Critical thinking: A core skill within education and healthcare

This is a co-publication with the British Medical Journal (BMJ), first published in May 2017 (BMJ 357: J2234)

Education and healthcare intersect in important ways, paving the way for exciting cross-sector collaborations. Critical thinking – the ability to think clearly and rationally about what to do or what to believe – is an essential skill that crosses both domains. Few doctors or teachers are likely to argue with this. Yet, until recently, the UK regulator, the General Medical Council, and similar bodies in North America did not mention ‘critical thinking’ anywhere in their standards for licensing and accreditation, and critical thinking is not explicitly taught or assessed in most education programmes for health professionals.

In this article, we argue that it is important for teachers, clinicians, patients and students to learn to think critically, and that teaching and learning these skills should be considered explicitly. We examine why and how education and healthcare professionals should work together to enable people to think critically, and highlight the emergence of collaborative projects that show promise in achieving this goal.

What is critical thinking and critical appraisal, and why are these skills and dispositions essential for doctors and patients?

In education, critical thinking is not a new concept: at the beginning of the last century Dewey identified the need to help students to ‘think well’ (Dewey, 1910). Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (e.g. analysis, inference and self-regulation); approaches to specific questions or problems (e.g. orderliness, diligence and reasonableness); and approaches to life in general (e.g. inquisitiveness, concern with being well informed, and open-mindedness) (Facione, 1990). An increasing body of evidence highlights the benefits of developing critical thinking skills, in terms of academic outcomes as well as wider reasoning and problem solving capabilities (Higgins et al., 2016). For example, ‘Thinking, Doing, Talking Science’ is a programme that trains teachers in a repertoire of strategies that encourages students to use critical thinking skills in primary science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on students’ science attainment, with signs that it was particularly beneficial for students from low-income families (Hanley et al., 2015).

In medicine, increasing attention has been paid to ‘critical appraisal’ over the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions (Sackett, 1981). The need for critical appraisal in medicine was recognised at least 75 years ago (Rynearson, 1940), and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. For example, when outlining the skills needed by Tomorrow’s doctors in 1993, the GMC made specific reference to the need for future doctors to be able to critically appraise the results of studies (GMC, 1993). More recently, the GMC’s Good medical practice guidance includes the need for doctors to be able to ‘provide effective treatments based on the best available evidence’ (GMC, 2013). The ability to think critically is correlated with academic success in medical education (Ross et al., 2016).

If patients and the public are to make well-informed health choices, they must also be able to assess the reliabilityIn assessment, the degree to which the outcome of a particul of health claims and information, regardless of whether they come from doctors or other sources. This is something that most people struggle to do, and it is becoming increasingly important as patients are empowered to manage their health both inside and outside of healthcare settings (Edwards and Elwyn, 2009), while needing to cope with more and more health information, much of which is not reliable (Schwartz et al., 2012).

Why is it important to consider critical thinking and critical appraisal skills explicitly?

Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curricula for primary and secondary schools (Voogt and Roblin, 2012). Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking (National Research Council, 2007; Nordheim et al., 2016). This shortcoming is important, as the ability to think critically is an essential life skill relevant to decision-making in a wide range of circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for students who live in homes where they are encouraged to think and talk about what they are doing, which, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the ‘critical thinking gap’ between students from disadvantaged communities and their more advantaged peers requires explicit attention as early as possible.

While it is possible to teach critical thinking to wider and mature audiences, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, beginning in primary school. Erroneous beliefs, attitudes and behaviours developed during childhood may be resistant to change later. This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on, and adequate time to learn them (as medical students, doctors, patients or the public).

Strategies for teaching students to think critically have been evaluated in health and medical education, in science, technology, engineering and math (STEM) subjects, and in non-STEM subjects (Abrami et al., 2015). These studies suggest that there are effective strategies for teaching critical thinking skills and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically (Ross et al., 2016).

Evaluations of strategies for teaching critical thinking in medicine have focused primarily on teaching critical appraisal skills, as a component of evidence-based healthcare. An overview of systematic reviews of these studies suggests that improving evidence-based healthcare competencies is likely to require multifaceted, clinically integrated approaches, with assessment as a component (Young et al., 2014).

Why and how should education and healthcare work together to enable people to think critically about health choices?

The Informed Health Choices (IHC) project provides a good illustration of the opportunities and benefits of cross-sector collaboration between education and health (www.informedhealthchoices.org). This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about ‘treatment’ claims; that is, claims about the effects of any action intended to improve health. It aims to develop, identify and promote the use of effective learning resources, beginning at primary school, to help people to make well-informed personal choices as patients and health professionals, and well-informed decisions as citizens and policy-makers.

The IHC project has drawn on several approaches used in education, including the development of a ‘spiral curriculum’, measurement tools and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals (Harden and Stamper, 1999). The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games (Sandoval et al., 2014). On the other hand, the IHC project has built on the traditions of clinical epidemiology and evidence-based medicine, in identifying the key concepts that need to be learned and applied to assessing treatment claims.

It is difficult to teach critical thinking abstractly; thus, focusing on health may have advantages beyond the public health benefits of increasing health literacy (Berkman et al., 2011). Firstly, nearly everyone is interested in health, including children, making it easy to engage learners. Secondly, it is immediately relevant to students. As reported by one 10-year-old in a school that piloted the IHC primary school resources, this is about ‘things we might actually use instead of things we might use when we are all grown up and by then we’ll forget’. While the current evaluation of the IHC project is focusing on outcomes relating to appraisal of treatment claims, a next step, if the intervention shows promise, could be to explore how these skills translate to wider educational contexts and outcomes.

Collaboration between education and healthcare beyond critical thinking

As this article highlights, exciting opportunities for cross-sector collaboration are emerging between healthcare and education. And while critical thinking is a useful example of this, there are other themes that cross the education and healthcare domains – such as nutrition, exercise, neuro-education, learning disabilities and special education needs, and mental health – where more extensive partnerships could also be explored.

In addition to shared topics, there are a range of common methodological and conceptual issues that also provide opportunities to cross-fertilise ideas and innovations, and learning from mistakes and successes. For example, discussions hosted by the Education Endowment Foundation (EEF), the UK government’s ‘What Works Centre’ for education, are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors. Similarly, the EEF’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted and applied in healthcare. By separating development and evaluation, evaluators have no vested interest in the results of the assessment, all results are published, and bias and spin in the analysis and presentation of results are reduced. In contrast, industry sponsorship of drug and device studies has consistently demonstrated results that favour the manufacturer (Lundh, 2012).

Further discussion is required to explore these opportunities in detail, and for practical applications in our respective fields. The Best Evidence Medical Education Collaboration is an example of a collaboration between education and healthcare with a specific focus on improving health professional education (Thistlethwaite and Hammick, 2010). ‘Evidence IN School TEachINg’ (EinSTein) is a project that supports introducing evidence-based medicine as part of the wider science activities in schools. It aims to engage students, teachers and the public in evidence-based medicine and develop critical thinking to assess health claims and make better choices. In May this year, the Royal College of Paediatrics and Child Health and the EEF co-hosted an event that will focus on their shared interest in critical thinking and appraisal skills. Underpinning these discussions has been the development of the Critical thinking and Appraisal Resource Library (CARL) (Castle et al., 2017), a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently underway at the EEF.

An example of wider collaboration is the Global Evidence Summit in September 2017, which will bring together people interested in improving the use of evidence to improve lives across healthcare, education, and other sectors (http://globalevidencesummit.org).

Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners and the public can all benefit from working together to help people to think critically about the choices they make.

Contributors

This paper reflects conclusions from a series of discussions during 2016, involving education researchers and health service researchers exploring opportunities for cross-sector collaboration and learning. This group includes individuals with a longstanding interest in evidence-informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation and critical thinking/appraisal.

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