Harvard Academy
Education Day
Mark Quirk, Ed.D.
Professor and Assistant Dean
University of Massachusetts
Medical School

Participants will be able to . . .
1.
Appreciate the ‘knowledge dilemma’ in medical education
2. Identify the components of critical thinking
3. Describe intuition and metacognition and their importance to critical thinking
4. Identify educational strategies that enhance metacognition

“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

Taylor, N Engl J Med 1992

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

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

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
Excerpt from: Upon this age
Edna St Vincent Millay 1939

Reasonable reflective thinking focused on what to believe or do
R. Ennis, Theory into Practice, 1993

Analysis; Compare and Contrast
Clarify and
Question; Recognize
Ambiguity
Independent,
Self-confident, Open-minded, Creative


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

22 March 2005 11

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

Anticipating
/planning
Problem Experience
Reflecting/c hecking/
Solutions
Monitoring/regulating/self
-assessing/perspectivetaking

Unconscious
Deliberate
Conscious
Quirk, M 2006;
Croskerry, 2009
Rapid

 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’

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!

 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

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

“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, Acad Med 2002

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

 50 year old man with multiple trauma
(MVC) – Level 1
 Excellent resident – Attendings want to work with this resident
 Patient begins to crash

Power of Simulation
HR
SpO
2
HR
SpO
2
185/145
(158)
• Resident orders Atropine -- was perfect until this moment

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

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 and another doctor on call had recommended Advil
• But the pain persisted
• At this visit o Shoulder and cardiac exam 100% normal o ECG normal

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

Unconscious
Deliberate
Conscious
M Quirk 2006
Rapid


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

 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

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:
** Took twice as long
1. Learner Questions (most effective) **
2. Teacher Questions (2 nd )
3. Re-read only (least effective)
Weinstein, McDermott & Roediger,
J Exp Psych Appl 2010

Study 2. Pause for Reflection (Lecture)
If we talk 6 minutes less students learn more
Methods Pause :
1. Two minutes (12-18 minute intervals)
2. Student dyads to reflect
3. No teacher interaction
4. Control group
5. Repeated two courses
Outcome Assessment: a. Immediate free recall b. 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,

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 computerbased learning environments.”
Atkinson, RK J Educ Psych 2003

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/Delibe rate Reflection )

Teaching Styles: Emphasis on Metacognition
Reliance on Teacher Reliance on Learner

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

Power of Simulation
HR
SpO
2
HR
SpO
2
185/145
(158)
• Resident orders Atropine -- was perfect until this moment

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).

Power of Simulation
 “What would you do differently next time?”
 “What are the alternatives?”

Simulation Training: Team Perspective
Trauma Bay: MVA – 70 yr old woman with multiple trauma

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 decisionmaking and clarified her role.
 Avoided visceral bias (influence of affective sources of error on decision-making) by reflecting.

1. Critical thinking is reasonable reflective thinking focused on what to believe or do
2. Metacognition is critically thinking about thinking
3. Teaching and practicing deliberate reflection improve metacognition
4. Positive outcomes include greater selfawareness, fewer diagnostic errors, more effective teamwork, greater self-directed learning and improved physician-patient relations

Medical
Knowledge
Patient
Care
Professionalism
Interpersonal and
Communication
Skills
System-based
Practice
Practice-based
Learning

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

“If you don’t know where you are going you might end up someplace else”