3. Ask and answer questions of clarification
and/or challenge
4. Judge the credibility of a source
5. Deduce
Ennis R. A Super-Streamlined Conception of Critical Thinking. www.criticalthinking.com/articles.html. 20 June 2002.
Sunday, March 9, 14
(Dellinges):
There are many published qualities of a critical thinker. Here are five that may be of importance in education. (read slide)
If a student doesn’t exhibit these, they should be flagged EARLY in their education to focus on developing those skills.
Promoting Thinking
“...if we want to ask questions that
get students thinking, then we have
to think about questions we are
going to ask...”
Brown & Atkins
Sunday, March 9, 14
(Dellinges):
In addition to flagging students, we have to make sure the culture of our learning environment supports critical thinking.
Such an environment is one in which it is okay for faculty AND students to ask questions of each other... in a mutually respectful manner.
We also need to put more time into building our tests, deciding how we assess our students.
This quote sums it up nicely... (read slide)
Promoting Thinking
Asking questions
Listening
Responding
Explaining
Expecting Prior
Preparation
Gaining
understanding
Critical thinking
Reasoning
Problem solving
Decision making
Creative thinking
Edmunds S, Brown G. Effective Small Group Learning: AMEE Guide No 48. Medical Teacher. 23: 715-726. 2010.
Sunday, March 9, 14
(Saeed):
So what do we do with students who come to us with inadequate critical thinking skills?
We have to...
- ask questions
- listen to their responses
- respond to them in ways that stimulate more reflection
- explain, when needed, by using analogies and relating to previous experiences
- and consistently expect them to prepare for their learning activities.
By making some of these small shifts in our teaching, we will help the student...
- gain understanding, critical thinking, clinical reasoning, problem solving, decision-making, and creative thinking skills.
Promoting Thinking
DEPTH of LEARNING
Answer
Justification for Answer
Evidence supporting Justification
Sunday, March 9, 14
(Saeed): (depth of knowledge)
Say I have a student who is planning to cement a gold crown.
She asks me which cement she should use.
I can approach this in one of two ways.
- I can tell her which cement I want her to use.
- Or I can ask her what she would do if I weren’t there. I can then ask her to justify her answer and provide evidence for it.
- If her answer is consistent with mine and her reasoning is correct, we’ve had a great learning experience, that allowed me to see her line of logic, not just the
final answer.
- If her answer is different from mine but she has justified her reasoning and it makes sense, she can see that dentistry is not just “right and wrong” answers, but
that it is about knowing what you’re doing and being able to justify your decisions.
- If she is completely off, you might just have to tell her what to use, and then debrief with her after the session.
Promoting students to “think aloud,” or “talk me through your thought process” increases depth of learning.
Promoting Thinking
“The use of questions by the instructor as well as the
student is a key part of this method. Students should
learn through a discovery process where they ask
questions and seek the answers. Instead of providing
answers, the teacher serves as a guide or facilitator
for the process. Through the question and answer
process, students should develop new knowledge
while applying critical thinking and problem solving
skills.” Oderda GM, Zavod RM, Carter JT et al called “An Environmental Scan on the Status of Critical Thinking and Problem Solving Skills in Colleges/Schools of Pharmacy: Report of the
2009-2010 Academic Affairs Standing Committee” in Amer J of Pharm Ed 2010; 74(10) Article S6
Sunday, March 9, 14
(Saeed):
This is supported by a study published in 2010 on critical thinking, which states... (read slide)
Exercise
Watch video (5 minutes)
Handout (5 minutes)
Discuss in small groups (15 minutes)
Present to large group (15 minutes)
Sunday, March 9, 14
(Saeed):
Now we have a foundation of the differences between novice and expert clinicians, and we also have discussed why critical thinking is important in teaching
tomorrow’s dentist. [PASS OUT HANDOUT]
We’re going to watch a real-life teaching encounter in the pre-clinical laboratory at UCSF to see how well we’re doing with promoting critical thinking in our
students. While you’re watching, we want you to focus on a few things, listed on your handout:
- is the learning environment safe for critical thinking?
- does the professor do a good job of promoting critical thinking?
- does the student do her part in terms of showing her thinking patterns?
- Were there missed opportunities to stimulate thinking?
After we watch the video together...
- Each of you will then spend 5 minutes working on the handout... individually.
- Then we’ll have a small group discussion at our table, and report back to the large group.
Ready for the video?
Sunday, March 9, 14
Exercise
Learning environment
Teaching methodology
Student learning
Sunday, March 9, 14
(Saeed):
So, spend 5 minutes working on the handout individually. (keep time)
Now we’ll ask you to spend 15 minutes at your table discussing what you thought.
Then we’ll ask you to report back to the large group and we’ll have a discussion.
(Saeed & Dellinges to lead discussion)
----------(Saeed)
Now we’re going to watch another learning encounter. This one is in the clinical environment. It’s a little hard to hear, so it’s subtitled as well.
We want you to focus on how this experience is different from the first. Was it better or worse in terms of understanding where the student lies in his learning?
What made it better or worse? Keep looking at your worksheet as a guide.
We won’t spend as much time on the discussion after this one.
Sunday, March 9, 14
(Dellinges):
So... what did you think?
(Facilitate discussion based on similar questions, but LARGE GROUP ONLY. (15 min max).
- So, what do you think? Did the first or second video do a better job of promoting critical thinking?
- How did the learning environment compare?
- How did the professors compare?
- How did the students compare?
Promoting Critical Thinking
Step 1: Set the tone of the learning environment
Settings:
morning huddle
debrief after procedure or at end of day
learning opportunities during the procedure
pull student to the side
Praise in Public, Perfect in Private
Sunday, March 9, 14
(Saeed):
Learning from the professor in the second video, we can see that there are a lot of opportunities for promoting critical thinking, even in the high-stakes clinical
environment when a patient is within earshot.
The first thing we have to do is set the tone of the learning environment.
Though we weren’t able to capture it on video, I know that the professor in the second video sets the tone before working with her students. She expects them to
be on-time, prepared, and put patient care above all else.
They KNOW that she will ask questions about the case, and they KNOW it’s okay to admit when they don’t know. She also role models this by admitting when
she does NOT have evidence to back up her clinical decisions.
Some faculty have morning huddles where they discuss patients in front of the group of students. Some debrief at the end of the session. Others, like in the
video, do the on-the-fly teaching during the appointment. Occasionally there will be times when a student is so ill-prepared or so off in his thinking that we have to
pull the student aside and have a discussion with them outside of the patient’s earshot and view.
Part of building an environment that is safe for critical thinking is praising the student in public, and perfecting the student in private.
Promoting Critical Thinking
Step 2: Asking the right questions
“think aloud”
“talk me through your thought process”
“what do you think?” / “why do you think that?”
“have you considered alternatives X and Y?”
“how is amalgam retained?” “do you have retention?”
Sunday, March 9, 14
(Saeed):
After we set the tone of the learning environment, we have to ask the right questions...
Start with open-ended questions like “can you think aloud for me” or “talk me through your thought process” or “what do you think?”
This helps to identify if the whole reasoning pathway is correct or if they just made a lucky guess.
If they are still struggling, you can ask more leading or close-ended or prompting questions. (e.g. on slide)
Some learners- particularly introverts- taking a longer time to recall from long-term memory. Once activated, they tend to do okay. Allow for SILENCE and time to
THINK.
Macroscopic Changes
•
Curriculum change
•
Changing the way we test or assess our
students
•
How well do we address the changes in
the accreditation standards?
Sunday, March 9, 14
(Dellinges):
Those were some simple, practical ways to make changes in your day-to-day teaching, no matter what your role is at your institution. If you teach students, YOU
have the power to promote critical thinking.
From the higher level, if any of you are involved with curriculum efforts at your institutions, there are opportunities for more macroscopic changes: promoting
critical thinking from day one in lectures, small groups, and large group settings, training your faculty in biomedical sciences, statistics, pre-clinical simulation, and
direct patient care. YOU can change the culture of your institution from the top down.
We also need to find ways to assess how well we’re teaching this skill to our students so that we can document it for our accreditation.
One of the things I’ve been looking at is ways we might provide evidence that we are incorporating the new CODA standards for critical thinking into our
curriculum.
Assessment of
Critical Thinking Skills
5 Clinical Scenarios
Wright Map
4 Questions Each
Questions Asked For
•
Knowledge
•
Justification
•
Evidence
Sunday, March 9, 14
(Dellinges):
I gave a written open-ended mock exam to 4th year dental students. It contained 5 clinical scenarios and each scenario asked four questions. Each question asked
for a response that would indicate the students level of critical thinking based on knowledge, justification and evidence to distinguish options. From this map of the
responses you can see that the students had the knowledge and could justify it but they had trouble supplying evidence for their answers. If the CODA Standards
require that schools ensure that students are competent critical thinkers we might have to look at either how we are teaching our students or how they are being
assessed.
What change will you make
to the teaching & learning
experiences you share with
your students?
The Collected Works of Mahatma Gandhi. Volume 13, Chapter 153.
Sunday, March 9, 14
(Saeed)
Before you leave today, we want you to think of at least one change you’re going to make to your teaching when you get back to your institution.
Some of you are administrators who can make macroscopic changes, others are “in-the-trenches” faculty. Each of you can make a difference.
Anyone want to share a change they’re planning to make? Or maybe something you already do that will help stimulate more creative ideas?
Summary
Novice vs. Expert in clinical reasoning
Asking questions → Greater depth of learning
Changes in our teaching and learning
Sunday, March 9, 14
(Saeed)
We spent a good amount of time looking at the differences between novices and experts in the way they make clinical decisions. We talked about why it’s
important for experts to understand the novice’s thinking patterns to help enrich the way their knowledge networks grow.
We talked about how critical thinking leads to greater depth of learning.
And we also talked about some minor and major changes we can make to promote critical thinking in our learners and learning environment.
References
Facione PA. Critical Thinking: a statement of expert consensus for purposes of
educational assessment and instruction. Millbrae, CA. The California Academic Press,
1990: 2.
De Bruin ABH, Schmidt HG, Rikers RMJP. The Role of Basic Science Knowledge and
Clinical Knowledge in Diagnostic Reasoning: A Structural Equation Modeling Approach.
Academic Medicine. 80(3): Aug 2004.
Supporting medical students‘ workplace learning: Experience-based Learning (ExBL).
The Clinical Teacher. 2009; 6: 167-171.
Critical Thinking Skills Toolbox. ADEA Commission on Change and Innovation in Dental
Education. http://www.adea.org/adeacci/Resources/Critical-Thinking-Skills-Toolkit/Pages/
default.aspx Accessed 27 Aug 2012.
Ennis R. A Super-Streamlined Conception of Critical Thinking.
www.criticalthinking.com/articles.html. 20 June 2002.
Edmunds S, Brown G. Effective Small Group Learning: AMEE Guide No 48. Medical
Teacher. 23: 715-726. 2010.
Sunday, March 9, 14
(Saeed)
Here are our references.
We thank you very much for your time.
We’ll stick around if anyone wants to have further discussion!