critical thinking questions medicine

Medical Student Guide For Critical Thinking

Critical thinking is an essential cognitive skill for every individual but is a crucial component for healthcare professionals such as doctors, nurses and dentists. It is a skill that should be developed and trained, not just during your career as a doctor, but before that when you are still a medical student.

To be more effective in their studies, students must think their way through abstract problems, work in teams and separate high quality from low quality information. These are the same qualities that today's medical students are supposed to possess regardless of whether they graduate in the UK or study medicine in Europe .

In both well-defined and ill-defined medical emergencies, doctors are expected to make competent decisions. Critical thinking can help medical students and doctors achieve improved productivity, better clinical decision making, higher grades and much more.

This article will explain why critical thinking is a must for people in the medical field.

Definition of Critical Thinking

You can find a variety of definitions of Critical Thinking (CT). It is a term that goes back to the Ancient Greek philosopher Socrates and his teaching practice and vision. Critical thinking and its meaning have changed over the years, but at its core always will be the pursuit of proper judgment.

We can agree on one thing. Critical thinkers question every idea, assumption, and possibility rather than accepting them at once.

The most basic definition of CT is provided by Beyer (1995):

"Critical thinking means making reasoned judgements."

In other words, it is the ability to think logically about what to do and/or believe. It also includes the ability to think critically and independently. CT is the process of identifying, analysing, and then making decisions about a particular topic, advice, opinion or challenge that we are facing.

Steps to critical thinking

There is no universal standard for becoming a critical thinker. It is more like a unique journey for each individual. But as a medical student, you have already so much going on in your academic and personal life. This is why we created a list with 6 steps that will help you develop the necessary skills for critical thinking.

1. Determine the issue or question

The first step is to answer the following questions:

• What is the problem?
• Why is it important?
• Why do we need to find a solution?
• Who is involved?

By answering them, you will define the situation and acquire a deeper understanding of the problem and of any factors that may impact it.

Only after you have a clear picture of the issue and people involved can you start to dive deeper into the problem and search for a solution.

2. Research

Nowadays, we are flooded with information. We have an unlimited source of knowledge – the Internet.

Before choosing which medical schools to apply to, most applicants researched their desired schools online. Some of the areas you might have researched include:

• If the degree is recognised worldwide
• Tuition fees
• Living costs
• Entry requirements
• Competition for entry
• Number of exams
• Programme style

Having done the research, you were able to make an informed decision about your medical future based on the gathered information. Our list may be a little different to yours but that's okay. You know what factors are most important and relevant to you as a person.

The process you followed when choosing which medical school to apply to also applies to step 2 of critical thinking. As a medical student and doctor, you will face situations when you have to compare different arguments and opinions about an issue. Independent research is the key to the right clinical decisions. Medical and dentistry students have to be especially careful when learning from online sources. You shouldn't believe everything you read and take it as the absolute truth. So, here is what you need to do when facing a medical/study argument:

• Gather relevant information from all available reputable sources
• Pay attention to the salient points
• Evaluate the quality of the information and the level of evidence (is it just an opinion, or is it based upon a clinical trial?)

Once you have all the information needed, you can start the process of analysing it. It’s helpful to write down the strong and weak points of the various recommendations  and identify the most evidence-based approach.

Here is an example of a comparison between two online course platforms , which shows their respective strengths and weaknesses.

When recommendations or conclusions are contradictory, you will need to make a judgement call on which point of view has the strongest level of evidence to back it up. You should leave aside your feelings and analyse the problem from every angle possible. In the end, you should aim to make your decision based on the available evidence, not assumptions or bias.

4. Be careful about confirmation bias

It is in our nature to want to confirm our existing ideas rather than challenge them. You should try your best to strive for objectivity while evaluating information.

Often, you may find yourself reading articles that support your ideas, but why not broaden your horizons by learning about the other viewpoint?

By doing so, you will have the opportunity to get closer to the truth and may even find unexpected support and evidence for your conclusion.

Curiosity will keep you on the right path. However, if you find yourself searching for information or confirmation that aligns only with your opinion, then it’s important to take a step back. Take a short break, acknowledge your bias, clear your mind and start researching all over.

5. Synthesis

As we have already mentioned a couple of times, medical students are preoccupied with their studies. Therefore, you have to learn how to synthesise information. This is where you take information from multiple sources and bring the information together. Learning how to do this effectively will save you time and help you make better decisions faster.

You will have already located and evaluated your sources in the previous steps. You now have to organise the data into a logical argument that backs up your position on the problem under consideration.

6. Make a decision

Once you have gathered and evaluated all the available evidence, your last step  is to make a logical and well-reasoned conclusion.

By following this process you will ensure that whatever decision you make can be backed up if challenged

Why is critical thinking so important for medical students?

The first and most important reason for mastering critical thinking is that it will help you to avoid medical and clinical errors during your studies and future medical career.

Another good reason is that you will be able to identify better alternative options for diagnoses and treatments. You will be able to find the best solution for the patient as a whole which may be different to generic advice specific to the disease.

Furthermore, thinking critically as a medical student will boost your confidence and improve your knowledge and understanding of subjects.

In conclusion, critical thinking is a skill that can be learned and improved.  It will encourage you to be the best version of yourself and teach you to take responsibility for your actions.

Critical thinking has become an essential for future health care professionals and you will find it an invaluable skill throughout your career.

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Critical Thinking in medical education: When and How?

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Critical thinking in healthcare and education

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Critical thinking is an essential cognitive skill for the individuals involved in various healthcare domains such as doctors, nurses, lab assistants, patients and so on, as is emphasized by the Authors. Recent evidence suggests that critical thinking is being perceived/evaluated as a domain-general construct and it is less distinguishable from that of general cognitive abilities [1].

People cannot think critically about topics for which they have little knowledge. Critical thinking should be viewed as a domain-specific construct that evolves as an individual acquires domain-specific knowledge [1]. For instance, most common people have no basis for prioritizing patients in the emergency department to be shifted to the only bed available in the intensive care unit. Medical professionals who could thinking critically in their own discipline would have difficulty thinking critically about problems in other fields. Therefore, ‘domain-general’ critical thinking training and evaluation could be non-specific and might not benefit the targeted domain i.e. medical profession.

Moreover, the literature does not demonstrate that it is possible to train universally effective critical thinking skills [1]. As medical teachers, we can start building up student’s critical thinking skill by contingent teaching-learning environment wherein one should encourage reasoning and analytics, problem solving abilities and welcome new ideas and opinions [2]. But at the same time, one should continue rather tapering the critical skills as one ascends towards a specialty, thereby targeting ‘domain-specific’ critical thinking.

For the benefit of healthcare, tools for training and evaluating ‘domain-specific’ critical thinking should be developed for each of the professional knowledge domains such as doctors, nurses, lab technicians and so on. As the Authors rightly pointed out, this humongous task can be accomplished only with cross border collaboration among cognitive neuroscientists, psychologists, medical education experts and medical professionals.

References 1. National Research Council. (2011). Assessing 21st Century Skills: Summary of a Workshop. J.A. Koenig, Rapporteur. Committee on the Assessment of 21st Century Skills. Board on Testing and Assessment, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. 2. Mafakheri Laleh M, Mohammadimehr M, Zargar Balaye Jame S. Designing a model for critical thinking development in AJA University of Medical Sciences. J Adv Med Educ Prof. 2016 Oct;4(4):179–87.

Competing interests: No competing interests

Critical thinking in clinical medicine: what is it?

Affiliation.

• 1 Department of Psychiatry, University of Montreal, Montreal, PQ, Canada. [email protected]
• PMID: 22994988
• DOI: 10.1111/j.1365-2753.2012.01897.x

In this paper, we explore the recent emphasis, in various medical contexts, of the term 'critical' or the notion of 'being critical'. We identify various definitions of being critical and note that they differ strikingly. What are these different uses of the term trying to capture that is important in clinical medicine and medical education? We have analysed these qualities as responsibilist, epistemic virtues. We believe that a virtues approach is best able to make sense of the non-cognitive elements of 'being critical', such as the honesty and courage to question claims in the face of persuasion, authority or social pressure. Medical educators and professional bodies seem to agree that being critical is important and desirable. Yet, it is unclear how this quality can be optimally fostered and balanced with the constraints that act upon individual practitioners in the context of institutional medicine including professional standards and the demands of the doctor-patient relationship. Other constraints such as authoritarianism, intimidation and financial pressures may act against the expression of being critical or even the cultivation of critical thinking. The issue of the constraints on critical thinking and the potential hazards it entails will require further consideration by those who encourage being critical in medicine.

© 2012 Blackwell Publishing Ltd.

• Antidepressive Agents / adverse effects
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• Antidepressive Agents

Science-Based Medicine

Exploring issues and controversies in the relationship between science and medicine

Critical Thinking in Medicine

Cognitive Errors and Diagnostic Mistakes is a superb new guide to critical thinking in medicine written by Jonathan Howard. It explains how our psychological foibles regularly bias and betray us, leading to diagnostic mistakes. Learning critical thinking skills is essential but difficult. Every known cognitive error is illustrated with memorable patient stories.

Rodin’s Thinker is doing his best to think but if he hasn’t learned critical thinking skills, he is likely to make mistakes. The human brain is prone to a multitude of cognitive errors.

Critical thinking in medicine is what the Science-Based Medicine ( SBM ) blog is all about. Jonathan Howard has written a superb book, Cognitive Errors and Diagnostic Mistakes: A Case-Based Guide to Critical Thinking in Medicine , that epitomizes the message of SBM . In fact, in the Acknowledgements, he credits the entire team at SBM for teaching him “an enormous amount about skepticism and critical thinking”, and he specifically thanks Steven Novella, Harriet Hall (moi!), and David Gorski.

Dr. Howard is a neurologist and psychiatrist at NYU and Bellevue Hospital. The book is a passionate defense of science and a devastating critique of Complementary and Alternative Medicine ( CAM ) and pseudoscience. Its case-based approach is a stroke of genius. We humans are story-tellers; we are far more impressed by stories than by studies or by textbook definitions of a disease. Dr. Howard points out that “Anecdotes are part of the very cognition that allows us to derive meaning from experience and turn noise into signal.” They are incredibly powerful from an emotional standpoint. That’s why he chose to begin every discussion of a cognitive error with a patient’s case, an anecdote.

CAM knows how effective this can be; that’s why it relies so heavily on anecdotes. When doctors think of a disease, they are likely to think of a memorable patient they treated with that disease, and that patient’s case is likely to bias their thinking about other patients with the same disease. If there is a bad outcome with a treatment, they will remember that and may reject that treatment for the next patient even if it is the most appropriate one. Dr. Howard uses patient stories to great advantage, first providing the bare facts of the case and then letting the patient’s doctors explain their thought processes so we can understand exactly where and why they went wrong. Then he goes on to explain the psychology behind the cognitive error, with study findings, other examples, and plentiful references. If readers remember these cases, they might avoid similar mishaps.

An encyclopedia of cognitive errors

The book is encyclopedic, running to 30 chapters and 588 pages. I can’t think of anything he failed to mention, and whenever an example or a quotation occurred to me, he had thought of it first and included it in the text. I couldn’t begin to list all the cognitive errors he covers, but they fall roughly into these six categories:

• Errors of overattachment to a particular diagnosis
• Errors due to failure to consider alternative diagnoses.
• Errors due to inheriting someone else’s thinking.
• Errors in prevalence perception or estimation.
• Errors involving patient characteristics or presentation context.
• Errors associated with physician affect, personality, or decision style.

A smattering of examples

There is so much information and wisdom in this book! I’ll try to whet your appetite with a few excerpts that particularly struck me.

• Discussing an issue with others who disagree can help us avoid confirmation bias and groupthink.
• Negative panic: when a group of people witness an emergency and fail to respond, thinking someone else will.
• Reactance bias: doctors who object to conventional practices and want to feel independent may reject science and embrace pseudoscience.
• Cyberchondria: using the Internet to interpret mundane symptoms as dire diagnoses.
• Motivated reasoning: People who “know” they have chronic Lyme disease will fail to believe 10 negative Lyme tests in a row and then believe the 11 th test if it is positive.
• The backfire effect: “encountering contradictory information can have the paradoxical effect of strengthening our initial belief rather than causing us to question it.”
• Biases are easy to see in others but nearly impossible to detect in oneself.
• Checklists for fake diseases take advantage of the Forer effect . As with horoscopes and cold readings, vague, nonspecific statements convince people that a specific truth about them is being revealed. Fake diseases are unfalsifiable: there is no way to rule them out.
• When presenting risk/benefit data to patients, don’t present risk data first; it will act as an “anchor” to make them fixate on risk.
• The doctor’s opinion of the patient will affect the quality of care.
• Randomness is difficult to grasp. The hot hand and the gambler’s fallacy can both fool doctors. If the last two patients had disease X and this patient has similar symptoms, the doctor will think he probably has disease X too. Or if the doctor has just seen two cases of a rare disease, it will seem unlikely that the next patient with similar symptoms will have it too.
• Apophenia : the tendency to perceive meaningful patterns with random information, like seeing the face on Mars.
• Information bias: doctors tend to think the more information, the better. But tests are indicated only if they will help establish a diagnosis or alter management. They should not be ordered out of curiosity or to make the clinician feel better. Sometimes doctors don’t know what to do with the information from a test. This should be a lesson for doctors who practice so-called functional medicine : they order all kinds of nonstandard tests whose questionable results give no evidence-based guidance for treating the patient. Doctors should ask “How will this test alter my management?” and if they can’t answer, they shouldn’t order the test.
• Once a treatment is started, it can be exceedingly difficult to stop. A study showed that 58% of medications could be stopped in elderly patients and only 2% had to be re-started.
• Doctors feel obligated to “do something” for the patient, but sometimes the best course is to do nothing. “Just don’t do something, stand there.” At the end of their own life, 90% of doctors would refuse the treatments they routinely give to patients with terminal illnesses.
• Incidentalomas: when a test reveals an unsuspected finding, it’s important to remember that abnormality doesn’t necessarily mean pathology or require treatment.
• Fear of possible unknown long-term consequences may lead doctors to reject a treatment, but that should be weighed carefully against the well-known consequences of the disease itself.
• It’s good for doctors to inform patients and let them participate in decisions, but too much information can overwhelm patients. He gives the example of a patient with multiple sclerosis whose doctor describes the effectiveness and risks of 8 injectables, 3 pills, and 4 infusions. The patient can’t choose; she misses the follow-up appointment and returns a year later with visual loss that might have been prevented.
• Most patients don’t benefit from drugs; the NNT tells us the Number of patients who will Need to be Treated for one person to benefit.
• Overconfidence bias: in the Dunning-Kruger effect, people think they know more than the experts about things like climate change, vaccines and evolution. Yet somehow these same people never question that experts know how to predict eclipses.
• Patient satisfaction does not measure effectiveness of treatment. A study showed that the most satisfied patients were 12% more likely to be admitted to the hospital, had 9% higher prescription costs, and were 26% more likely to die.
• The availability heuristic and the frequency illusion: “Clinicians should be aware that their experience is distorted by recent or memorable [cases], the experiences of their colleagues, and the news.” He repeats Mark Crislip’s aphorism that the three most dangerous words in medicine are “in my experience”.
• Illusory truth: people are likely to believe a statement simply because they have heard it many times.
• What makes an effective screening test? He covers concepts like lead time bias, length bias, and selection bias. Screening tests may do more harm than good. The PSA test is hardly better than a coin toss.
• Blind spot bias: Everyone has blind spots; we recognize them in others but can’t see our own. Most doctors believe they won’t be influenced by gifts from drug companies, but they believe others are unconsciously biased by such gifts. Books like this can make things worse: they give us false confidence. “Being inclined to think that you can avoid a bias because you [are] aware of it is a bias in itself.”
• He quotes from Contrived Platitudes: “Everything happens for a reason except when it doesn’t. But even then you can in hindsight fabricate a reason that will satisfy your belief system.” This is the essence of what CAM does, especially the versions that attribute all diseases to a single cause.

Some juicy quotes

Knowledge of bias should contribute to your humility, not your confidence.

Only by studying treatments in large, randomized, blinded, controlled trials can the efficacy of a treatment truly be measured.

When beliefs are based in emotion, facts alone stand little chance.

CAM , when not outright fraudulent, is nothing more than the triumph of cognitive biases over rationality and science.

Reason evolved primarily to win arguments, not to solve problems.

He includes a thorough discussion of the pros and cons of limiting doctors’ work hours, with factors most people have never considered, and a thorough discussion of financial motivations.

The book is profusely illustrated with pictures, diagrams, posters, and images from the Internet like “The Red Flags of Quackery” from sci-ence.org. Many famous quotations are presented with pictures of the person quoted, like Christopher Hitchens and his “What can be asserted without evidence can be dismissed without evidence”.

He never goes beyond the evidence. Rather than just giving study results, he tells the reader when other researchers have failed to replicate the findings.

We rely on scientific evidence, but researchers are not immune from bias. He describes the many ways research can go astray: 235 biases have been identified that can lead to erroneous results. As Ioannidis said, most published research findings are wrong. But all is not lost: people who understand statistics and the methodologies of science can usually distinguish a good study from a bad one.

He tells the infamous N-ray story. He covers the file drawer effect, publication bias, conflicts of interest, predatory journals, ghostwriting, citation plagiarism, retractions, measuring poor surrogates instead of meaningful clinical outcomes, and outright fraud. Andrew Wakefield features prominently. Dr. Howard’s discussions of p-hacking, multiple variables, random chance, and effect size are particularly valuable. HARKing is Hypothesizing After the Results are Known. It can be exploited to create erroneous results.

He tells a funny story that was new to me. Two scientists wrote a paper consisting entirely of the repeated sentence “Get me off your fucking mailing list” complete with diagrams of that sentence. It was rated as excellent and was accepted for publication!

Conclusion: Well worth reading for doctors and for everyone else

As the book explains, “The brain is a self-affirming spin-doctor with a bottomless bag of tricks…” Our brains are “pattern-seeking machines that fill in the gaps in our perception and knowledge consistent with our expectations, beliefs, and wishes”. This book is a textbook explaining our cognitive errors. Its theme is medicine but the same errors occur everywhere. We all need to understand our psychological foibles in order to think clearly about every aspect of our lives and to make the best decisions. Every doctor would benefit from reading this book, and I wish it could be required reading in medical schools. I wish everyone who considers trying CAM would read it first. I wish patients would ask doctors to explain why they ordered a test.

The book is not inexpensive. The price on Amazon is $56.99 for both softcover and Kindle versions. But it might be a good investment: you might save much more money that that by applying the principles it teaches, and critical thinking skills might even save your life. Well-written, important, timely, easy, and entertaining to read, lots of illustrations, packed with good stuff. Highly recommended.

Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, Women Aren't Supposed to Fly .

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• Posted in: Book & movie reviews , Critical Thinking , Neuroscience/Mental Health , Science and Medicine
• Tagged in: bias , CAM , cognitive errors , diagnostic mistakes , Jonathan Howard

Posted by Harriet Hall

Fallacies in Medicine and Health pp 1–28 Cite as

Critical Thinking in Medicine and Health

• Louise Cummings 2  
• First Online: 01 March 2020

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1 Citations

This chapter addresses why there is a need for experts and lay people to think critically about medicine and health. It will be argued that illogical, misleading, and contradictory information in medicine and health can have pernicious consequences, including patient harm and poor compliance with health recommendations. Our cognitive resources are our only bulwark to the misinformation and faulty logic that exists in medicine and health. One resource in particular—reasoning—can counter the flawed thinking that pervades many medical and health issues. This chapter examines how concepts such as reasoning, logic and argument must be conceptualised somewhat differently (namely, in non-deductive terms) to accommodate the rationality of the informal fallacies. It also addresses the relevance of the informal fallacies to medicine and health and considers how these apparently defective arguments are a source of new analytical possibilities in both domains.

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Chapter Summary

Medicine and health have tended to be overlooked in the critical thinking literature . And yet robust critical thinking skills are needed to evaluate the large number and range of health messages that we are exposed to on a daily basis.

An ability to think critically helps us to make better personal health choices and to uncover biases and errors in health messages and other information. An ability to think critically allows us to make informed decisions about medical treatments and is vital to efforts to reduce medical diagnostic errors.

A key element in critical thinking is the ability to distinguish strong or valid reasoning from weak or invalid reasoning. When an argument is weak or invalid, it is called a ‘fallacy’ or a ‘fallacious argument’.

The informal fallacies are so-called on account of the presence of epistemic and dialectical flaws that cannot be captured by formal logic . They have been discussed by many generations of philosophers and logicians , beginning with Aristotle .

Historically, philosophers and logicians have taken a pejorative view of the informal fallacies. Much of the criticism of these arguments is related to a latent deductivism in logic , the notion that arguments should be evaluated according to deductive standards of validity and soundness . Against deductive standards and norms, many reasonable arguments are judged to be fallacies.

Developments in logic , particularly the teaching of logic, forced a reconsideration of the prominence afforded to deductive logic in the evaluation of arguments. New criteria based on presumptive reasoning and plausible argument started to emerge. Against this backdrop, non-fallacious variants of most of the informal fallacies began to be described for the first time.

Today, some argument analysts characterize non-fallacious variants of the informal fallacies in terms of cognitive heuristics . During reasoning , these heuristics function as mental shortcuts, allowing us to bypass knowledge and come to judgement about complex health problems.

Suggestions for Further Reading

Sharples, J. M., Oxman, A. D., Mahtani, K. R., Chalmers, I., Oliver, S., Collins, K., Austvoll-Dahlgren, A., & Hoffmann, T. (2017). Critical thinking in healthcare and education. British Medical Journal, 357 : j2234. https://doi.org/10.1136/bmj.j2234 .

The authors examine the role of critical thinking in medicine and healthcare, arguing that critical thinking skills are essential for doctors and patients. They describe an international project that involves collaboration between education and health. Its aim is to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health.

Hitchcock, D. (2017). On reasoning and argument: Essays in informal logic and on critical thinking . Cham: Switzerland: Springer.

This collection of essays provides more advanced reading on several of the topics addressed in this chapter, including the fallacies, informal logic , and the teaching of critical thinking . Chapter 25 considers if fallacies have a place in the teaching of critical thinking and reasoning skills.

Hansen, H. V., & Pinto, R. C. (Eds.). (1995). Fallacies: Classical and contemporary readings . University Park: The Pennsylvania State University Press.

This edited collection of 24 chapters contains historical selections on the fallacies, contemporary theory and criticism, and analyses of specific fallacies. It also examines fallacies and teaching. There are chapters on four of the fallacies that will be examined in this book: appeal to force; appeal to ignorance ; appeal to authority; and post hoc ergo propter hoc .

Diagnostic errors are a significant cause of death and serious injury in patients. Many of these errors are related to cognitive factors. Trowbridge ( 2008 ) has devised twelve tips to familiarize medical students and physician trainees with the cognitive underpinnings of diagnostic errors. One of these tips is to explicitly describe heuristics and how they affect clinical reasoning . These heuristics include the following:

Representativeness —a patient’s presentation is compared to a ‘typical’ case of specific diagnoses.

Availability —physicians arrive at a diagnosis based on what is easily accessible in their minds, rather than what is actually most probable.

Anchoring —physicians may settle on a diagnosis early in the diagnostic process and subsequently become ‘anchored’ in that diagnosis.

Confirmation bias —as a result of anchoring, physicians may discount information discordant with the original diagnosis and accept only that which supports the diagnosis.

Using the above information, identify any heuristics and biases that occur in the following scenarios:

Scenario 1: A 60-year-old man has epigastric pain and nausea. He is sitting forward clutching his abdomen. He has a history of several bouts of alcoholic pancreatitis. He states that he felt similar during these bouts to what he is currently feeling. The patient states that he has had no alcohol in many years. He has normal blood levels of pancreatic enzymes. He is given a diagnosis of acute pancreatitis. It is eventually discovered that he has had acute myocardial infarction.

Scenario 2: A 20-year-old, healthy man presents with sudden onset of severe, sharp chest pain and back pain. Based on these symptoms, he is suspected of having a dissecting thoracic aortic aneurysm. (In an aortic dissection, there is a separation of the layers within the wall of the aorta, the large blood vessel branching off the heart.) He is eventually diagnosed with pleuritis (inflammation of the pleura, the thin, transparent, two-layered membrane that covers the lungs).

Many of the logical terms that were introduced in this chapter also have non-logical uses in everyday language. Below are several examples of the use of these terms. For each example, indicate if the word in italics has a logical or a non - logical meaning or use:

University ‘safe spaces’ are a dangerous fallacy —they do not exist in the real world ( The Telegraph , 13 February 2017).

The MRI findings beg the question as to whether a careful ultrasound examination might have yielded some of the same information on haemorrhages ( British Medical Journal: Fetal & Neonatal , 2011).

The youth justice system is a slippery slope of failure ( The Sydney Morning Herald , 26 July 2016).

The EU countered with its own gastronomic analogy , saying that “cherry picking” the best bits of the EU would not be tolerated ( BBC News , 28 July 2017).

As Ebola spreads, so have several fallacies ( The New York Times , 23 October 2014).

Removing the statue of Confederacy Army General Robert E. Lee no more puts us on a slippery slope towards ousting far more nuanced figures from the public square than building the statue in the first place put us on a slippery slope toward, say, putting up statues of Hitler outside of Holocaust museums or of Ho Chi Minh at Vietnam War memorials ( Chicago Tribune , 16 August 2017).

We can expand the analogy a bit and think of a culture as something akin to a society’s immune system—it works best when it is exposed to as many foreign bodies as possible ( New Zealand Herald , 4 May 2010).

The Josh Norman Bowl begs the question : What’s an elite cornerback worth? ( The Washington Post , 17 December 2016).

The intuition behind these analogies is simple: As a homeowner, I generally have the right to exclude whoever I want from my property. I don’t even have to have a good justification for the exclusion. I can choose to bar you from my home for virtually any reason I want, or even just no reason at all. Similarly, a nation has the right to bar foreigners from its land for almost any reason it wants, or perhaps even no reason at all ( The Washington Post , 6 August 2017).

Legalising assisted suicide is a slippery slope toward widespread killing of the sick, Members of Parliament and peers were told yesterday ( Mail Online , 9 July 2014).

In the Special Topic ‘What’s in a name?’, an example of a question-begging argument from the author’s recent personal experience was used. How would you reconstruct the argument in this case to illustrate the presence of a fallacy?

On 9 July 2017, the effect of coconut oil on health was also discussed in an article in The Guardian entitled ‘Coconut oil: Are the health benefits a big fat lie?’ The following extract is taken from that article. (a) What type of reasoning is the author using in this extract? In your response, you should reconstruct the argument by presenting its premises and conclusion . Also, is this argument valid or fallacious in this particular context?

When it comes to superfoods, coconut oil presses all the buttons: it’s natural, it’s enticingly exotic, it’s surrounded by health claims and at up to £8 for a 500 ml pot at Tesco, it’s suitably pricey. But where this latest superfood differs from benign rivals such as blueberries, goji berries, kale and avocado is that a diet rich in coconut oil may actually be bad for us.

The article in The Guardian also makes extensive use of expert opinion. Two such opinions are shown below. (b) What three linguistic devices does the author use to confer expertise or authority on the individuals who advance these opinions?

Christine Williams, professor of human nutrition at the University of Reading, states: “There is very limited evidence of beneficial health effects of this oil”.

Tom Sanders, emeritus professor of nutrition and dietetics at King’s College London, says: “It is a poor source of vitamin E compared with other vegetable oils”.

The author of the article in The Guardian went on to summarize the findings of a study by two researchers that was published in the British Nutrition Foundation’s Nutrition Bulletin. The author’s summary included the following statement: There is no good evidence that coconut oil helps boost mental performance or prevent Alzheimer’s disease . (c) In what type of informal fallacy might this statement be a premise ?

Scenario 1: An anchoring error has occurred in which the patient is given a diagnosis of acute pancreatitis early in the diagnostic process. The clinician becomes anchored in this diagnosis, with the result that he overlooks two pieces of information that would have allowed this diagnosis to be disconfirmed—the fact that the patient has reported no alcohol use in many years and the presence of normal blood levels of pancreatic enzymes. By dismissing this information, the clinician is also showing a confirmation bias —he attends only to information that confirms his original diagnosis.

Scenario 2: A representativeness error has occurred. The patient’s presentation is typical of aortic dissection. However, this condition can be dismissed in favour of conditions like pleuritis or pneumothorax on account of the fact that aortic dissection is exceptionally rare in 20-year-olds.

(2) (a) non-logical; (b) non-logical; (c) non-logical; (d) non-logical; (e) non-logical; (f) logical; (g) logical; (h) non-logical; (i) logical; (j) logical

(3) The fallacy can be illustrated as follows. The head of department asks the question ‘Why did so many of these students get ‘A’ grades’? He receives the reply ‘Because they did very well’. But someone might reasonably ask ‘How do we know that they did very well?’ To which the reply is ‘Because so many students got ‘A’ grades’. The reasoning can be reconstructed in diagram form as follows:

The author is using an analogical argument , which has the following form:

P1: Blueberries, goji berries, kale, avocado and coconut oil are natural, exotic, pricey and surrounded by health claims.

P2: Blueberries, goji berries, kale and avocado have health benefits.

C: Coconut oil has health benefits.

This is a false analogy , or a fallacious analogical argument , because coconut oil does not share with these other superfoods the property or attribute < has health benefits >.

The author uses academic rank, field of specialization, and university affiliation to confer authority or expertise on individuals who advance expert opinions.

This statement could be a premise in an argument from ignorance .

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Cummings, L. (2020). Critical Thinking in Medicine and Health. In: Fallacies in Medicine and Health. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-28513-5_1

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• Open access
• Published: 20 March 2023

Thinking more wisely: using the Socratic method to develop critical thinking skills amongst healthcare students

• Yueh-Ren Ho 1 , 2 ,
• Bao-Yu Chen 3 &
• Chien-Ming Li 2 , 4  

BMC Medical Education volume  23 , Article number:  173 ( 2023 ) Cite this article

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In medicine, critical thinking is required for managing and tolerating medical uncertainty, as well as solving professional problems and treating diseases. However, the core of Confucianism, teacher-centered and exam-oriented settings in middle and high school education may pose challenges to developing critical thinking in Han Chinese or Taiwanese students. Students may be adversely affected by these pedagogies since student-centered settings were more effective in stimulating their critical and reflective thinking, as well as a sense of responsibility, in the ever-changing world. Therefore, guiding students with less stable foundations of critical thinking might require a different approach. A review article highlighted the potential utility of the Socratic method as a tool for teaching critical thinking in the healthcare field. The method involves posing a series of questions to students. More importantly, medical students and residents in clinical teaching are familiar with the method. Almost all healthcare students must complete a biochemistry laboratory course as part of their basic science training. Thus, we aimed to train students to develop critical thinking in the biochemistry laboratory course by using learning sheets and teacher guidance based on the Socratic method and questioning.

We recruited second-year students from a medical school, of whom 32 had medical science and biotechnology majors (MSB), 27 had pharmaceutical science majors (PS), and 85 were medical undergraduate (MU) students. An exercise in critical thinking was conducted during a biochemistry laboratory course, which consisted of five different biochemical experiments, along with learning sheets that contained three or four critical thinking questions. Then, the teacher evaluated the students’ ability to think critically based on nine intellectual dimensions (clarity, accuracy, precision, relevance, depth, breadth, logic, fairness, and significance) based on the universal intellectual standards developed by Prof. Linda Elder and Richard Paul. In the following analysis, regression models and multivariate analysis were used to determine how students improved over time, and trajectory analysis were carried out in order to observe the trends in students’ critical thinking skills construction.

Clarity and logic dimensions were identified as the key elements to facilitate the development of critical thinking skills through learning sheets and teacher guidance in students across all three different healthcare majors. The results showed that metacognitive monitoring via Socratic questioning learning sheets have demonstrated potential encourage students to develop critical thinking skills in all dimensions. Another unique contribution of current study was present the heterogeneous learning patterns and progress trajectories of clarity and logic dimensions within classes.

Using the Socratic learning model could effectively develop students’ critical thinking skills so they can more effectively care for their patients.

Peer Review reports

Introduction

Emerging trends in information technology requires that the new generation of medical students become critical thinkers [ 1 ]. The General Medical Council (GMC) of the United Kingdom encourages teachers to facilitate the acquisition of critical thinking skills by students in the medical and health professions [ 2 ]. Decades of research have proven that critical thinkers can present dispositions like flexibility, persistence, and willingness when faced with a range of tasks; they display meta-cognitive monitoring and a willingness to self-correct to seek long-term consensus[ 3 ]. Although, critical thinking is constructed from childhood in most Western countries and are valued by higher education as a necessary skill for coping with society [ 4 ]. However, critical thinking constructing and teaching has attracted little attention in Eastern education systems until recently [ 5 , 6 ].

Aside from the development of critical thinking skills is a key component of educational systems, recent educational philosophy also emphasizes both thinking processes as well as metacognitive integration skills [ 7 ]. Metacognitive monitoring includes making ease-of-learning judgments (i.e., processing fluency and beliefs), judgments of learning, feeling-of-knowing judgments (i.e., assessing the familiarity of the cue and the question itself or the domain of the question), and having confidence in the retrieved answers [ 8 , 9 ]. It is an adaptive skill of personal insight that health-profession students need to succeed in the rapidly changing and challenging healthcare industry [ 2 , 10 ]. Despite this, higher education curriculum does not emphasize on teaching these skills [ 7 ]. Additionally, any attempts to change the standards in higher education are generally met with resistance and challenges since they are require to encourage teachers to create new curriculum and change the current teaching content by researchers in current study who have more than 40 years’ teaching experience observaions. Healthcare curriculum, in general, remains conservative; Taiwan is not an exception.

Critical thinking is a fundamental component of innovative thinking and has thus become the fundamental skill for cultivating innovative talents in Western education [ 11 ]. Western scholars have asserted that teaching critical thinking should start at an early age and that its foundations should be laid in elementary and secondary schools. There are many ways to define critical thinking. A leading educational expert, Prof. Dewey, defined critical thinking as inclusive of reflective thinking and argued that the thinking process should also be taken as one of the objectives of education [ 12 ]. There are a few general dispositions that an ideal critical thinker would present according to Prof. Ennis’ observation of the constitutive abilities, such as (1) provide a clear statement of the conclusion or question; (2) provide clear reasons and be specific about their relationships with each other; (3) try to be well informed; (4) always seek and use credible sources, observations and mention them frequently; (5) consider the entire situation; (6) be mindful of the context’s primary concern; (7) be aware of alternative options; (8) be open-minded toward other points of view and refrain from making a judgment when there are insufficient evidence and reasons; (9) be willing to change your position when sufficient evidence and reasons support it; (10) seek as much precision as the nature of the subject admits; (11) whenever possible, seek the truth, and more broadly, strive to “get it right”; and (12) utilize their critical thinking abilities and dispositions [ 13 , 14 , 15 , 16 ]. In the eyes of Profs. Dewey and Ennis, critical thinking is a process of careful thought and reflection before a decision is made [ 17 ].

Nevertheless, the measurement or evaluation of critical thinking skills and abilities does not seem easy. Based on another perspective on critical thinking, intellectual standards are evolving [ 18 ]. According to Profs. Elder and Paul, critical thinking is the ability to use the most appropriate reasoning in any situation [ 18 ]. To evaluate these abilities, they established nine dimensions of critical thinking to represent different aspects of critical thinking: clarity, accuracy, precision, relevance, depth, breadth, logic, significance, and fairness [ 18 ]. As Profs. Elder and Paul concluded, those who possess discipline and critical thinking skills would make use of intellectual standards every day; thus, people should target these standards when they ask questions during the thinking process [ 18 , 19 ]. As a result of teachers’ regular introduction of the tools of critical thinking in their classrooms, the Socratic questioning and discussions become more productive and disciplined, thereby enabling students to realize the significance of questioning during the learning process [ 20 , 21 , 22 ].

According to a review article, teaching critical thinking to healthcare students (primarily medical and pharmacy students) through Socratic methods is more effective in developing critical thinking for a number of reasons [ 23 ]. In particular, Socratic questioning provides students with the opportunity to justify their own preconceived beliefs and thoughts after a series of specific, targeted inquiries [ 24 ]. Using Socratic questioning can also assist healthcare students, interns, or residents in thinking critically by understanding the “deep structure” of the question, i.e., deconstructing the question and understanding its true meaning [ 23 ]. The effectiveness of Socratic questioning lies in ascertaining the current knowledge of the students [ 25 ] and establishing a foundation for teaching at their level [ 26 ]. The teacher can accomplish this probing by asking progressively more challenging questions until the limits of the students’ knowledge are discovered [ 25 , 27 , 28 ], as well as by allowing students to express their existing knowledge, which in turn will allow them to synthesize new knowledge [ 26 ], and the dialogue represents the Socratic method [ 29 ]. Alternatively, a critical thinker is more likely to engage in certain established metacognitive strategies under the Socratic paradigm and/or channel the intellectual dimensions of critical thinking [ 17 ].

Unfortunately, Han Chinese students have struggled with learning critical thinking, which is thought to be part of their characterological profile [ 30 ]. This struggle has been faced by students studying abroad [ 11 ] and in students enrolled in the Han Chinese education system, which mainly cultivates Confucianism [ 31 ]. There are at least two types of problems with developing critical thinking in Han Chinese or Taiwanese education. The first involves the core of Confucianism, where foreign teachers have tried to promote critical thinking in elementary and high schools but sensed ethical concerns from the students who refused to participate. This is likely because if they chose to participate, they would have felt obligated to express disagreement and negative feelings to the instructor. The Han Chinese culture values harmony and “not losing face,” emphasizing a holistic perspective and collective good. Thus, students would feel uncomfortable because disagreeing with someone’s opinion in public is consciously or often avoided [ 30 ]. Therefore, encouraging the student to participate in healthy discussions and respectfully challenge their teachers is the starting point for promoting critical thinking in students enrolled in the Han Chinese educational system.

Second, in the Western education approach, learners take an active role in and are responsible for their learning process. On the contrary, the Han Chinese and Taiwan education systems are teacher-centered and exam-oriented; students are expected to follow their teachers’ instructions and perform well in class. More importantly, the textbook or teacher-centered framework lacks half of Ennis’s twelve constitutive abilities for critical thinking [ 13 , 14 , 15 ], such as judging the credibility of a source, observing and judging observation reports, drawing explanatory conclusions (including hypotheses), making and judging value judgments, and attributing unstated assumptions. As a result, Han Chinese students may find it difficult to develop critical thinking skills and present key traits and dispositions that are indicative of an ideal critical thinker. Hence, guiding and evaluating critical thinking in students might not be implemented through the same approach in Eastern educational circumstances as in the West. By understanding the difficulties that Han Chinese students face in developing critical thinking, the current study aims to design a set of critical thinking models that are suitable for Han Chinese students as a starting point for reform teaching.

Research questions, hypotheses and objectives

Research has shown that the laboratory class is not just limited to a step-wise approach to experimentation. It also allows students to develop their critical thinking skills by repeatedly engaging a simple learning framework [ 32 ]. To explore this further, the current study’s primary purpose is to use Socratic questioning in a biochemistry laboratory course with specifically designed learning sheets and feedback from teacher to guide students to improve their critical thinking skills. The learning sheets were evaluated following the universal intellectual standards for critical thinking developed by Prof. Elder and Paul [ 19 , 33 ]. For this study, we hypothesized that students with different healthcare majors might present different improvement trajectories in their intellectual dimensions according to the years of teaching observations in the three healthcare majors. Based on the research and rationale described above, the intervention effect of Socratic questioning in a biochemistry laboratory course was hypothesized as follows (see Fig.  1 ):

Pre-intervention critical thinking abilities are different amongst students of different healthcare majors, especially in each intellectual dimension (H1a). Post-intervention critical thinking abilities would develop in students from each healthcare major after using the Socratic method (H1b).

Critical thinking abilities differs significantly between pre- and post-assessments of the intellectual dimensions of students with the three different healthcare majors (H2).

After clarifying the relation of Socratic method interventions in the class, we aim to scrutinize the trajectories of students between majors further to understand the learning style in class (Aim 1). Furthermore, we also aim to identify the key intellectual dimensions that could lead to an overall improvement in the critical thinking of students in each major (Aim 2). Additionally, we observed improvement trajectories of specific intellectual dimensions within major (Aim 3).

Socratic method framework and structure of the research hypotheses behind the biochemistry laboratory course

Literature review

Critical thinking engagement in the eastern and western medical education.

Over the last decade, medical education has been undergoing a variety of approaches for effectiveness teaching and transformation [ 34 ]. Many paradigms of active teaching/learning methodologies have been adopted in both Eastern and Western medical education systems, some of which are used partially (actual or conceptual similar) Socratic questioning to challenge students’ critical thinking. In this regard, the primary philosophy of case-based learning (CBL) established in the 1920s by Harvard Medical School is to guide students to apply their acquired knowledge base via critical thinking to make clinical decisions to solve the problems that they may encounter in the healthcare environment [ 35 ]. A meta-analysis study of China’s dental education reported that the CBL was a practical pedagogical method across the Chinese dental education system [ 36 ]. The results showed that the CBL method significantly increased knowledge scores, skill scores, comprehensive ability scores, and teaching satisfaction compared with the traditional lecture-based learning (LBL) mode in 2,356 dental students. Hence, there is an urgent need to change the traditional didactic lecture or teacher-centered classroom setting in which students are passive listeners instead of active participants.

Healthcare professionals are also required to solve complex problems and efficiently integrate didactic preclinical knowledge into actual clinical application in patient care [ 35 ]. On the other hand, the design thinking process may enhance both creativity and innovation so that healthcare professionals can respond to clinical problems effectively [ 37 , 38 ]. Problem-based learning (PBL) is a pedagogical approach widely accepted in medical education. It promotes active learning and results in better outcomes [ 39 , 40 , 41 ]. PBL focuses on active lifelong learning by triggering problems, directing student focus, and facilitating tutor involvement [ 39 , 42 , 43 , 44 ]. However, it is noteworthy that some hybrid PBL models have become less effective over time, as well as less aligned with the intended philosophy of student-centered learning [ 45 ]. Another alternative blended learning approach of PBL is team-based learning (TBL), which allows medical educators to provide students with pre-class work, in-class initial tests with immediate feedback, and real clinical problem-solving activities [ 46 ]. In the year-one studies of the Sydney Medical Program, a greater level of engagement in learning, a deeper understanding of concepts, and a sense of responsibility were shown among the medical students working in a TBL setting than among those in a PBL setting [ 47 , 48 ].

Medical educators face another significant challenge with the millennial generation, which has ubiquitous information technology access throughout its education. Thus, it is extremely important to improve students’ motivation to learn through hands-on instruction or teacher–student interaction and then stimulate students’ thinking and learning. In recent years, gamification has been successfully integrated into medical and scientific endeavors, enhancing motivation, participation, and time commitment across a variety of settings [ 49 , 50 , 51 ]. Another healthcare curriculum reform to stimulate active learning is flipped classroom (FC), which assigns learners didactic material, creating opportunities of longitudinal and interprofessional learning experiences for students during class participation [ 52 ] to encourage extracurricular learning, such as critical thinking. As part of the FC model, medical educators also develop formative and diagnostic assessments to identify learning gaps. According to these teaching modules, encouraging students to participate, emphasizing their learning, and observing their development trajectory are the core ideas in recent educational designs [ 53 ].

Although most of above-mentioned studies have been performed in the Eastern and Western education systems, however, without mentioning the differences between cultures and learning styles. Most importantly, the cultivation and foundations of critical thinking neglect the fact that Eastern and Western education systems emerged from very different learning and thinking patterns. Moreover, clinical reasoning and decision achievements depend on established critical thinking skills, therefore, it becomes more important to construct critical thinking early and comprehensively [ 54 ]. While Han Chinese students are not familiar with the core of critical thinking, the most effective approach to teaching critical thinking is still a highly debated topic in medical schools. Taken Taiwan medical education as an example, most clinical courses focuses on professional skills, problem solving, and disease treatment rather than construct critical mindset and metacognitive skills. Education strategies often emphasize the outcome while neglecting the process. Nevertheless, medical educators should also emphasize the process of forming students’ critical thinking when instructing and guiding them in this regard. Consequently, using metacognitive monitoring to enhance critical thinking in healthcare education would be appropriate, especially for Han Chinese systems with a Confucianist outlook. Thus, critical thinking via metacognitive monitoring is important in healthcare education, especially in Han Chinese systems with a Confucianist background.

Proficiency in the art of socratic questioning to enhance students’ critical thinking

Socratic questioning is a disciplined method of engaging in content-driven discourse that can be applied for various purposes: analyzing concepts, finding out the truth, examining assumptions, uncovering assumptions, understanding concepts, distinguishing knowledge from ignorance, and following the logical implications of thought. The scholars who established the intellectual standards of critical thinking have consistently indicated that “The key to distinguishing it from other types of questioning is that the Socratic questioning is systemic, disciplined, and deep and usually focus on foundational concepts, principles, theories, issues, or problems [ 20 , 21 , 22 ].” In short, the Socratic method is a questioning method that stimulates personal understanding. More importantly, the core principle of learning from the unknown fits best within healthcare environments.

Numerous studies have consistently urged teachers to develop Socratic dialogue in their classrooms, regardless of their learning stages and situations [ 55 , 56 , 57 ]. Using enhancement exercises in an elementary school, a study introduced a Socratic questioning strategy to provide guidance and hints to students so that they could think more deeply about an issue or problem before sharing their thoughts [ 55 ]. The lecturer of a speech course in higher education demonstrated how Socratic questioning could help students learn when confronted with a series of questions [ 56 ]. The process improves students’ ability to ask and answer questions and helps them overcome some obstacles related to their lack of self-confidence. In the book Socratic circles: Fostering critical and creative thinking in middle and high school , Dr. Matt Copeland stated that, in middle and high schools, teachers must facilitate discussions by asking questions [ 58 ]. Furthermore, this method could be applied not only to elementary school, middle school, high school but also to higher education classes [ 59 ]. During the Covid-19 pandemic, synchronous discussions in online learning demonstrated that the Socratic questioning strategy successfully improves students’ critical thinking skills [ 57 ].

The incorporation of Socratic questioning in healthcare education curriculum is under development, including for general medical education [ 60 ], medical [ 61 ], pharmacy [ 54 , 62 ], and nursing students [ 63 ]. A review article of revisiting the Socratic method as a tool for teaching critical thinking in healthcare professions revels few advantages of Socratic questioning [ 23 ]. Three type of Socratic questions were mention and could commonly used in different clinical situations [ 23 ], such as procedure question would use in those with correct answers (e.g., Which of the following medications has antithrombotic function? ); preference question can apply in those with no correct answers (e.g., What type of consultation is most suitable for this patient? ); judgment question would be the most challenge critical thinking within a Socratic paradigm by integrating different domain knowledge and skills (e.g., Does this patient require antibiotic treatment? ). It is necessary to apply and analyze information in a logical manner as well as self-regulate and use critical thinking in order to achieve the best outcome for patients. For medical doctors, pharmacists or clinical laboratory technicians to provide high quality health care across all disciplines, critical thinking is inherently required.

In medical school, the emphasis is laid on training learners in meta-capabilities, such as self-driven pattern recognition, ideally as part of an apprenticeship under the supervision of an expert diagnostician [ 61 ]. An in-depth study of the current trends in developing critical thinking amongst medical students demonstrated the use of dialogue for proper questioning and how it directs the learner’s thinking [ 64 ]. Moreover, another study confirmed that critical thinking occurs only when students are motivated and challenged to engage in higher-level thought processes [ 65 ]. In the pharmacy classroom, educators can play a significant role in influencing their students’ mindsets.  Growth mindsets can be cultivated through the creation of an environment that encourages it. [ 62 ]. The Socratic questioning method can facilitate critical thinking in nursing education. One study showed that problem solving using critical thinking skills can be facilitated in both educational and practice settings by using Socratic inquiry [ 63 ].

The Socratic method has been adapted in different ways to different domains, but it has become closely associated with many areas, such as basic scientific thinking training, legal dialectical guidance, and clinical teaching. Some adaptations are helpful, some are not. The adaptations can be looked at through reasoning-focused lenses with varying degrees of magnification —a high-magnification adaptation rigorously and precisely tracks or guides the path of reasoning. Thus, how to use the Socratic method to direct students onto the path of critical thinking with appropriate guidance, but not revealing answers becomes an art that tests instructors’ teaching experience and proficiency in questioning.

Critical thinking and reflection exercises in the laboratory course

Medical schools have increasingly encouraged students to become life-long, self-directed learners because of the continual changes in the evidence-based healthcare environment. Science is often applied in everyday life, including translating knowledge from scholarly fields [ 66 ]. However, there is a vast gap between what is taught in medical schools and what is actually required in practice has increasingly widened in this information era. The majority of healthcare professionals are not considered to be real scientists. [ 2 ]. Nevertheless, they need to know how to apply scientific knowledge to their practice. Therefore, a science curriculum in medical school, such as a biochemistry laboratory course, should provide an opportunity to learn scientific methods and conceptual frameworks. It should also promote critical reasoning, providing healthcare students with problem-solving skills.

Medical educators need to accept that critical thinking is important for healthcare students and know how to teach it effectively [ 67 ]. Medical educators are now faced with a dilemma: should they develop a new course or adapt old course to develop critical thinking skills?  An effective learning model should promote and stimulate students’ development of such skills [ 67 ]. One of the most common compulsory courses for healthcare students is the biochemistry laboratory course [ 68 , 69 ]. These courses are specifically designed to introduce students to prescribed experiments, requiring them to complete stepwise protocols by themselves [ 68 , 70 ]. The students are expected to understand the concepts behind the methods, procedures, and assays. However, this type of curriculum construction often fails to provide students with adequate opportunities to monitor their critical thinking and thus reduces the chances of developing problem-solving skills [ 70 ]. In order to provide students with more opportunities to think critically, previous studies have also adapted laboratory, basic science, and science fusion courses to help students develop critical thinking skills [ 67 , 68 , 71 , 72 , 73 ].

Several studies have demonstrated that students need critical thinking skills to interpret data and formulate arguments. Thus, science education, particularly in the laboratory setting, is designed to teach quantitative critical thinking (i.e. interpretation and critical evaluation of statistical reports), but the evidence has suggested that this is seldom, if ever, achieved [ 74 , 75 , 76 , 77 , 78 , 79 ]. By providing multiple opportunities for students to participate in critical thinking in the physics laboratory classes at Stanford University, scholars engaged the students to improve the experiment and modify the model repeatedly [ 32 ]. Additionally, a simple learning framework using decision-making cycles and demonstrating experts’ critical thinking significantly improved students’ critical thinking. We thus argue that students should engage in critical thinking exercises with repeated comparisons, decisions, and teacher guidance that are meant to construct their critical thinking in each of their disciplines.

Participants

This research was conducted during the 2017–2018 academic year. The participants were second-year students in the College of Medicine at the National Cheng Kung University (NCKU) of Taiwan. A total of 144 students participated in this study, of whom 32 had medical science and biotechnology majors (hereafter, MSB), 27 had pharmaceutical science majors (hereafter, PS), and 85 were medical undergraduate (hereafter, MU) students. The biochemistry laboratory course was compulsory for these three majors.

For each biochemistry laboratory class, the teacher assembled five to six groups of four to five students each. The course contained five different biochemical experiments: (1) Plasmid DNA (deoxyribonucleic acid) extraction and purification; (2) restriction enzyme digestion and electrophoresis of plasmid DNA; (3) polymerase chain reaction (PCR) amplification of plasmid DNA; (4) recombinant protein expression in Escherichia coli ; and (5) quantification of recombinant protein. The experimental learning sheets included three or four critical thinking questions (Table S1 ), encouraging students to explore experimental principles and alternative explanations further. To facilitate discussion, students were organized into small groups of four to five students seated around a single table, discussing and answering the questions. At this time, the students would pen down their first answers to the critical thinking questions, and the teacher would grade them based on the universal intellectual standards (learning sheets, first evaluation).

Furthermore, according to the students’ answers, the teacher offered a response by asking more questions according to the Socratic method to encourage students to think deeper rather than provide the correct answers. At the following week’s class, the teacher returned the learning sheet and supervised the ongoing activity, clarifying any questions raised by students and encouraging them to re-discuss and re-answer the critical thinking questions according to the teacher’s suggestions. The objective was to create a highly interactive environment to engage students in learning the relevant principles of each laboratory, including troubleshooting experiments and formulating critical concepts and skills. After the discussion, the teacher reexamined the students’ responses and assessed them based on the universal intellectual standards for subsequent grading (learning sheets, second evaluation).

The biochemistry laboratory courses and the Socratic method in current study are performed and taught by a senior biochemistry teacher (PhD in Institute of Basic Medical Science, NCKU) who has 40 years teaching experience. The teacher has long focused on teaching critical thinking skills to students, and also offers four senior clinical case related courses by practicing the Socratic method, such as clinical concept, critical thinking in medicine, clinical reasoning and special topics in clinical reasoning with more than 20 years of experience. Therefore, in the course, teacher will often ask a series of questions for students to think about the relevance of biochemical science and clinical practice.

Assessment development

The research team designed the learning sheets to guide discussion on the key issues concerning five biochemical experiments. The learning sheets were assessed according to the universal intellectual standards for critical thinking [ 33 ]. However, the assessment was adapted to include nine intellectual dimensions to assess student reasoning [ 19 , 33 ]: clarity, accuracy, precision, relevance, depth, breadth, logic, fairness, and significance (Table S2 ). Each dimension was evaluated using a binary score (0 = does not present the skill; 1 = presents the skill) for each question in the learning sheets for both the first and second evaluations. The students received the teacher’s guidance following the first evaluation, providing them with the opportunity to reconsider their reasoning and revise their answers. Our goal was to improve our students’ learning by stimulating the teaching process; at the same time, we were committed to allowing students to speak freely so that we could more effectively facilitate prospective discussions. Thus, the critical thinking scoring system based on nine intellectual dimensions was only for the purpose of the research, without consequences on students’ study progress. In this regard, students were not able to know their intellectual scores. As a result, their course grades were not determined by the learning sheets; rather, they were determined by the general operation, experiment report, and the learning attitude demonstrated during the experiments.

Statistical analysis

Descriptive statistics and variable tests.

We calculated the differences between the performance means for the first and second evaluations using paired t -tests. The mean differences between the students from the three majors were analyzed using a one-way analysis of variance (ANOVA). For the improvement slope for each universal intellectual dimension, we used the second evaluation scores of each experiment as the point with which to construct a quadratic equation curve in one variable (dimension) and then access the slope to represent the students’ improvement. The higher the slope score, the greater the students’ progress on that dimension.

Multivariate analysis

We used traditional analytical methods to observe and analyze the students’ improvement in the five experiments. Data from the second evaluation scores of each experiment served as the multi-time point measurement data. The Cox regression model for multivariate analysis was used to investigate the effect of several variables upon the time during which a specified outcome happened [ 80 ]. For each dimension, the model’s outcome determined that a student’s improvement slope was defined as minor progress if it was lower than the improvement slopes of their peers in the same major overall. However, if the student’s improvement slope was higher than the overall progress intercept of their peers, then it was defined as greater progress. The Cox regression models’ outcomes for each dimension were divided into two groups: minor and more progress. For this model’s outcome, (1) we calculated all dimensions’ slopes mean from each major (MSB: 0.369; PS: 0.405; MU: 0.401); (2) then compared the mean slope of the individual students with the mean slope of major; (3) if the student’s individual improvement slope was lower than mean slope of major, then defined as minor progress; if the student’s individual improvement slope was higher than mean slope of major, then defined as greater progress. From the analysis at this point, we understood that teacher could help students from different majors develop the different dimensions of critical thinking with the use of Socratic methods and simple repeated thinking framework practice. Additionally, we wanted to represent the improvement of intellectual dimensions between the students of different majors and their heterogeneity in critical thinking.

Dimension identification and comparison

To understand which intellectual dimensions were most representative of student improvement across majors, the analysis was divided into three sections: (1) to identify the progress percentage of all nine intellectual dimensions; (2) to identify the progress percentage of statistically significant intellectual dimensions; (3) to compare the differences among all nine dimensions, the significant dimensions, and the reciprocal dimensions. This analysis offered a better understanding of what dimensions represented the overall improvement of students’ critical thinking. Our first step was to calculate the percentage of improvement for each experiment by determining the results of the first and second evaluations for each intellectual dimension. Second, we took average percentage of improvements for each dimension. Finally, we used Student’s t -test to compare the differences among the average of all nine dimensions, the significant dimensions, and the reciprocal dimensions.

Trajectory analysis

In this study, we also hypothesized that each student’s learning and progress trajectories were heterogeneous across different majors. Depending on the major, there may also be differences between students in the same class. To focus our observations on the students’ use of the clarity and logic dimensions, we used a trajectory-tracking analysis [ 81 , 82 ] and categorized the students into two groups based on the participants’ improvement levels within the same major.

Descriptive data

We recruited 144 second-year students from three majors in the College of Medicine, among which 32 were MSB, 27 were PS, and 85 were MU students. All participants’ first and second evaluations were compared in all five biochemistry experiments. The statistically significant between-group differences in the mean initial evaluation results for each dimension are presented in Table  1 .

Overall improvement from the initial to second evaluations throughout the five experiments (H1, H2, and Aim 1)

Table  1 presents the mean results of the first and second evaluations; the five experiments exhibited statistically significant differences ( p  < 0.05) across all study groups and dimensions. More detailed analyses revealed significant differences in performance in the second evaluation between the groups after all five biochemistry experiments in the clarity ( p  = 0.0019), depth ( p  = 0.0097), breadth ( p  < 0.0001), logic ( p  = 0.0371), and significance ( p  = 0.0037) dimensions. However, for some of the dimensions (clarity, accuracy, precision, logic, and fairness), the initial evaluation results differ significantly between the MU and the MSB students, but this was not the case for the secondary evaluation results. The MSB students exhibited the best progress (2nd mean score minus 1st mean score) in the clarity dimension across all experiments. The PS students exhibited the best performance in the logic dimension ( p  < 0.05) in the second evaluation after the five experiments.

The results of the MSB students improved steeply in most dimensions in the five experiments, especially depth (slope: 0.472), logic (0.455), and clarity (0.410) (Table  2 ). Time had a stronger effect on several of the dimensions in the multivariate analysis, specifically clarity ( p  = 0.0012), relevance ( p  = 0.0007), and logic ( p  < 0.0001). By contrast, the PS students showed a significant overall improvement in the clarity (slope: 0.212, p  < 0.0001), accuracy (0.539, p  = 0.0063), precision (0.381, p  = 0.0085), relevance (0.216, p  < 0.0001), breadth (0.426, p  = 0.0045), and logic (0.515, p  = 0.0027) dimensions over the observation period (Table  3 ). Finally, the MU students showed a significant overall improvement in six dimensions: clarity (slope: 0.277, p  < 0.0001), accuracy (0.520, p  = 0.0003), depth (0.459, p  = 0.0092), breadth (0.356, p  = 0.0100), logic (0.544, p  = 0.0190), and significance (0.327, p  = 0.0225) (Table  4 ).

Trajectory tracking of the overall, significant, and reciprocal dimensions (Aim 2 and Aim 3)

Figure  2 a illustrates the overall improvement of students across the three majors in all nine dimensions, as assessed via trajectory analysis. The trajectory-tracking algorithm revealed that the significant dimensions for each group were as follows: MSB students—clarity, relevance, and logic; PS students—clarity, accuracy, precision, relevance, breadth, and logic; and MU students—clarity, accuracy, depth, breadth, logic, and significance (Tables  2 , 3 and 4 ; Fig.  2 b). The comparison of each group’s average percentage of improvement between the nine dimensions, the significant dimensions, and the reciprocal dimensions (clarity and logic) is summarized in Fig.  2 c. Figure  2 d–i depicts the students’ improvement in clarity and logic within the different majors using group-based trajectory modeling.

Overall improvement comparison between the students of three majors using a trajectory-tracking analysis approach . ( a ) The mean evaluation scores from the second evaluation minus those from the first evaluation for the nine dimensions were considered an improvement. They were converted to percentages to compare them to the performance in the first evaluation. ( b ) The mean evaluation scores from the second evaluation minus those from the first evaluation for the significant dimensions (within the students of each major, Tables  2 – 4 ) were considered to represent improvement and were converted to percentages to compare them to the performance in the first evaluation. ( c ) Comparison of the average percentage improvement among all nine dimensions, the significant dimensions, and the reciprocal dimensions (i.e., clarity and logic). ( d ) Trajectory analysis to assess the progress of the two subgroups of medical laboratory science and biotechnology students in the clarity dimension. ( e ) Trajectory analysis to assess the progress of the two subgroups of pharmaceutical students in the clarity dimension. ( f ) Trajectory analysis to assess the progress of the two subgroups of undergraduate medical students in the clarity dimension. ( g ) Trajectory analysis to identify the progress of the two subgroups of medical laboratory science and biotechnology students in the logic dimension. ( h ) Trajectory analysis to assess the progress of the two subgroups of pharmaceutical students in the logic dimension. ( i ) Trajectory analysis to assess the progress of the two subgroups of undergraduate medical students in the logic dimension

Empirical contributions

The Han Chinese educational system relies on the passive transmission of knowledge, as evidenced by the years of preparation by students’ through paper-based exams. By adopting this approach during teaching and learning, students do not develop a critical thinking mindset. Our experience has shown that when we encounter first-year students who have just graduated from high school, their previous education failed to develop critical thinking skills. Many foreign and Western teachers have the same experience when they encounter Asian students studying abroad for the first time. Thus, this research aims to provide clinical teachers with guidance on reducing the blind spots that students face when introduced to critical thinking. Moreover, this research aims to provide teachers with a simple teaching model and structure to guide students with less stable foundations in critical thinking. For the teaching structure and process, please refer to the procedure paragraph in the methods section and the teaching flow chart in Fig.  1 . Furthermore, the scoring system shown in the assessment development paragraph in the methods, as well as the scoring rubric is presented in Table S1 .

To our knowledge, this is the first study that uses the Socratic method and the universal intellectual standards to assess and improve critical thinking skills in biochemistry laboratory courses across different healthcare majors. We also used a novel design for teaching critical thinking, with multi-timepoint assessments and trajectory-tracking analysis to observe the students’ process and the improvement intheir critical thinking. This Socratic method, combined with critical thinking-based learning sheets, significantly improved the students’ critical thinking in all nine dimensions of the universal intellectual standards, according to the first and second evaluations conducted in each of the five sessions. Another unique contribution of this study is that it analyzed the progression results at multiple time points in the critical thinking performance of students across different majors. According to the results of comparing the average percentage improvement between all nine dimensions, the significant and reciprocal dimensions (i.e., clarity and logic) do not significantly differ from each other statistically speaking. By reducing the nine intellectual dimensions scoring system, medical educators can focus more on establishing clarity and logic skills in students. In sum, our most important finding was the identification of the clarity and logic dimensions as key elements that facilitate the development of critical thinking skills via the Socratic method in students across three different healthcare majors.

The trajectories of outcomes for students of medical science and biotechnology majors

Understanding what we learn has been identified as the starting point in the professional-development journey [ 2 ]. In principle, if thinking and decision making can be taught, educational intervention is possible. Nevertheless, for a science class like biochemistry, abductive reasoning requires a deep understanding of knowledge, and thinking must be inspired through stimulation.

In this study, the evaluation scores for MSB students did not improve significantly in almost any dimension at the beginning of the course. At first, most students felt uncomfortable with criticizing others, disagreeing with others, or challenging teacher’s knowledge and authority when they spoke their minds. Other MSB students believed that their ability to find answers and make decisions was inadequate and expected the teacher to provide the correct answers. However, preclinical medical technologists must gradually develop their critical thinking skills. Thus, the teacher provided critical thinking cues during the class and monitored the group discussions.

On the other hand, teachers must encourage these types of students, enabling them to accomplish simpler learning goals by providing them with easier-to-attempt clues. The joy of discovering answers on their own rather than the frustration of not achieving high goals should be encouraged. This coaching process improved the MSB students’ willingness to think and explore, leading to greater relevance and breadth of coverage.

The teacher used generation, conceptualization, optimization, and implementation [ 33 ] with the Socratic method to stimulate critical thinking in a four-step cycle in the five experiments. When the spontaneous discussion started in the generation phase, they tried to clarify their knowledge of the theme and identify the problem from the learning sheet. The following step was to conceptualize the problem, and the students drafted all of the possibilities and problems. Teacher frequently asked the students, ‘ What are other possible reasons? ’ Finally, the teacher provided feedback to help the MSB students reach a proper solution and implement it. The teacher would also ask the students leading questions like ‘ What relevant theories can be confirmed more precisely? ’ These guiding processes sharpened their logic and helped them better understand what they had learned. In sum, the benefits of this process included an enhanced ability to think logically, clarification of questions and knowledge gaps, and improvements in the thought process about the theme discussed.

The steady improvement of critical thinking in the students of pharmaceutical science

Currently, pharmacists are seeing their roles and responsibilities shift to becoming patient counselors and educators on the rational use of medicine. Pharmacists are trained to focus on patient-centered care and resolve current and potential drug-related problems [ 83 , 84 ]. Critical thinking, clinical reasoning, and decision-making skills are needed to solve these problems. Nowadays, pharmacists are not just responsible for carrying out doctor’s orders, while there are always alternative treatment options available for them to recommend. Teacher therefore repeatedly emphasized the link between critical thinking and pharmacist practice and encouraged students to ask questions and find out the best alternative through Socratic method in the classroom.

During class, the PS students were required to exert considerable mental effort to conduct an inquiry to solve the learning sheet questions. Instead of providing students with clues or information to help them solve the problems, the teacher guided the PS students on how to seek the information they needed for themselves. The question for the PS students was be ‘ What are the possibly executable strategies? ’ The teacher also joined the students in discussion, using the Socratic method to stimulate critical thinking and draw out ideas and underlying suppositions. In high-quality cooperative argumentative dialogue, teacher should not direct or refer learning, nor should they ask students for the correct answers as in a traditional classroom. The hints that teacher would provide were more like ‘ The narrative explanation can be more precise. ’ Thus, asking high-quality questions and providing feedback also challenges the instructors’ teaching experience.

The PS students were guided not only toward the development of critical thinking skills but also toward solving problems using evidence-based knowledge and decision-making skills. The Socratic method process meets the student where they are on the educational spectrum and encourages and helps them advance. Using this method, the PS students engaged in student-to-student interaction to build knowledge as a group and individually. The course of five experiments conducted via the learning sheets improved many aspects of the students’ critical thinking, including their clarity, relevance, breadth, and logic. In sum, the abilities that they developed in the course should help them focus more on the possible outcomes of pharmacotherapy, medication surveillance, and proper communication and therefore improve the quality of their professional future.

The advanced construction of critical thinking skills in undergraduate medical students

In medical education, “ better thinking and learning skills grounded in understanding ” are recommended for future doctors [ 2 ]. Practicing medicine requires an ability to address current and future diseases using new diagnostic and therapeutic methods [ 10 ]. Therefore, problem solving is not the only core medical skill; the ability to deal with complex, insoluble health issues is also required [ 83 ]. In this domain, critical thinking skills have proven essential in tackling difficult, complex, interdisciplinary health problems [ 10 ].

In our study, the MU students began with high-performance scores in almost all dimensions. As a result, teachers needed to create a more challenging and thought-provoking learning environment to encourage them to think more broadly and deeply. Thus, the teacher would give students advice like ‘ Searching for more relevant information can increase the breadth of knowledge ’ and ‘ If the result is true, what is the relevant theory? ’ Most MU students were faster than other majors at defining and constructing critical thinking. However, another phenomenon often observed in the classroom was that the MU students were more reluctant to express their reasoning than the students of other majors. In other words, MU students were afraid to speak openly about their reasoning and thinking, probably due to the excessive pursuit of the correct answer. In sum, the course of five experiments conducted via the learning sheets enhanced abilities of clarity, accuracy, depth, breadth, logic, and significance in MU students.

Apart from providing structure for their critical thinking, as was done with the other preclinical students, the teacher guided the MU students to use advanced critical thinking skills by regularly analyze their thinking processes, reflecting on the decision-making and thinking process [ 84 ]. Researchers have suggested that reflective practice is key to successful medical professionalism [ 85 ] and humanism [ 86 , 87 ]; but more importantly, it may help medical professionals develop better physician–patient relationships [ 88 ]. Therefore, to advance the critical thinking experience of the MU students, teacher should encourage them to gather ideas, analyze, evaluate, and synthesize information. The teacher guided them to reflect on their plan and solve the questions on the learning sheets using their thoughts and words. These reflective practices could involve various biases in the thinking process and outcome, such as the base-rate fallacy, bias blind spot, or choice-supportive bias. The Socratic debate is a common way to model a complex thinking situation and may help teachers inspire students to become critical thinkers. MU students improved their abilities in the clarity, accuracy, depth, breadth, logic, and significance dimensions in the five experiments. This kind of training in thinking should help preclinical students constantly challenge and critically appraise evidence within their context, as well as their patients’ and their own belief and value systems.

Limitations

This study provides a model for developing a specific learning environment like a biochemistry laboratory class into one that will help students develop their critical thinking skills through inquiry. Our results have shown this method to be feasible and effective. However, there were a few limitations to this study. First, although it included students from three different majors, there was no interdisciplinary collaboration that would have simulated collaborations and communication among other healthcare professionals from different fields, as occurs in clinical practice. Introducing such collaboration may have produced more exciting and comprehensive ideas for solving the problems. Training in these professions is specialized to a considerable extent, so inter-professional collaboration should improve therapeutic outcomes and optimize patient care. Second, the original scoring system was time-consuming. However, one of our study objectives was to modify and reduce the nine intellectual dimensions scoring system into the clarity and logic dimensions. Based on the analysis in the current study, the clarity and logic dimensions were sufficient for monitoring the growth of students’ critical thinking.

The present curriculum innovation aimed to teach critical thinking skills to preclinical students in various medical majors using a Socratic questioning learning model instead of a cookbook approach to learning in laboratory courses. The development of problem-solving and critical thinking skills, in addition to process-related skills, in biochemistry laboratory courses supplements traditional curriculum in a helpful way. The curriculum innovation that we described and proposed may represent an incremental step forward for the discipline; it is a novel educational approach for promoting critical thinking skills, fostering an appreciation of the affective domain, and enabling reflective practice by using small-group processing skill instruction and one-on-one Socratic questioning. The current study results are based on training critical thinking skills that should enable students to engage in the “reflection-on-action” process, which might provide an additional bridge between basic medical knowledge and clinical practice. More importantly, reconstructive mental reviews may indirectly shape preclinical students’ future actions in the challenging healthcare industry characterized by uncertainty and novel circumstances.

Data Availability

Due to conditions on participant consent and other ethical restrictions, the datasets used and analysed in the current study are not publicly available. If you have any database data requirements, please contact the corresponding author of this study.

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Acknowledgements

The authors wish to thank Chi-Her Lin, MD for their encouragement and support in the writing of this manuscript, and Prof. Woei-Jer Chuang, Hung-Chi Cheng, Chang-Shi Chen, Po-Hsin J. Huang, Chien-hung Yu, and Wen-Tsan Chang for their help with the experimental design. Special thanks to Tanvi Gupta for her help with the improving reading fluency.

This work was supported by the Teaching Practice Research Program, Ministry of Education, Taiwan (Grant No: PMN1110350, PMN1100853, PMN1090364, PMN108075, PMN107018).

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Yueh-Ren Ho: substantially contributed to the conception, data curation, interpretation, drafting and critical revision of the paper. She has given final approval to the manuscript and agrees to be accountable for the work. Bao-Yu Chen: substantially contributed to the conception, formal analysis, methodology, visualization, and writing and editing the manuscript. Chien-Ming Li: substantially contributed to the conception, data curation, review and editing the manuscript.

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Ho, YR., Chen, BY. & Li, CM. Thinking more wisely: using the Socratic method to develop critical thinking skills amongst healthcare students. BMC Med Educ 23 , 173 (2023). https://doi.org/10.1186/s12909-023-04134-2

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Barriers of Critical Thinking in Medical Students' Curriculum from the Viewpoint of Medical Education Experts: A Qualitative Study

Afshineh kasalaei, msc.

1 Shiraz University of Medical Sciences, Shiraz, Iran

MITRA AMINI, MD

2 Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

PARISA NABEIEI, MSc

Leila bazrafkan, phd, houri mousavinezhad, bsc.

3 Cardiovascular Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran

Introduction:

 The widespread developments of the twenty-first century have been accompanied by the presentation of intellectual patterns and theories and new achievements. These new achievements emphasize the skill of thinking at high levels, especially in the educational system of universities. This skill is essential for medical students; therefore, the present study aimed to investigate the qualitative barriers of critical thinking in medical students' curriculum.

 This is a qualitative study in which the content analysis method has been used. Participants of this study included 11 medical education experts and medical students (6 females and 5 males) who were selected through a semi-structured interview and purposeful sampling. The data analysis method was conventional content analysis. In the next part, by more investigation of the data, various obtained concepts will be presented in the form of themes, categories, and subcategories.

We obtained two themes (socio-cultural conditions and traditional and unchanging system of education), eight categories and 14 subcategories. Also, these categories were resistance to critical society, intellectual tension, personality characteristics, lack of understanding of society's need for criticism, the rule of traditional teaching pattern, lack of critical thinking skills, ineffective evaluation, and difficulty of critical thinking training.

Conclusion:

 Given the results and the main emphasis of curriculum planners on incorporating high-level critical thinking and revision skills into the curriculum, the country's academic education system requires a change in the thinking style, research, deepening critical thinking, and a change in teachers' attitudes toward curriculum designing (goals, content, teaching and evaluation methods); also, it is suggested that the authorities should pay attention to the need to develop and utilize critical thinking skills in the learners’ education.

Introduction

The widespread and vast developments of the 21st century are accompanied by the presentation of intellectual patterns and theories and the production of modern science and technology. One of the new achievements of this century is emphasis on thinking methods, especially in the educational system ( 1 ).

Critical education is a relatively modern theory developed by educators such as Paulo Freiere, Henry Giroux, Peter McLaren, Michael Apple, and Douglass Kellner based on the principles of critical theory ( 2 ). In this type of education, wisdom, critique, and interpretation are considered as valuable educational goals. The primary approach of this tutorial is, as mentioned before, toward critical thinking. In this type of training, the use of memory and old knowledge is diminished, and learners can analyze, evaluate, and interpret the material. Accordingly, the training of the criticizer and wise students is the first goal of university education to confront the changing society in this age of multiple information explosion ( 3 ).

Critical thinking is a type of high-level thinking skills used by students, i.e. they use personal perspectives and approaches rather than simple acceptance without evaluating the others' judgments, attitudes, and information ( 4 ). The central core of critical thinking is cognitive skills such as interpretation, analysis, evaluation, inference, explanation, and self-regulation.

Critical thinking in the field of medical sciences is a kind of cognitive activity for understanding and evaluating the phenomena based on reasoning and analysing ( 5 - 6 ). Having a critical thinking skill for a physician helps him make the right clinical decision and provide the best care in the patient care process ( 7 - 8 ). The ability to solve a problem at the patient's bedside is valuable in the health process.

Designing the curricula can reflect the important belief in medical students that they should learn these experiences not only to maximize their potential, but also use it as a general skill in classrooms, and conduct this vital issue to the other areas, their other life aspects, and future career ( 9 , 10 ). With this in mind, the importance of the students' curriculum in fostering the students' critical thinking becomes apparent.

Therefore, the institution of education in academic education must carry out its mission to review the goals, content and educational materials, methods of teaching-learning, and the evaluation system and everything related to the curriculum. It should be noticed that the surface change will not be responsive to the revision of the curriculum and that fundamental and logical changes in all curriculum processes are essential ( 11 , 12 ).

The university education course is one of the most critical training courses in every person's life. As the period of school education transition, and objective thinking is the entry into the abstract and adolescent thinking that comes with entering the job market and assuming significant responsibilities in life ( 5 ). It should be stated that people studying critical thinking skills at the university are always looking for reasons and evaluating them in real life and resisting misleading prejudices ( 13 ). Therefore, if students engage in critical thinking skills and critical thinking values are developed in them, social benefits will have to be obtained that will be so huge ( 14 - 15 ).

Amini and Fazli Nejad (2000) reviewed the critical thinking skills of the students of the general practitioners of the medical school of Shiraz University of Medical Sciences; the results of this study showed that students were weak in using critical thinking skills ( 16 ).

Mc Grace's study (2003) showed that the mean scores of critical thinking skills of medical students are increasing from year 1 to 4 (except the third year) ( 17 ). The results of Paul's (2014) Delphi study showed that the curriculum should be designed in such a way as to enhance critical thinking and make it possible to evaluate it. Sufficient time needs to be allocated to assess critical thinking ( 18 ).

Agnesno and Marie (2005) in a study criticized barriers to critical thinking, such as lack of faculty knowledge, use of teaching and assessment methods that do not facilitate the critical thinking of the learners, negative attitudes of faculty members towards change and their resistance to change, inappropriate selection process and poor educational backgrounds that do not facilitate the students' critical thinking, insufficient socialization, culture, and inadequacies of education ( 19 ).

Recently, given the dramatic changes in the students' curriculum, especially the volume of courses and the need to integrate medical courses, the attention of the academic education system to curriculum revisions has been criticized. On the other hand, given the integrated complexity of critical thinking, the importance of revising the curriculum becomes more critical. Therefore, the present study aimed to investigate the barriers of critical thinking in the medical school curriculum from the viewpoints of medical education experts. Perhaps, the qualitative recognition of these barriers in the curriculum has made it possible to redefine it to develop critical thinking in medical students and its importance in their future lives and careers.

This is a qualitative study aiming to explain the barriers of critical thinking in the medical school curriculum. In this study, using the qualitative research approach, critical thinking barriers in the medical school curriculum were explained from the viewpoint of medical education experts of Shiraz University of Medical Sciences. In this section, semi-structured interviews were used to collect the data.

The research context was affiliated to Shiraz University of Medical Sciences, School of Medicine, and clinical and basic sciences groups. These environments provided access to qualified teachers. In this study, participants were selected from the Faculty of Medicine in the departments of Basic and Clinical Sciences, and faculty members of the Department of Medical Education and five medical students were selected by purposive sampling method. The sampling was continued until the previous information was repeated, and the content or new nature of the participants were not extracted.

Inclusion criteria were the participants’willingness to participate in the study and express their views, opinions and wealth of information, and teachers with more than five years of teaching experience in the university regarding the concept under the study. 

Before collecting the data, the researcher provided explanations about the goals, process and conditions of the interview. The data were then extracted using semi-structured interviews with open non-led questions and collected using a few guide questions. The interviews were started with general questions such as “What do you mean by critical thinking?”, “Have you experienced critical thinking in the curriculum?” and "How did you incorporate critical thinking into the curriculum?", Or "What are facilitators or inhibitors of critical thinking in medical students' curriculum? Explain it. Interviews continued based on the responses of contributors and with the help of exploratory questions, such as "Explain more. What is your example?, or What do you mean? ". Subsequent questions were based on initial responses of individuals or analysis of previous interviews. The duration of each interview was about 30 to 45 minutes, considering the faculty members' time. Interviews continued until data saturation, and sufficient information was received. After the participants' agreement interview was done in a relaxed and comfortable environment. All interviews were digitally recorded and verbatim word by word. Data analysis was carried out simultaneously with data collection. The simultaneous analysis of the interviews provided the main people with access to further interviews, resulting in more valuable information.

In the present study, to analyze the data obtained from interviews, we used a qualitative content analysis approach in the conventional way ( 20 ). The analytical unit was firstly determined by rewriting the interviews right after each section. Data analysis began by repeated reading of interviews, so that the researcher obtained an overview of the concept. Subsequently, based on the descriptions of the participants, semantic units containing meaningful sentences and words were identified and analyzed. In this way, the order of raw codes was extracted based on the nature of the data.

Continuously, the process of reduction and compression of semantic units was done. Thus, each semantic unit was named and conceptualized in terms of its implications. Then, the same necessary codes were merged and organized and categorized into the first classes.

We tried to group the codes that are more similar to each other in the same categories. In other words, the codes categorized within the classes were homogeneous and heterogeneous with other classes. Then, the primary classes were merged based on the relationship between them, and the main classes were formed. In the final stage, the researcher tried to discover the central themes by comparing and revisiting the classes and subclasses. At this stage, by integrating the same main classes, the content of the barriers to critical thinking was derived from the curriculum of medical students.

Strobert and Carpenter (2011) have proposed four criteria of validity or reliability, transferability, and verifiability for evaluating and validating data in qualitative research that have been used in this research ( 21 ).

Trustworthiness

In the end, the extracted themes were presented to the participants (member check) and it was found that some changes were needed. The themes were also provided by one of the qualified qualitative experts who tried to present all the opinions of the experts in conveying the concepts to the audience (peer check).

In this part of the study, the findings of the research are presented in order to explain and identify the barriers of critical thinking in the medical school curriculum by content analysis method. In general, the analysis of the interviews in this study was that during the data comparison process, 47 codes were initially extracted from the interviews, which were subdivided into nine main categories after data analysis and integration. Finally, from the clean codes, 14 subcategories, 8 main classes, 2 themes (socio-cultural conditions and traditional and unchanging system of education) were formed. Table 1 shows the themes, categories, and subcategories.

Subjects, main categories, and subcategories extracted from the study

A) Socio-cultural conditions

Providing the right educational and cultural conditions that separate the individual from school education and provide rapid and widespread access to the community and labor market in a college education course is useful in fostering a critical personality. . Given the importance of this topic, social-cultural conditions were the first themes extracted from the qualitative data analysis in this study. The theme consists of three main categories: "resistance to critical society," "tension," and personality factors, which are described below in each of the main categories and subcategories of this theme.

1. Resistance to the critical community: Based on the experiences of the study participants, resistance to society and belief in the superiority of collective thinking over independent thinking as the first significant category were the two subcategories of "linear thinking-intellectual dogmatism" and "systemic obedience."

1-1. The Linear Thinking-Intellectual Dogmatism

Based on the concept of this subcategory, the participants in this study acknowledged that in the current situation, some linear thinking prevails, according to which, without sufficient knowledge of the community's need for criticism, medical schools only train students in a parrot-like and linear fashion.

One contributor commented on positive support for critical thinking:

"When we train the learner with traditional methods, like lectures, and do not use collaborative educational methods and class discussions, the focus and accuracy will be reduced, and the quality of education will also be affected."  (Professor-Contributor No. 8).

The same participant said:

"... there are many students, and it is not easy to control them in the collaborative space and the discussion in the class; on the other hand, the increase in the volume of the course contents and the need to teach all the concepts in the classroom does not provide the opportunity for participatory teaching; therefore, there is not enough opportunity to interact or educate. "  (Professor-Contributor No. 8).

An increase in the volume of the course content, a large amount of documentation in the curriculum, unbalanced workload, and the need to maintain the conditions and get used to implementing traditional training in the classroom are the items participants referred to in expressing their experiences in examining the causes of linear thinking.

1.2. Obedience in the system

Submissiveness in the system is the second main category, and this means that obedient thinking is the product of linear thinking. Contributors mentioned the critical role of obedience, stereotyping, and non-positive mental flexibility in the learning system of learners. One of the participants said:

"The current educational system of the university directs the learner to follow a routine and uniform process and expects them to take a clear and coherent framework. In this atmosphere, the student moves toward a kind of stereotype and cliché. " (Participant No. 3).

One of the contributors believed in the students' desire for traditional education and use of simple mental stereotypes rather than using specific solutions and says:

"Students are interested in temporary and common solutions because of their past education during school time; they are reluctant to participate in class discussions and find creative solutions to the problems."  (Professor- Contributor No. 4).

Another participant believed that:

"Given that the professor has provided space for collaborative learning, in most cases, mental prejudice and lack of critical thinking of learners into specific ideologies and beliefs and mental stereotypes on a particular issue prevent the use of critical thinking skills and the emergence of creative solutions in the classroom." (Professor- Participant No. 12).

2. Intellectual tension

Intellectual stress is the second major category of socio-cultural conditions based on the participants' experiences, consisting of three subcategories of "anxiety, stress and fatigue," "curriculum overload," and "mental messiness." 

2.1. Anxiety, stress, and fatigue

Anxiety, stress, and fatigue were one of the aspects of distracting factors that triggered specific social conditions and factors such as war and sanctions, and ultimately prevented critical focus and thinking on the issues.

One of the participants stated his experiences on stress and exhaustion of learners in the educational environment:

"Sometimes in the classroom I find that some students do not have enough focus on lessons because of fatigue, and sometimes they take a nap in the classroom; stress makes them sick, perhaps due to the educational method, which has taken the opportunity of students to participate and think. "  (Professor- Participant No. 1).

2.2. Curriculum Overload

Providing enough space and time to think about the subject and participate in different topics that were experienced by most of the participants can be useful in enhancing critical thinking skills.

In this regard, one of the participants believed that:

"Due to the compactness of the curriculum of the basic sciences of students, there is no opportunity to present the concepts collaboratively, and they must quickly teach the subject, which removes the atmosphere of thinking and discussing from students." (Student- Participant No. 3).

Also, another participant believed that:

"A large amount of course content in the basic sciences causes the dispersion and confusion of students and takes the opportunity to discuss and think about different concepts from the students."  (Student- Participant No. 6).

2.3. Not-Organized Thinking

Most students expressed distraction, slackness, and lack of mental focus on various subject areas in their experiences, which reduced or neglected the use of critical thinking skills.

"Some participants at the time of entering the university do not have any specific plans of their future, and they are also confused, unobtrusive, and wacky in the classroom, and they usually go from branch to branch."  (Professor-Participant No. 5).

The other participant noted that:

"The confusion and distraction of learners during the education period and the lack of focus on the concepts of learning may prevent the acquisition of new information."  (Student-Participant No. 14).

Another participant in her experience stated that:

"Many entrance exam counselors advise the learners to endure the hardships of studying for a course that will make them more comfortable and free after passing the exam, which will confuse the learners."  (Student-Participant No. 15).

 Most learners in high-level mental situations often think of routines and familiar affairs, which is caused by the entrance exam thoughts leading to lack of attention to innovative and new options. This is due to brain dispersion ?? and slackness and, on the other hand, to thinking in a particular mental context that prevents a person from thinking and creative solutions.

3. Personality characteristics

Faculty members believe that increasing self-confidence is one of the essential needs of all people, especially students. We usually get the most out of those who have high self-esteem because these people have characteristics which make loving people and are often more admired. These people cause classroom dynamics, challenge different issues and opinions, and support their ideas in various topics and provide them with acceptable collective arguments. The existence of such learners is necessary for every educational environment. This theme consists of three categories: "lack of self-esteem," "lack of motivation," and "lack of curiosity in the search for information."

3.1. Lack of confidence

Based on the experiences of the participants, one of the characteristics of the learner's personality that is effective in strengthening critical thinking is self-confidence.

One of the participants believed that:

"Learners who have higher levels of self-esteem in the learning environment and lessons of discussion use critical thinking in decision making and solving different issues, and do not retreat from class positions in class discussions and debates. They have various reasons for their answers, which make a significant contribution to classroom dynamics. " (Student-Participant No. 12).

In this regard, one other participant also said:

"One of the significant barriers to developing critical thinking is the very nature of personal thinking processes. Individuals with high self-esteem seek information and exchange their thoughts in the classroom, and this results in classroom dynamics and better education and higher quality for all learners. " (Professor-Participant No. 4).

The findings suggest that learners with high self-esteem are more successful than their classmates. In other words, learners with a higher level of self-esteem have a better job and a better position than the others and achieve more success in society. This is why increasing self-esteem is one of the essential steps in the success of critical thinking in learners.

3.2. Lack of motivation

Participants' experiences confirm that lack of risk-taking, low self-esteem, and lack of motivation to risk are the primary barriers to critical thinking in learners.

One of the participants stated that:

"Teaching critical thinking is useless to learners who do not have the incentive to use critical thinking in the classroom." (Professor-Participant No. 3).

The participant adds that:

"Learners in the classroom have to work together with faculty members and other learners to analyze issues and topics and find the right solutions actively. To achieve this educational success, the learners should have sufficient motivation as a prerequisite. This motivation can be enhanced with various rewards such as class support and encouragement and feedback, and even so, to say, it can motivate learners to become more risk-averse. " (Professor-Participant No. 4)

3.3. Curiosity in search of information

Participants have experienced that curiosity is the key to developing learning intelligence, and it is a personality trait of some people. Having this feature strengthens critical thinking skills in classroom debates and topics.

“The faculty members must allocate more time for negotiation and show critical thinking while they are teaching. They should also use methods to raise the students’ curiosity.” (Professor- Participant No. 9).

Having some personality traits such as self-confidence, curiosity, flexibility, and creativity, willingness to think is useful in developing critical thinking.

B) The traditional and unchanging system of education

According to the participants and their experiences, the traditional and unchanging system is hard to change, and it doesn't accept any innovation. Believing in this method of passive teaching and learning is a common practice in many academic educational settings. In recent years, considering the positive effects of modern teaching and their acceptance in academic settings, the use of modern teaching methods has been considered that can provide a space for the use of critical thinking skills. The five main categories included "lack of understanding of the community needs for criticism," "dominance of the traditional teaching model," "lack of experts in critical thinking," "ineffective evaluation," and "the difficulty of critical thinking education."

1. Lack of understanding of social needs for criticism

Based on the experiences of the participants, the role of criticism in the curriculum is unclear, and the need for criticism seems urgent. In this regard, fostering critical thinking and developing an appropriate curriculum by incorporating critical thinking concepts and skills can be very useful.

One participant believed that:

"The current curriculum concepts are usually incompatible with the needs of learners and today's society, and the need to rethink curricula is very much felt, while students need to educate themselves on critical thinking and not just accumulate much content in their minds."  (Student- Participant No. 14).

Another participant adds that:

"Teaching students to use critical thinking skills helps them to solve real-life issues and situations in their community and their career prospects, which should be specifically addressed in the curriculum."  (Professor- Participant No. 9).

"Curriculum design is fundamental considering the space for research, hypothesis and idea development in different topics and appropriate timing for learners to utilize critical skills, and it will also have an impact on the future of students' careers and community needs. " (Professor- Participant No. 2).

Critical thinking can be improved through needs assessment and curriculum development which includes essential components such as goals, content, teaching, and evaluation process to foster the learners' critical thinking to achieve creativity and academic achievement.

2. The Rule of Traditional Teaching Pattern

New ways of planning and integrating student courses based on the participants' experiences have been considered. The use of these new teaching methods provides the appropriate space for practicing and critical thinking skills in learners. However, in practice, traditional teaching patterns usually preclude the comprehensive and complete implementation of new teaching methods.

"Most teachers are interested in using traditional teaching methods, and learners have become accustomed to these methods, and they are more than happy to be provided with written content and only memorize the content. " (Professor- Participant No. 10).

Another participant added that:

"Students usually fail to think multidimensional in a variety of subjects around the classroom, and they usually continue one-dimensionally and just memorize the lesson content and avoid participating in different topics or thinking about different subjects."  (Student- Participant No. 16).

This section notes that the use of new teaching methods can provide a space for the use of critical thinking skills.

3. Lack of critical thinking skills

Participants in their experiences stated that faculty members did not have sufficient mastery of critical thinking concepts at present. The use of highly qualified teachers in modern teaching methods and the provision of a suitable environment for student learning has made critical and questioning skills essential in the current teaching environment.

One participant added that:

"Young teachers are usually interested in new teaching methods in their teaching and provide a space for discussion, suggestions, and criticism of free and independent concepts and thinking, which is usually reduced by the work experience of the faculty members, as well as their lack of time. " (Professor- Participant No. 6).

"Some subjects are not considered by the teachers because they cannot be taught in traditional teaching methods. These topics will only be transferable to collaborative discussions or classroom discussions with learners."  (Professor- Participant No. 5).

4. Ineffective evaluation

The experiences of the participants in this study confirm that evaluation without feedback and taxonomy of critical thinking is ineffective in evaluating the learners, and providing feedback in this space is one of the most difficult challenges to which the teachers are faced. On the one hand, the provided feedback must be truthful. On the other hand, feedback should be given to learners at the right time in order to be active and efficient. Providing students with the right feedback at the right time can be one of the appropriate methods of evaluation that enhances their critical thinking skills.

One participant in providing feedback to the students mentioned that:

"Despite the fact that students enjoy receiving rewards or correcting their bugs during their teaching, university faculty members, due to their busy work and high volume of teaching materials, avoid providing a collaborative learning environment with questions and answers while teaching and appropriate evaluation and feedback and they usually finish the teaching with traditional teaching methods, which can affect the quality of teaching. " (Professor- Participant No. 11).

Good feedback always comes with positive things that help the learners feel more at ease and take more steps to succeed, advance and ask questions that require excellent thinking skills to be answered.

5. The difficulty of teaching critical thinking

Providing students with critical thinking skills in educational settings is very difficult, making it less likely to use this teaching method in the classroom.

One contributor believed that:

"Due to the size of the curriculum and the need to train all the resources, teaching traditionally seems more appropriate because taking classes in a new way of teaching will waste the time and not transfer all the subjects to the students."  (Participant No. 6).

"Holding the classroom in new ways is time-consuming and difficult, and the trainees usually do not make effective use of the available space, so the teaching time is spent on unnecessary discussions instead of transferring lesson concepts that will not do better for students than wasting class time."  (Participant No. 7).

It is necessary to develop critical thinking for a learner, due to the increased amount of information, judgment and decision making, and the improvement of the individual and professional life, ( 22 ). Analyzing the data showed that the two themes of cultural-social conditions and the unchanging traditional system are the main barriers of critical thinking in the medical school curriculum.

Cultural-social conditions constituted the first key infrastructure of critical thinking barriers for medical students. The findings of the present study showed that lack of support for independent and critical thinking was one of the most critical issues that most participants mentioned. Rezaei and Haqqani (2015) have studied the causes of resistance to change; they considered the lack of participation of learners in classroom education and values and the shortage of support for creative thinking as one of the most important reasons for resisting changes. What is more, he believes that in order to implement the change successfully, we need to find appropriate solutions to overcome these causes ( 23 ). The results of this study are consistent with those of the present research.

On the other hand, submissiveness in the system is another aspect of this dimension, which is incompatible with the results of the research by Graham (1991) ( 24 ). He has concluded that older people, especially if they are single, look at obedience superficially, and try to solve the issues more creatively and discuss different issues more critically. This result is also consistent with those of the Kalantari and Babayan’s (2014) study ( 25 ).

According to the findings of this study, distortion factors are one of the other themes of this research. Anxiety, stress, and fatigue were the most important aspects of this research. Najafian Zadeh et al. (2014) have concluded that the critical thinking of the students in our country is weak, and one of the causative factors was anxiety and fatigue in students, which was due to the high volume of the courses ( 26 ). Since critical thinking is not considered as an essential dimension in the teaching of students during the educational process by the educational system, and critical thinking is a complex mental process that provides flexibility, proper response, correct predictions and rational decision making of the students in different situations, it is necessary to pay attention to this issue by improving educational patterns, which is consistent with the results of this study.

The lack of enough time to think was another obstacle to this dimension. In this regard, Sharifi et al. (2016) concluded that the use of the assistants of critical thinking capabilities was weak, and this was because they are so busy and do not have enough time during the study that is in the same line with the results of this study ( 27 ).

Intellectual stress is the last theme of this study, the most important aspects of which were anxiety, stress and fatigue, an overload of curriculum, and intellectual fatigue. 

In the research by Durova et al., ( 28 ) participation learning was also a method of developing critical thinking; also, discussing and revealing new ideas and evaluating other people's ideas for developing critical thinking and problem-solving skills and participatory learning were usd. By creating learning management and meaningful experiences and stimulating the learners to think, faculty members have a facilitating role in this issue.

The last subject of this research was the personality factors that included issues such as lack of self-esteem, lack of motivation, and curiosity in seeking information that was attractive to the participants. In this regard, the results showed that, in the viewpoint of the experts participating in this study, one of the most effective barriers to the use of critical thinking is personality barriers. The investigation of numerous texts has shown that having some personality traits such as self-esteem, curiosity, flexibility, creativity, and willingness to think is valid in critical thinking skills ( 13 ). Therefore, the absence of any of these personality traits in individuals can be a barrier to critical thinking. Some scholars believe that critical thinking embraces something beyond the aspects of intelligence and individual performance, and other factors such as emotional and personality traits also affect it ( 14 ). As a result, it seems that before entering the clinical field, it is necessary to go through psychological courses to improve individual characteristics and, thus, increase the skill in critical thinking because the goal of teaching critical thinking is to educate people who are far from personal prejudice and who are careful about their work ( 13 ).

In the personality aspect of the students, "lack of self-esteem" was considered by the experts participating in this study to be the most crucial factor in not using critical thinking, which could cause passive confrontation with events and referral to the authorities. Therefore, along with nursing lessons and in-service training, it is necessary to use strategies for increasing the self-esteem of the nurses and students.

The second theme of this study was the traditional and unchanging system of education which consisted of five categories: "lack of understanding of the need for critical society," "rule of traditional teaching," "lack of experties in critical thinking," "ineffective evaluation" and "difficulty in teaching critical thinking." As noted, the lack of understanding of the community's needs for criticism was one of the main categories of the subject, and it addressed issues such as the lack of attention of curriculum planners to critical thinking and high-level skills in the curriculum. In this regard, researches have been done to confirm the impact of goals on the content, teaching methods, and evaluation as curriculum elements in fostering critical thinking. Based on Vagra’s research (2007) in Lipton School, which teaches in-service teachers, consideration of structure, theory process, this is an essential indicator that critical thinking skills can be achieved through the selection of goals, content, and processes and methods ( 29 ).

Another aspect of this theme was the ineffectiveness of the traditional model of teaching and evaluation. In other words, enhancing motivation to use thinking as the key to improving the quality of students' critical thinking is typically overlooked in the formal curriculum of students; therefore, one of the most effective measures in this regard is to improve the attitude aspects of critical thinking, considering the hidden curriculum function in higher education. In this regard, the researches by Alipour ( 2 ), Sharifi ( 26 ), and Shariatmadari ( 30 ), have neglected development of questioning, analysis, composition and evaluation skills and judgment in learner curriculum, and the lack of attention to the hidden curriculum has been considered one of the significant barriers to developing critical thinking skills. Research by Talebzadeh et al. (2009) has also considered attention to hidden curriculum elements as one of the influential factors in fostering critical thinking ( 29 - 31 ).

Lack of experts in critical thinking was one of the other main categories of this theme. In this regard, Cook and Mull's research points to learning-based approaches to promoting critical thinking, problem-solving, active participation, identification of learning needs, creative discussion, peer learning, and the integration and production of knowledge that make learning realistic, entertaining and attractive.

The difficulty of teaching critical thinking was the last category of this theme; in this regard, research by Drewa et al. found it necessary to discuss and reveal new ideas and evaluate the ideas of others to develop critical thinking and problem-solving skills and collaborative learning, and young teachers have been identified as facilitators or leaders of learning and creators of meaningful experiences that stimulate the learners to think.

According to the results of research done in this dimension, most educational systems tend to have a fixed curriculum content in the curriculum without the use of new, collaborative learning methods in learners, all of which discouraging the students from using critical thinking skills.

Application of findings

The findings of this study provide an overview of the critical thinking situation in the academic environment and the barriers of utilizing critical skills in medical students that can be a practical step in revising and designing curricula with a more comprehensive view of new educational practices, especially concepts and critical thinking skills.

Study limitation

In this study, access to experienced professors in this field was difficult nationwide. However, we sought to use any source of information, scholars, and students in this field.

The educational system Our educational system needs a development which relegates the education from extreme reliance on old knowledge; brings prospects into thinking, intellection, research, creativity, and innovation;blossoms the students’ talents; deepens the critical spirit of critique and review; boosts the self-esteem and self-confidence; and promotes the educational, biological, technical and professional skills in the young generation. Such a change will be possible by changes in the attitudes of the faculty members, planners and curriculum in formulating strategic plans for goals and content, and also teaching and evaluation methods for curricula and attention to the importance and necessity of developing critical thinking at different levels of education. 

In general, the cultural and social conditions of the traditional and unchanging system of education were two significant barriers to the implementation of the critical thinking program, which seems to overcome these barriers to provide critical thinking concepts and skills in medical students' curricula. Therefore, it can be concluded that the reform of the educational system in educational and clinical environments is one of the strategies for increasing the use of critical thinking.

Academic faculty members can help to improve the critical thinking skills of their learners by creating an atmosphere of inquiry and an appropriate platform for negotiation. Establishing workshops and meetings for familiarizing and enhancing search skills, questioning techniques, and evaluating the value and content of information, as well as holding workshops, can reduce the significant barriers to critical thinking development with effective use of information by students. Therefore, based on the results of this study, it is recommended that an effort should be made to transform the classroom environment into the interface between learners and faculty members through the elimination of the existing barriers.

Conflict of Interests: None Declared.