critical thinking in medical education

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Critical thinking in healthcare and education

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• Peer review
• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
• Astrid Austvoll-Dahlgren , senior researcher 2 ,
• Tammy Hoffmann , professor 6
• 1 EPPI-Centre, UCL Department of Social Science, London, UK
• 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
• 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
• 4 James Lind Initiative, Oxford, UK
• 5 Education Endowment Foundation, London, UK
• 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking is not a new concept in education: at the beginning of the last century the US educational reformer John Dewey identified the need to help students “to think well.” 3 Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (such as analysis, inference, and self regulation); approaches to specific questions or problems (orderliness, diligence, and reasonableness); and approaches to life in general (inquisitiveness, concern with being well informed, and open mindedness). 4

An increasing body of evidence highlights that developing critical thinking skills can benefit academic outcomes as well as wider reasoning and problem solving capabilities. 5 For example, the Thinking, Doing, Talking Science programme trains teachers in a repertoire of strategies that encourage pupils to use critical thinking skills in primary school science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on pupils’ science attainment, with signs that it was particularly beneficial for pupils from poorer families. 6

In medicine, increasing attention has been paid to “critical appraisal” in the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions. 7 8 9 The need for critical appraisal in medicine was recognised at least 75 years ago, 10 and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. 11 The General Medical Council’s Good Medical Practice guidance includes the need for doctors to be able to “provide effective treatments based on the best available evidence.” 12

If patients and the public are to make well informed health choices, they must also be able to assess the reliability of health claims and information. This is something that most people struggle to do, and it is becoming increasingly important because patients are taking on a bigger role in managing their health and making healthcare decisions, 13 while needing to cope with more and more health information, much of which is not reliable. 14 15 16 17

Teaching critical thinking

Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curriculums for primary and secondary schools in many countries. 18 Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking. 19 20 This matters because the ability to think critically is an essential life skill relevant to decision making in many circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for pupils who live in homes where they are encouraged to think and talk about what they are doing. This, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the “critical thinking gap” between children from disadvantaged communities and their more advantaged peers requires attention as early as possible.

Although it is possible to teach critical thinking to adults, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, starting in primary school. Erroneous beliefs, attitudes, and behaviours developed during childhood may be difficult to change later. 21 22 This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on and adequate time to learn them.

Strategies for teaching students to think critically have been evaluated in health and medical education; in science, technology, engineering, and maths; and in other subjects. 23 These studies suggest that critical thinking skills can be taught and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students to make sound judgments. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically , and the ability to think critically is correlated with academic success. 24 25

Evaluations of strategies for teaching critical thinking in medicine have focused primarily on critical appraisal skills as part of evidence based healthcare. An overview of systematic reviews of these studies suggests that improving evidence based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment. 26

Cross sector collaboration

Informed Health Choices, an international project aiming to improve decision making, shows the opportunities and benefits of cross sector collaboration between education and health. 27 This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health. It aims to develop, identify, and promote the use of effective learning resources, beginning at primary school, to help people to make well informed choices as patients and health professionals, and well informed decisions as citizens and policy makers.

The project has drawn on several approaches used in education, including the development of a “spiral curriculum,” measurement tools, and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals. The basic ideas are revisited repeatedly, building on them until the student has grasped a deep understanding of the concepts. 28 29 The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. 30 31 32 The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games. 33 34 35 It has also built on the traditions of clinical epidemiology and evidence based medicine to identify the key concepts required to assess health claims. 29

It is difficult to teach critical thinking abstractly, so focusing on health may have advantages beyond the public health benefits of increasing health literacy. 36 Nearly everyone is interested in health, including children, making it easy to engage learners. It is also immediately relevant to students. As reported by one 10 year old in a school that piloted primary school resources, this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget.” Although the current evaluation of the project is focusing on outcomes relating to appraisal of treatment claims, if the intervention shows promise the next step could be to explore how these skills translate to wider educational contexts and outcomes.

Beyond critical thinking

Exciting opportunities for cross sector collaboration are emerging between healthcare and education. Although critical thinking is a useful example of this, other themes cross the education and healthcare domains, including nutrition, exercise, educational neuroscience, learning disabilities and special education needs, and mental health.

In addition to shared topics, several common methodological and conceptual issues also provide opportunities for sharing ideas and innovations and learning from mistakes and successes. For example, the Education Endowment Foundation is the UK government’s What Works Centre for education, aiming to improve evidence based decision making. Discussions hosted by the foundation are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors.

Similarly, the foundation’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted, and applied in healthcare. Since the development and evaluation of educational interventions are separated, evaluators have no vested interested in the results of the assessment, all results are published, and bias and spin in how results are analysed and presented are reduced. By contrast, industry sponsorship of drug and device studies consistently produces results that favour the manufacturer. 37

Another example of joint working between educators and health is the Best Evidence Medical Education Collaboration, an international collaboration focused on improving education of health professionals. 38 And in the UK, the Centre for Evidence Based Medicine coordinates Evidence in School Teaching (Einstein), a project that supports introducing evidence based medicine as part of wider science activities in schools. 39 It aims to engage students, teachers, and the public in evidence based medicine and develop critical thinking to assess health claims and make better choices.

Collaboration has also been important in the development of the Critical Thinking and Appraisal Resource Library (CARL), 40 a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently under way at the Education Endowment Foundation. On 22 May 2017, the foundation is also cohosting an event with the Royal College of Paediatrics and Child Health that will focus on their shared interest in critical thinking and appraisal skills.

Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners, and the public can all benefit from working together to help people to think critically about the choices they make. Events such as the global evidence summit in September 2017 ( https://globalevidencesummit.org ) can help bring people together and build on current international experience.

Contributors and sources: This article reflects conclusions from discussions during 2016 among education and health service researchers exploring opportunities for cross sector collaboration and learning. This group includes people with a longstanding interest in evidence informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation, and critical thinking and appraisal.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Not commissioned; externally peer reviewed.

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Teaching Critical Thinking and Problem-Solving Skills to Healthcare Professionals

• Published: 27 October 2020
• Volume 31 , pages 235–239, ( 2021 )

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• Jessica A. Chacon 1 &
• Herb Janssen   ORCID: orcid.org/0000-0001-8015-9369 1  

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Introduction

Determining approaches that improve student learning is far more beneficial than determining what can improve a professor’s teaching. As previously stated, “Lecturing is that mysterious process by which the contents of the note-book of the professor are transferred through the instrumentation of the fountain-pen to the note-book of the student without passing through the mind of either” [ 1 ]. This process continues today, except that the professor’s note-book has been replaced with a PowerPoint lecture and the student’s note-book is now a computer.

In 1910, the Flexner report noted that didactic lectures were antiquated and should be left to a time when “professors knew and students learned” [ 2 ]. Approximately 100 years later, the Liaison Committee on Medical Education (LCME) affirmed Flexner’s comment and suggested that student learning must involve active components [ 3 ]: It seems somewhat obscured that almost 100 years separated these two statements.

Our strategy requires the following: student engagement in the learning process; a curriculum that develops a foundation for each student’s knowledge acquisition; focusing primarily on student learning instead of professor teaching; helping enable students develop critical thinking skills; and encouraging students to develop “expertise” in their chosen discipline.

Six fundamental topics that play a role in the development of a health sciences student’s critical thinking ability will be described. In “Section I,” these topics will be discussed independently, highlighting the importance of each. In “Section II: Proposed Curriculum and Pedagogy to Improve Student Learning,” the topics will be united into a practical approach that can be used to improve student learning, curriculum, pedagogy, and assessment.

Foundation Knowledge

Students use mnemonics to provide a foundation for new information. Although mnemonics help students associate information that they want to remember with something they already know, students learn tads of information that is not placed into a practical, meaningful framework developed by the student [ 4 , 5 ]. This commentary highlights the problem of recalling facts when these facts are presented in isolation. The responsibility for this resides not with the student, but with a curriculum that teaches isolated facts, instead of integrated concepts.

A taxonomy for significant learning presented by Dr. Fink emphasizes the need to develop foundational knowledge before additional information can be learned in an effective manner [ 6 ]. He provides suggestions on developing specific learning goals in given courses. Two of his most important criteria are (1) the development of a foundation of knowledge and (2) helping students “learn how to learn” [ 6 ].

Learning Approaches and Abilities

Howard Gardner introduced the concept of multiple intelligences in the 1980s [ 7 ]. Gardner expanded this idea to include intelligence in the areas of (1) Verbal-linguistic, (2) Logical-mathematical, (3) Spatial-visual, (4) Bodily-kinesthetic, (5) Musical, (6) Interpersonal, (7) Intrapersonal personal, (8) Naturalist, and (9) Existential. He concluded that students gifted in certain areas will be drawn in that direction due to the ease with which they excel. While it is important to recognize these differences, it is crucial to not ignore the need for student development in areas where they are less gifted. For example, students gifted in mathematics who fail to develop intrapersonal and interpersonal skills will more likely become recluse, limiting their success in real-world situations [ 7 , 8 ]. Similar examples can also be found in the medical world [ 7 , 8 ].

Based on Gardner’s work, it seems evident that students admitted to our health sciences schools will arrive with different skills and abilities. Despite this, educators are required to produce graduates who have mastered the competencies required by the various accrediting agencies. Accomplishing this task demands sensitivity to the students’ different abilities. While the curriculum remains focused on the competencies students must demonstrate when training is complete. Creating this transition using a traditional lecture format is difficult, if not impossible.

Active Engagement

In 1910, Flexner suggested that didactic lecture is important; however, it should be limited only to the introduction or conclusion of a given topic [ 2 ]. Flexner stated that students should be given the opportunity to experience learning in a context that allowed them to use scientific principles rather than empirical observations [ 2 ]. Active engagement of the student in their learning process has been recently promoted by the LCME [ 3 ]. This reaffirmation of Flexner’s 1910 report highlights the incredibly slow pace at which education changes.

Critical Thinking

Critical thinking is an active process that, when applied appropriately, allows each of us to evaluate our own activities and achievements. Critical thinking also allows an individual to make minor, mid-course corrections in thinking, instead of waiting until disastrous outcomes are unavoidable.

Educators in Allied Health and Nursing have included critical thinking as part of their curriculum for many years [ 9 ]. Medical educators, on the other hand, have not fully integrated critical thinking as part of their curriculum [ 10 , 11 ].

Bloom’s taxonomy has often been used to define curriculum [ 12 ]. The usefulness and importance of Bloom’s taxonomy is not to be underestimated; however, its limitations must also be addressed. As Bloom and his colleagues clearly stated, their taxonomy describes behavioral outcomes and is incapable of determining the logical steps through which this behavior was developed [ 12 ]. Bloom highlights this shortcoming in his initial book on the cognitive domain. He described two students who solved the same algebra problem. One student does this by rote memory, having been exposed to the problem previously, while the other student accomplishes the task by applying mathematical principles. The observer has no way of knowing which approach was used unless they have prior knowledge of the students’ background [ 12 ]. The importance of this distinction becomes apparent in medical problem-solving.

Contextual Learning

Enabling students to learn in context is critical; however, trying to teach everything in context results in a double-edged sword [ 13 ]. On the one hand, learning material in context helps the student develop a solid foundation in which the new information can be built. On the other hand, the educator will find it impossible to duplicate all situations the student will encounter throughout his or her career as a healthcare provider. This dilemma again challenges the educator to develop a variety of learning situations that simulate real-world situations. It seems that “in context” can at best be developed by presenting a variety of patients in a variety of different situations.

In the clinical setting, the physician cannot use a strict hypothesis-driven study on each patient, but must treat patients using the best, most logical treatment selected based on his or her knowledge and the most reliable information.

Development of Expertise

Several researchers have studied the characteristics required of expert performance, the time required to obtain these traits, and the steps that are followed as an individual’s performance progresses from novice to expert.

Studies involving expert physicians have provided data that can be directly used in our attempt to improve curriculum and pedagogy in the healthcare profession. Patel demonstrated that medical students and entry-level residents can recall a considerable amount of non-relevant data while the expert cannot [ 14 ]. Conversely, the expert physician has a much higher level of relevant recall, suggesting they have omitted the non-relevant information and retained only relevant information that is useful in their practice. Using these methods, the expert physicians produce accurate diagnosis in almost 100% of cases, while the medical students can achieve only patricianly correct or component diagnosis only [ 14 ].

In the healthcare setting, both methods are used. The expert physicians will use forward reasoning when the accuracy of the data allows this rapid problem-solving method. When the patient’s conditions cannot be accurately described using known information, the expert diagnostician will resort to the slower hypothesis-driven, backward reasoning approach. In this manner, the highest probability of achieving an accurate diagnosis in the shortest time will be realized [ 14 ].

Section II: Proposed Curriculum and Pedagogy to Improve Student Learning

The following section will outline several distinct but interrelated approaches to accomplish the six educational principles discussed above. The topics will be highlighted as they apply to the specific topic and each section will be comprised of curriculum, pedagogy, and assessment.

Developing a Knowledge Base Using Active Learning Sensitive to Students’ Abilities

Students admitted into healthcare training programs come from various backgrounds. This is both a strength for the program and a challenge for the educator. The strength is recognized in the diversity the varied backgrounds bring to the class and ultimately the profession. The challenge for the educator is attempting to provide each student with the material and a learning approach that will fit their individual ability and knowledge level. The educator can provide prerequisite objectives that identify the basic knowledge required before the student attempts the more advanced curriculum. Scaffolding questions can also be provided that allow students to determine their mastery of these prerequisite objectives. Briefly, scaffolding questions are categorized based on complexity. Simple, factual questions are identified with a subscript “0” (i.e. 1. 0 , 2. 0 , etc.). Advanced questions have a subscript suggesting the estimated number of basic concepts that must be included/combined to derive the answer.

Using technology to provide these individual learning opportunities online allows each student to address his or her own potential deficits. Obviously, those who find their knowledge lacking will need to spend additional time learning this information; however, using technology, this can be accomplished without requiring additional class time. This approach will decrease learning gaps for students, while excluding unnecessarily repeating material known by others.

The curriculum is divided into two parts: (1) content and (2) critical thinking/problem-solving skills. The basic knowledge and factual content can be provided online. Students are expected to learn this by actively engaging the material during independent study. This saves classroom or small-group sessions for interaction where students can actively learn critical thinking/problem-solving skills.

The curriculum should be designed so that students can start at their own level of understanding. The more advanced students can identify the level appropriate for themselves and/or review the more rudimentary information as needed. As shown by previous investigators, experts omit non-relevant information so that they can focus on appropriate problem-solving. Requiring students to learn by solving problems or exploring case studies will be emphasized when possible.

Technology can be used to deliver the “content” portion of the curriculum. Voice-over PowerPoints and/or video clips made available online through WebCT or PodCast will allow each student to study separately or in groups at their own rate, starting at their own level of knowledge. The content delivered in this fashion will complement the handout and/or textbook information recommended to the students. This will provide the needed basic information that will be used as a foundation for the development of critical thinking and problem-solving. The flipped classroom and/or team-based learning can both be used to help facilitate this type of learning. [ 15 ]

Student Assessments

It is imperative for students to know whether they have mastered the material to the extent needed. This can be accomplished by providing online formative evaluations. These will not be used to determine student performance; however, the results will be provided to the educator to determine the class’s progress and evaluation of the curriculum.

Developing Critical Thinking Skills in the Classroom or Small-Group Setting

Critical thinking skills are essential to the development of well-trained healthcare professionals. These skills are not “taught” but must be “learned” by the student. The educator provides learning experiences through which the students can gain the needed skills and experience. Mastery of the content should be a responsibility placed on the student. Information and assistance are given to the students, but students are held accountable for learning the content. This does not indicate that the educator is freed from responsibility. In fact, the educator will most likely spend more time planning and preparing, compared to when didactic lectures were given; however, the spotlight will be placed on the student. Once the learning modules are developed, they can be readily updated, allowing the educators to improve their sessions with each evaluation.

Curriculum designed to help student students develop critical thinking/problem-solving skills should be learned in context. During the introductory portions of the training, this can be accomplished by providing problem-based scenarios similar to what will be expected in the later clinical setting. The transition to competency-based evaluation in many disciplines has made this a virtual necessity. Critical thinking/problem-solving skills should emphasize self-examination. It should teach an individual to accomplish this using a series of steps that progress in a logical fashion, stressing that critical thinking is a progression of logical thought, not an unguided process.

The methods of teaching critical thinking can be traced back to the dialectic methods used by Socrates. Helping the students learn by posing questions remains an effective tool. Accomplishing this in a group setting also provides each student with the opportunity to learn, not only from their mistakes and accomplishments, but from the mistakes and accomplishments of others. Scenario questions can be presented in a manner similar to those found in many board and licensure exams. This exposes students to material in a format relevant to the clinical setting and to future exams. In larger groups, PowerPoint presentation of scenario questions can be used. Team-based learning (TBL) is useful in encouraging individual self-assessment and peer-peer instruction, while also providing an opportunity for the development of critical thinking and problem-solving skills. After the Individual Readiness Assurance Test (iRAT) exam, students work together to answer the Group Readiness Assurance Test (gRAT). Following this, relevant material is covered by clinicians and basic scientists working together and questions asked using an audience response system. This has been useful in encouraging individual self-assessment and peer-peer instruction while also providing an opportunity for the development of critical thinking and problem-solving skills.

Formative assessment of the students will be given in the class session. This can be accomplished using an audience response system. This gives each individual a chance to determine their own critical thinking skill level. It will prevent the “Oh, I knew that” response from students who are in denial of their own inabilities. Summative assessment in the class will be based on the critical thinking skills presented in the classroom or small-group setting. As mentioned earlier, the students will be evaluated on their ability to think critically and to problem-solve. This will by necessity include evaluation of content knowledge—but only as it pertains to the critical thinking and problem-solving skills. This will be made clear through the use of objectives that describe both content and critical thinking.

Enhancing Critical Thinking Skills in Simulation Centers and Clinics

The development of critical thinking skills in healthcare is somewhat unique. In chess, students can start playing using the same tools employed by the experts (the chess board); however, in healthcare, allowing students to make medical decisions is ethically inappropriate and irresponsible. Simulations centers allow students to gain needed experience and confidence without placing patients at risk. Once the students have mastered simulation center experiences and acquired the needed confidence, they can participate in patient diagnosis under the watchful eye of the expert healthcare professional.

The student’s curriculum now becomes the entire knowledge base of each healthcare discipline. This includes textbooks and journal articles. Students are required to come well prepared to the clinics and/or hospital having developed and in-depth understanding of each patient in their care.

Each day, the expert healthcare provider, serving as a mentor, will provide formative evaluation of the student and his/her performance. Mentors will guide the student, suggesting changes in the skills needed to evaluate the patients properly. In addition, standardized patients provide an excellent method of student/resident evaluation.

Summative evaluation is in the form of subject/board exams. These test the student’s or resident’s ability to accurately describe and evaluate the patient. The objective structured clinical examination (OSCE) is used to evaluate the student’s ability to correctly assess the patient’s condition. Thinking aloud had been previously shown as an effective tool for evaluating expert performance in such settings [ 16 ]. Briefly, think aloud strategies require the student to explain verbally the logic they are using to combine facts to arrive at correct answers. This approach helps the evaluator to determine both the accuracy of the answer and if the correct thought process was followed by the student.

If the time required to develop an expert is a minimum of ten years, what influence can education have on the process?

Education can:

Provide the student with a foundation of knowledge required for the development of future knowledge and skills.

Introduce the student to critical thinking and problem-solving techniques.

Require the student to actively engage the material instead of attempting to learn using rote memory only.

Assess the performance of the student in a formative manner, allowing the lack of information of skills to be identified early, thus reducing the risk of failure when changes in study skills are more difficult and/or occur too late to help.

Provide learning in a contextual format that makes the information meaningful and easier to remember.

Provide training in forward reasoning and backward reasoning skills. It can relate these skills to the problem-solving techniques in healthcare.

Help students develop the qualities of an expert healthcare provider.

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Chacon, J.A., Janssen, H. Teaching Critical Thinking and Problem-Solving Skills to Healthcare Professionals. Med.Sci.Educ. 31 , 235–239 (2021). https://doi.org/10.1007/s40670-020-01128-3

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DOI : https://doi.org/10.1007/s40670-020-01128-3

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A systematic review on critical thinking in medical education

Background:.

Critical thinking is the ability to raise discriminating questions in an attempt to search for better ideas, a deeper understanding and better solutions relating to a given issue.

This systematic review provides a summary of efforts that have been made to enhance and assess critical thinking in medical education.

Nine databases [Ovid MEDLINE(R), AMED, Academic Search Premier, ERIC, CINAHL, Web of Science, JSTOR, SCOPUS and PsycINFO] were searched to identify journal articles published from the start of each database to October 2012.

A total of 41 articles published from 1981 to 2012 were categorised into two main themes: (i) evaluation of current education on critical thinking and (ii) development of new strategies about critical thinking. Under each theme, the teaching strategies, assessment tools, uses of multimedia and stakeholders were analysed.

Discussion:

While a majority of studies developed teaching strategies and multimedia tools, a further examination of their quality and variety could yield some insights. The articles on assessment placed a greater focus on learning outcomes than on learning processes. It is expected that more research will be conducted on teacher development and students’ voices.

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West DC , Pomeroy JR , Park JK , Gerstenberger EA , Sandoval J. Critical Thinking in Graduate Medical Education : A Role for Concept Mapping Assessment? JAMA. 2000;284(9):1105–1110. doi:10.1001/jama.284.9.1105

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Critical Thinking in Graduate Medical Education : A Role for Concept Mapping Assessment?

Author Affiliations: Department of Pediatrics, School of Medicine (Drs West, Park, and Gerstenberger) and Division of Education (Drs Pomeroy and Sandoval), University of California, Davis.

Context  Tools to assess the evolving conceptual framework of physicians-in-training are limited, despite their critical importance to physicians' evolving clinical expertise. Concept mapping assessment (CMA) enables teachers to view students' organization of their knowledge at various points in training.

Objective  To assess whether CMA reflects expected differences and changes in the conceptual framework of resident physicians, whether concept maps can be scored reliably, and how well CMA scores relate to the results of standard in-training examination.

Design, Setting, and Participants  A group of 21 resident physicians (9 first-year and 12 second- and third-year residents) from a university-based pediatric training program underwent concept map training, drew a preinstruction concept map about seizures, completed an education course on seizures, and then drew a postinstruction map. Maps were scored independently by 3 raters using a standardized method. The study was conducted in May and June 1999.

Main Outcome Measures  Preinstruction map total scores and subscores in 4 categories compared with postinstruction map scores; map scores of second- and third-year residents compared with first-year residents; and interrater correlation of map scores.

Results  Total CMA scores increased after instruction from a mean (SD) preinstruction map score of 429 (119) to a mean postinstruction map score of 516 (196) ( P = .03). Second- and third-year residents scored significantly higher than first-year residents before instruction (mean [SD] score of 472 [116] vs 371 [102], respectively; P = .04), but not after instruction (mean [SD] scores, 561 [203] vs 456 [179], respectively; P = .16). Second- and third-year residents had greater preinstruction map complexity as measured by cross-link score ( P = .01) than first-year residents. The CMA score had a weak to no correlation with the American Board of Pediatrics In-training Examination score ( r = 0.10-0.54). Interrater correlation of map scoring ranged from weak to moderate for the preinstruction map ( r = 0.51-0.69) and moderate to strong for the postinstruction map ( r = 0.74-0.88).

Conclusions  Our data provide preliminary evidence that concept mapping assessment reflects expected differences and change in the conceptual framework of resident physicians. Concept mapping assessment and standardized testing may measure different cognitive domains.

During the past few decades medical curricula have increasingly reflected the belief that students should understand concepts, as opposed to rote memorization of facts or procedural algorithms. Many medical schools have adopted alternative teaching and learning strategies that challenge students to become self-directed learners who continuously expand the limits of their knowledge and seek evidence for clinical decision making. 1 The root of these ideas lies in the constructivist theory of learning, which states that meaningful learning occurs when students assimilate new knowledge into a preexisting conceptual framework. 2 - 9 This evolving conceptual framework supports expertise in critical thinking and clinical problem solving. 10 - 12 Despite its critical importance in the education of future physicians, tools to evaluate the quality of students' conceptual frameworks are limited because of the difficulty in designing and administering objective measures.

In this article, we describe an application of concept mapping assessment (CMA) that provides a "window" into learners' organization of knowledge at various points in training. Concept mapping is a technique developed by Joseph Novak in the 1970s in which students create a 2-dimensional diagram outlining their understanding of the relationships between and among important concepts within a given subject area. 13 - 15 Unlike most conventional examinations, CMA may provide unique insights into how an individual organizes his or her knowledge or comes to think about a problem. While concept mapping has been used frequently as a learning tool, especially in high school and college science education, it has only rarely been used as an assessment method, primarily because there is limited information regarding its validity and reliability. 12 , 16 - 18

Therefore, we undertook this preliminary study to assess whether CMA can measure predicted differences and expected changes in the conceptual framework of resident physicians. In addition, we sought to determine whether concept maps could be scored in a reliable way.

All pediatric residents (33 total) at our institution were eligible to participate in this study, which was approved by our institutional human subjects committee. Written informed consent was obtained. A total of 21 residents enrolled: 9 first-year residents, 8 second-year residents, and 4 third-year residents. Each participant underwent concept map training followed by drawing a preinstruction concept map about the topic seizures . They then participated in a 3-session seizure education course followed by drawing a postinstruction map about seizures.

All study subjects participated in a standardized concept map training exercise based on previously described methods. 14 Within 2 to 3 weeks of completing map training, participants were given 30 minutes to independently, and without study aids, draw their concept of seizures on a blank sheet of paper (preinstruction map). Residents then participated in a 3-session (1 hour per session) seizure education course consisting of case-based instruction. One week after completing the course, residents drew a postinstruction concept map about seizures under the same conditions as before.

We used a modification of the "hierarchical technique" of concept mapping in which a concept map consists of 5 components: concepts, concept links, hierarchies, cross-links, and examples (see Figure 1 for an example concept map of water ). 14 , 19

A concept is defined as a perceived regularity in events or objects designated by a label and, when depicted on a map, enclosed with a circle. Creating a concept map involves connecting related concepts using arrow lines with a statement or proposition written above the line describing how the concepts are related.

A concept linked to another concept by an arrow line with a propositional statement, called a concept link , represents the foundational unit of a concept map. 3 , 14 , 20 , 21 In Figure 1 , the concept water connected to living things by the proposition needed by represents a concept link. The expression of the hierarchy between concepts is indicated by the direction of the arrow in the concept link with the most general concepts arranged at the top and more specific concepts arranged hierarchically below. Three levels of hierarchy are represented in Figure 1 . The linking of a series of related concept links in a hierarchical fashion represents a domain of knowledge . Cross-links are the method by which the map author indicates how different domains of knowledge are related to each other and are a critical measure of map complexity. In a manner similar to propositions, cross-links are labeled with a phrase that describes the relationship of the domains. In the example map, motion connected to states by the proposition determines defines a cross-link.

Examples are labeled and connected to the related concept in the most subordinate position on the map. In Figure 1 , Lake Tahoe is a specific example of a lake. Theoretically, as a learner's conceptual framework changes, he or she links new propositions sequentially (concept links), general to specific (hierarchy), and across domains (cross-links), thus demonstrating integration of knowledge. 22

Maps were scored independently by 3 different raters, blinded to the identity of the map author, and using a modification of the structural scoring method previously described. 7 , 14 Each rater was a board-certified pediatrician who underwent a 30-minute concept map scoring training exercise immediately prior to grading the maps. Maps were scored in 4 categories: concept links, hierarchy, cross-links, and examples. The value of each scoring category represents the depth of thinking required to form the category. 7 , 14 Each valid concept link was given 2 points, and each level of hierarchy was given 5 points. A cross-link was given 10 points, while an example counted for 1 point. Invalid links or concepts were given 0 points. A total score and subscore for each category (concept links, cross-links, hierarchy, and examples) were generated for each map. Standard total scores and standard subscores consisting of the sum of individual rater total scores and subscores, respectively, were assigned to each map.

Statistical analysis was done using STATA, version 6.0 (College Station, Tex). The correlation of each rater's total scores and subscores for each map was tested using Spearman rank correlation. All other data analyses were done using standard total scores and standard subscores. We compared preinstruction map to postinstruction map scores using the Wilcoxon signed rank test. To assess whether there was a difference in map scores based on level of training or experience, we combined the more experienced second- and third-year residents (n = 12) into 1 group and compared their scores with those of the first-year (n = 9) residents using the 2-sample Wilcoxon rank sum test. To assess the relationship of concept map scores to standard written examinations, we compared the most recent American Board of Pediatrics In-training Examination (ITE) scores of second- and third-year residents to first-year residents using the 2-sample Wilcoxon rank sum test. First- and second-year residents took the examination within 1 month of completing this study, while third-year residents took the examination 10 months prior to completing the study. We then tested the relationship of concept map scores to ITE scores using Spearman rank correlation.

All 21 participants completed all phases of the study including concept map training, the seizure education course, and both preinstruction and postinstruction concept maps.

Figure 2 shows a complete low-scoring concept map from a first-year resident, while Figure 3 shows a high-scoring map from a resident in the second- and third-year group. Note the complexity, with numerous cross-links in the map from the second- and third-year group compared with the linear simplicity of the first-year resident's map. Table 1 summarizes the mean standard total and mean standard subscores of study participants by level of training. The second- and third-year residents had significantly higher total ( P = .04) and cross-link scores on the preinstruction map ( P = .01) compared with first-year residents. There was no significant difference between concept link, hierarchy, and example scores based on level of training. The postinstruction maps demonstrated that while the total and subscores for second- and third-year residents remained higher, these differences did not reach significance. Of particular note is that the significant difference in total score and cross-link score seen on the preinstruction maps was no longer apparent after instruction ( P = .16 and .15, respectively).

Total scores increased significantly after the educational intervention ( P = .03). In addition, cross-link ( P = .02) and concept link ( P = .01) subscores also increased significantly. Subscores for hierarchy and examples both decreased slightly, but this change did not reach significance. Preinstruction and postinstruction maps from 1 subject are shown in Figure 4 . The resident added a new conceptual domain for prevention and education as well as new cross-links to increased intracranial pressure . The vague concept cerebral irritation included as a focal point in the preinstruction map was omitted in the postinstruction map. Table 2 summarizes the mean standard score and subscores of all subjects before (preinstruction map) and after (postinstruction map) the seizure education course. Total scores increased significantly after the educational intervention ( P = .03). In addition, cross-link ( P = .02) and concept link ( P = .01) subscores also increased significantly. Subscores for hierarchy and examples both decreased slightly, but this change did not reach significance.

The mean (SD) ITE score of second- and third-year residents was 358 (135) and of first-year residents, 243 (94). The ITE scores of second- and third-year residents were significantly higher than those of first-year residents ( P = .05). There was weak to no correlation between CMA scores (total and subscores) and ITE scores ( r = 0.10-0.54). The strongest correlation was between ITE score and the example score on the preinstruction ( r = 0.54; P = .01) and postinstruction map total score ( r = 0.53; P = .01). The correlation between ITE scores and postinstruction map total scores, preinstruction map cross-link scores, and postinstruction map cross-link scores was r = 0.29, 0.34, and 0.20. respectively.

The interrater correlation was weak to moderate ( r = 0.51-0.69) for the preinstruction map and moderate to strong for the postinstruction map ( r = 0.74-0.88). The interrater correlation for subscores demonstrated an almost identical range to that seen in the analysis of total scores.

We found that concept map scores of residents increased significantly following completion of an educational program after which conceptual framework would be expected to change. This change is perhaps best illustrated by qualitative comparison of the preinstruction and postinstruction maps (eg, Figure 4 ), which demonstrates the incorporation of additional concepts into the postintervention map, further differentiation of existing concepts, and a change in cross-linking between concepts. Quantitatively, these changes are reflected in a statistically significant increase in total map score and concept link and cross-link subscores. Despite the small sample size, we also found that CMA scores of residents with more training and expertise were significantly higher than those with less training. This difference was the result of greater map complexity, as reflected in the significantly higher cross-link scores of second- and third-year residents. Thus, more experienced residents appeared to organize their knowledge differently, expressing links between concepts that were not observed by less experienced residents. It is important to note that this difference narrowed, as one might anticipate, after all residents participated in the same educational intervention. While not conclusive, these findings provide important preliminary evidence supporting our hypothesis that CMA is a valid measure of conceptual framework and the expected change in that framework with new learning.

We also found that while ITE scores of second- and third-year residents were significantly higher than those of first-year residents, these scores did not correlate well with CMA scores. Thus, residents who scored highly on CMA were not the same residents who scored highly on the ITE examination. This finding is consistent with other reports, which note that CMA scores of college students do not correlate with conventional measures of learning, such as final course grades or scores on standardized tests. 16 While there may be other explanations, the absence of a positive correlation suggests that CMA measures a different knowledge characteristic than do multiple choice examinations.

The issue of scoring reliability is critically important to any future use of CMA. We found that interrater reliability was moderate to strong and, notably, was greater on postinstruction maps. This level of scoring reliability is similar to that reported by others and suggests that gains in scoring experience lead to increased consistency across raters. 23 Therefore, rater training would be important to any future applications.

The vast majority of previous research regarding concept mapping has involved high school and college science education. In reviewing this literature, there is clear evidence that concept mapping can be an effective learning tool in a variety of classroom settings—including the education of health care professionals. 16 - 18 , 24 - 30 However, evidence supporting the validity of concept mapping as an assessment tool is much more limited, probably because there is no criterion standard measure of conceptual framework to which CMA can be compared. Traditional measures of competence, such as board scores or even newer competency-based assessments (eg, Objective Structured Clinical Examinations), may not represent appropriate comparisons since they shed little light on how a learner thinks about a problem. 12 Thus, other investigators have used the same strategy to build a case for the validity of CMA. For example, in a variety of secondary school and undergraduate settings, CMA has consistently been found to measure conceptual change in situations in which such change would be expected and to detect differences between students with more training in a particular field compared with those with less. 14 , 16 - 18 , 22 , 31 , 32 In medical education, we identified only a single related study in which Pathfinder networks, a substantially different form of concept mapping, was used to assess student understanding of pulmonary physiology. 33 In that study, the investigators found that, after instruction, student Pathfinder networks became more similar to the networks generated by faculty experts. These findings appear consistent with our study, and while not conclusive, provide additional evidence suggesting the predictive validity of CMA.

We have provided encouraging preliminary evidence supporting the validity of CMA as a way to measure conceptual change and differences among resident physicians. Our findings also indicate that rater training is critical to the use of CMA. Future research must focus on further validating this method and addressing issues of reliability before CMA can be applied on a larger scale. Nevertheless, CMA has the potential to evaluate how students or residents organize and use knowledge in a way that traditional objective tests cannot. It also could provide a tool for educators to identify unique distortions in students' understanding of content and to identify errors of omission. Finally, CMA might provide insight into why some residents score well on objective written examinations but have difficulty applying this knowledge to clinical situations.

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• Published: 30 March 2023

Medical students’ reflective capacity and its role in their critical thinking disposition

• Zohreh Khoshgoftar 1 &
• Maasoumeh Barkhordari-Sharifabad   ORCID: orcid.org/0000-0002-9832-2280 2 , 3  

BMC Medical Education volume  23 , Article number:  198 ( 2023 ) Cite this article

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Developing reflective capacity and critical thinking is one of the prerequisites of education in health professions, especially medicine. This study aimed to determine the reflective capacity of medical students and its role in their critical thinking disposition.

In this cross-sectional descriptive research, conducted in 2022, a total of 240 medical intern students were selected using the convenient sampling method. Data were collected using a reflective capacity questionnaire and critical thinking disposition questionnaire and analyzed with descriptive and inferential statistics using SPSS20.

The mean reflective capacity was 4.53 ± 0.50, and mean critical thinking disposition was 127.52 ± 10.85. Among the dimensions of reflection, “active self-appraisal (SA)” and “reflective with others (RO)” had the highest and lowest means, respectively. The dimensions of critical thinking disposition with the highest and lowest means were related to innovation and intellectual maturity, respectively. Reflective capacity and its dimensions were found to have a direct and statistically significant relationship with critical thinking disposition and its dimensions. Regression analysis results showed that reflective capacity accounts for 28% of students’ critical thinking disposition.

The relationship between students’ reflective capacity and their critical thinking disposition has rendered reflection as one of the necessary components of medical education. Thus, determining the learning activities by considering the reflection process and models will be very effective in creating and strengthening critical thinking disposition.

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Thinking and reflecting on what has been learned have been emphasized as key factors in the learning process, one considered a metacognitive phenomenon that can occur before, during, and after the learning process [ 1 , 2 ]. Reflective capacity is considered one of the important competencies in any healthcare system [ 3 ] and refers to “the ability, willingness, and tendency of students to participate in reflective thinking during the course of study and clinical practices” [ 4 ]. Reflective capacity is rethinking about one’s own and others’ experiences to make decisions about future behaviors [ 3 , 5 ]. This capacity is an important ability that allows physicians to be alert, interested, aware, and ready to identify and correct errors [ 6 ].

In health professions, it is necessary to cultivate learners who, in addition to clinical abilities, have the ability for problem-solving, clinical reasoning, and self-regulated learning, followed by life-long learning. Reflection is one of the processes that provide the possibility of cultivating and creating such capacities in the learners of health professions [ 7 ]. Fostering reflection improves professionalism, which is one of the core competencies of medicine [ 5 , 8 ]. A review of the relevant literature showed that the reflection process is useful in achieving a higher level in professional life [ 3 , 9 , 10 ]. Reflecting on past experiences leads to deeper learning and better performance [ 11 ]. Reflection leads to “transformational learning” and learners gain an understanding of their responsibility in providing health care [ 4 ]; moreover, it promotes self-awareness, clinical insight, and quality of care [ 12 , 13 ], stress management and teamwork [ 12 , 14 ], and empathy and professionalism [ 15 ], and it helps clinicians make difficult or ethical decisions when faced with complex cases in clinical practice [ 16 ].

Certainly, the ability to rethink or reflect should be learned and encouraged, indicating that it does not emerge automatically; rather, it requires active effort and energy [ 17 ]. Therefore, reflection can be seen as an important learning tool in university education, which leads to the cultivation of students by health professions who, in addition to clinical capabilities, have the ability to solve problems and think critically [ 7 ].

The reflective practice, which is an ad hoc process of evaluating and strengthening skills and information acquired or being acquired, is closely related to critical thinking [ 18 ]. Critical thinking is one of the main thinking skills. It is a mental process that leads to the purposeful performance of people and prevents the repetition of usual patterns and stereotypes; it further evaluates prejudices, assumptions, and types of information and discusses different aspects, meanings, and results [ 19 ]. Reflection has been mentioned as one of the processes that lead to the improvement of critical thinking ability [ 20 ]. In other words, incorporating reflection into practice can support the development of critical thinking skills and the professional progression of students [ 21 ]. Educators can encourage the development of critical thinking in students using reflection methods, which allow students to understand how their behaviors and attitudes are perceived by others [ 22 ]. Of course, to improve critical thinking, affective dispositions in addition to basic cognitive abilities should be considered. A person’s critical thinking disposition refers to certain features of their thinking process that cultivate critical thinking [ 23 ].

Based on current knowledge, reflective practice is important in gaining professional expertise, and experience alone is not enough. Hence, it is essential to teach reflection as a necessary ability for students of health professions to strengthen it to create meaningful and continuous learning and develop professional performance. This study determined the reflective capacity of medical students and investigated its role in critical thinking disposition as both of these abilities are emphasized in the medical curriculum.

Study Design

This descriptive-cross-sectional study was conducted in 2022. The research community consisted of all students studying in the medical schools of medical sciences universities of Iran. Samples size was estimated to be 240 using the sample size formula, with a confidence level of less than 5%, test power of 80% according to a previous similar study [ 24 ], and an approximate correlation coefficient of at least r = 0.18. Sampling was done by the convenient sampling method. Inclusion criteria comprised being employed, studying at the internship level, and willingness to participate in the study. Anyone lacking interest in participating in the study or failing to complete the scales was excluded.

Data Collection Tools

The following tools were used to collect data in the current research.

Demographic Information Questionnaire : This questionnaire gathered participant demographic information including age, gender, grand point average (GPA), and marital status.

Reflective Capacity Scale : Developed by Priddis and Rogers in 2018 [ 25 ], this scale contains 16 items that measure the four dimensions of Reflective-in-action (RiA), Reflective-on-action (RoA), Reflective with others (RO), and Self-appraisal (SA) [ 4 , 25 ]. These sub-components together form the scale of reflective capacity. Items 4, 7, 11, and 14 are related to the dimension of RiA, items 2, 8, 10, and 13 are related to the dimension of RoA, items 1, 5, 12, and 16 are related to the dimension of RO, and items 3, 6, 9 and 15 are related to the dimension of SA. All items in the scale are scored based on a 6-point Likert scale (from “not at all” to “very much”), and grades range from 1 to 6 with higher scores indicating a greater capacity for reflection. The current study used this scale for the first time in Iran; therefore, after obtaining permission from the original developer of the scale, it was translated by two translators using the forward-backward method. After the translation was approved, its face and content validities were checked. Face validity was examined qualitatively by asking the opinion of ten medical intern students about its difficulty and ambiguity. To check the content validity of the scale, it was given to ten experts in the field of medical education and reflection, and they were asked to give their professional subjective judgment and viewpoints on the relevance, necessity, representativeness, and comprehensiveness of the items. Construct validity was surveyed with exploratory and confirmatory factor analysis using the questionnaires completed by 320 medical students, who were selected using convenience sampling. Exploratory factor analysis identified four factors, which accounted for 63.79% of the variance in the scores. In the confirmatory factor analysis, the values of the fit indices confirmed the appropriate fit of the model. To establish the reliability of the tool, the questionnaire was given to 20 random samples from the studied population. Cronbach’s α coefficient was 0.83 for the overall scale.

Critical Thinking Disposition Scale : Developed by Ricketts (2003) [ 26 ], this scale contains 33 items in the 3 dimensions of innovation, intellectual maturity, and mental engagement. Eleven items (1, 5, 7, 11, 14, 17, 24, 25, 26, 28, and 29) relate to innovation; 9 items incluidng items (2, 12, 15, 19, 23, 30, 31, 32 and 33) relate to intellectual maturity; and the remaining 13 items are related to mental engagement. This scale is graded using a 5-point Likert scale from completely disagree (1 point) to completely agree (5 points). Items 2, 12, 15, 19, 23, 30, 32, and 33 are graded in reverse, so that “I completely agree” is given 1 point and “I completely disagree” is given 5 points. The total score of critical thinking disposition is obtained by summing up of the three subscale scores; based on the mean total score, strong, medium and weak disposition may be determined. A total score of 135.31 + describes a strong disposition, a score of 108.91 to 135.30 indicates a mean disposition, and a score of 108.90 or less indicates a weak disposition to critical thinking. The Persian version of the scale was culturally and linguistically adapted by Pakmehr et al. [ 27 ] and has been used in several studies to evaluate critical thinking dispositions of Iranian medical, nursing, and midwifery students [ 28 , 29 ]. To verify the validity of the Persian version of this scale, its face and content validity was confirmed by 6 professors of educational sciences [ 30 ]. The results of construct validity determined using confirmatory factor analysis indicated the appropriate fit of the model [ 27 ]. The overall alpha was 0.74, and the subscales alphas ranged from 0.71 to 0.78 [ 30 ]. In this study, Cronbach’s α coefficient was 0.78.

Data Analysis

After coding, the data was imported into SPSS20 and analyzed using descriptive statistics (frequency distribution tables, calculation of numerical indices) and inferential statistics (independent t-tests, Pearson’s correlation coefficient, and linear regression) ( p  < 0.05). Before running the tests, the normal distribution of the data was confirmed using the Kolmogorov-Smironov (KS) test ( p  > 0.05).

In total, 240 questionnaires were completed and analyzed. Participants had a mean age of 24.75 ± 1.77 years and mean GPA of 16.73 ± 1.13. The majority of participants were female (52.5%) and single (87.9%) (Table  1 ).

As displayed in Table  2 , the mean reflective capacity was 4.53 ± 0.50 and that of critical thinking disposition was 127.52 ± 10.85. Among the dimensions of reflection, SA and RO had the highest and lowest means, respectively. To calculate the weight of each dimension in the critical thinking disposition score, all scores were converted into a coefficient of 100. The highest mean was related to innovation and the lowest mean was related to intellectual maturity (Table  2 ).

The results indicated that critical thinking disposition was at an average level in 164 (68.3%), at a low level in 13 (5.4%), and at a high level in 63 (26.3%) participants.

Pearson’s correlation test revealed a direct and significant statistical relationship between “reflective capacity and its dimensions” and “critical thinking disposittion and its dimensions” (Table  3 ).

Based on linear regression using the enter method, the coefficient of correlation (R) between critical thinking disposition as the dependent variable and reflective capacity as the predictor variable was 0.53 and the square of the coefficient (R 2 ) was 0.28. The results of analysis of variance (F [1, 238] = 95.38, p  < 0.001) showed that this amount of R 2 is significant (Table  4 ).

Based on the results of Pearson’s correlation coefficient test, neither age nor GPA had a statistically significant relationship with either reflective capacity or critical thinking disposition ( p  > 0.05). Moreover, the independent t-test showed that there was no statistically significant difference between reflective capacity and gender ( p  = 0.173); yet, the difference between reflective capacity and critical thinking disposition was significant ( p  = 0.003); the mean score of critical thinking disposition in men (129.72 ± 10.21) was significantly higher than that of women (125.53 ± 11.06).

The independent t-test revealed a statistically significant difference between reflective capacity and critical thinking disposition in terms of marital status ( p  < 0.001). Reflective capacity was significantly higher in single people (4.58 ± 0.47) compared to married people (4.17 ± 0.51). Additionally, single people with a mean score of 128.72 ± 10.27 had a significantly higher critical thinking disposition compared to married people with a mean score of 118.79 ± 11.12.

This research was conducted to determine the reflective capacity and its role in critical thinking disposition of medical students. It is the first study in Iran to have used the reflective capacity scale to examine the reflective capacity of Iranian medical students.

Reflective capacity is one of the important competencies in the health care system [ 3 ]. The results of the present study showed that the amount of reflective capacity of medical students (4.53 ± 0.50) was at a medium to high level. Consistent with our results, Rogers et al. (2019) reported the mean score of 4.16 ± 0.53 for reflective capacity among medical students in a university in Colorado, U.S.A. This mean was 4.27 ± 0.68 in mental health professionals and 3.51 ± 1.02 in the general population [ 4 ]. Gustafsson et al. (2021) conducted their study on nurses enrolled in advanced level specialized training at two universities in northern Sweden and showed that the mean score of reflective capacity was 4.19 [ 31 ]. The results of a study on students in Spain indicated that students’ reflective capacity was at an almost average level (3.88) [ 32 ]. As can be seen, the mean scores of reflective capacity are lower in these studies than in the current one. Nonetheless, another study that examined reflective capacity in Scottish students trained in three different initial teacher education programs reported an approximate mean of 4.85 [ 33 ], which is slightly higher than in the present study.

It has been largely proven that reflection is not a spontaneous process but one that can be controlled and taught. Reflective capacity can be cultivated to the point where it even becomes a habit. Hence, the reason for the difference in research results can be attributed to the community, the research environment, and different teaching methods and techniques in universities. Educators play an important role in creating reflective capacity by providing a learning environment that facilitates real reflection. They can strengthen the capacity of reflection in learners by designing and using valid and structured methods during clinical practice.

Reflective capacity comprises four dimensions: RiA, RoA, RO, and SA. RiA involves considering prior beliefs, thoughts, and feelings of the individual and the client during the interaction that can influence the interaction. RoA is related to the interaction with the client and reflecting on what was said and done. RO includes things like gaining new awareness, perspectives, and insights while examining interaction and performance processes with others. Finally, SA consists of thinking about strengths and weaknesses when working with clients, improving abilities, and critically evaluating strategies and techniques used when working with clients [ 25 ]. In the present study, the dimension of SA had the highest mean (4.78 ± 0.65) and the dimension of RO had the lowest mean (4.36 ± 0.62). These results were contrary to the research findings of Khalil and Hashish (2022), who reported RO and SA dimensions had the highest and lowest averages, respectively [ 23 ]. Participants in the study by Priddis and Rogers (2018) obtained the highest mean in the dimension of RO (4.69 ± 0.68) and the lowest mean in the dimension of RiA (4.31 ± 0.70); the mean SA score in their study was 4.46 ± 0.74 [ 25 ]. In the study by Gustafsson et al. (2021), the lowest mean was related to RiA (3.879) [ 31 ]. RO having the lowest mean in the current study may be attributed to culture. Iranians have learned the ways of individual solutions to reach basic goals and values more than any other nation [ 34 ].

The results of the present study showed that the mean critical thinking disposition was 127.52 ± 10.85 and the majority of students had an average level of critical thinking disposition. The highest mean pertained to innovation, and the lowest mean was related to intellectual maturity. A study conducted on medical students in China suggested that almost 60% of the students had a positive critical thinking disposition; the highest mean belonged to the “searching dimension”, while the lowest mean was related to the truth-seeking dimension [ 35 ]. Of course, the California Critical Thinking Disposition Questionnaire was used in the mentioned study, the dimensions of which were different from the questionnaire used in the present study. Nonetheless, Bixler et al. demonstrated that medical students at the School of Medicine, Ohio State University, had relatively strong critical thinking tendencies [ 36 ]. Moreover, in a study conducted on medical students of Gonabad/Iran, the mean score of critical thinking disposition (143.57 ± 23.59) [ 37 ] was higher than in the current study; unlike the present study, the highest mean was related to commitment and the lowest mean pertained to innovation [ 37 ]. The mean score of critical thinking disposition in medical students of Jundishapour/Iran was 70.75 ± 11.12, and the highest and lowest means, respectively, were related to the dimension of mental engagement and innovation [ 38 ]; this is inconsistent with the results of the present study. This disparity can be attributed to differences in research communities, education, and culture. The results of the present study indicate that Iranian medical education needs to be reformed in order to develop critical thinking disposition in students. The use of active teaching methods such as case studies [ 39 ], learning based on problem solving [ 40 ], and concept maps [ 41 ] by medical educators can help improve students’critical thinking dispositions and skills.

According to Ricketts (2017), innovation shows one’s background to search for truth. A person’s intellectual maturity shows that they are aware of the complexity of real issues and know that there may be more than one solution to a problem. Mental engagement discloses how much a person is looking for opportunities to reason [ 42 ]. Considering that intellectual maturity in this research has been assigned the lowest score, and considering the complex nature of the issues in medicine, it seems that the Iranian medical schools should pay more attention to this dimension in medical education, a point that should be taken as a serious warning.

The currents findings revealed statistically significant relationship between reflective capacity and critical thinking disposition, and higher reflection ability includes greater critical thinking disposition. Reflective capacity is a predictor factor of critical thinking disposition. A study conducted on 93 nursing students in Saudi Arabia also showed that reflection performance has a positive and significant correlation with critical thinking disposition. It also has the ability to predict the variance of critical thinking disposition [ 23 ]. The results of another study on nurses in Taiwan indicated that reflection significantly affects critical thinking [ 43 ]. Hashim (2019) also states that there is a close connection between reflective practice, which is an ad hoc process of evaluating and reinforcing skills and information acquired or in the process of being acquired, with critical thinking. He states that critical thinking and reflective practice are two intertwined processes that play a role in guiding a student [ 18 ]. The effect of reflection on critical thinking has also been reported in interventional studies [ 44 , 45 , 46 ], and reflection has been introduced as one of the processes that can improve critical thinking [ 20 ].

The current findings have important practical implications for current educational programs that aim to improve students’ critical thinking by enhancing their reflective capacity. Our findings that reflective capacity plays a significant role in critical thinking highlight the need for more emphasis on enhancing reflective thinking. Providing reflection exercises, choosing and determining appropriate educational methods [ 47 ], deciding on the use of a structured or unstructured approach, creating a learning environment that stimulates and encourages reflection for students [ 48 ] can help to create and strengthen reflective capacity and then promote critical thinking.

Strengths and limitations of the study

Among the strengths of the current study is the first-time use of a reliable and valid assessment instrument to measure the reflective capacity of Iranian medical students. In addition, an adequate sample (N = 240) and 100% overall response rate provided reliable estimates in the study. the present study was limited by the self-report nature of the questionnaires, which created the discussion of social desirability, and some participants may have refused to provide real answers. However, efforts were made to control this confounding variable to a large extent by assuring the participants of the confidentiality of information and the anonymity of the questionnaires. Furthermore, this research was conducted cross-sectionally, which makes it difficult to draw conclusions about causality. The all number of retrieved studies that had used the reflective capacity scale also limited any comparison of the results.

There was a significant correlation between reflective capacity and critical thinking disposition. In addition, 28% of the variance of the dependent variable (critical thinking disposition) can be predicted by the reflective capacity. The results makes reflection one of the necessary components of medical education. Therefore, determining the learning activities by considering the reflection process and models will be very effective in creating and enhancing critical thinking disposition. Based on the findings of the present study, educators should use effective educational strategies to strengthen students’ reflective capacity, so that the critical thinking disposition increases. It is important to train instructors to learn and apply effective teaching and learning methods in creating students’ reflective capacity.

Data Availability

The datasets generated and analyzed during the current study are not publicly available due to an agreement with the participants on the confidentiality of the data but are available from the corresponding author on reasonable request.

Abbreviations

Reflective-in-action

Reflective-on-action

Reflective with others

Self-appraisal

Standard Deviation

Kolmogorov-Smirnov

Grand point average.

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Acknowledgements

We would like to thank Shane L.Rogers for granting permission to translate the reflective capacity scale and his input on the translation process. We are also grateful to the students who helped us in conducting this research.

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All authors (ZKH and MB-SH) have participated in the conception and design of the study. MB-SH contributed the data collection and prepared the first draft of the manuscript. ZKH critically revised and checked closely the proposal, the analysis and interpretation of the data and design the article. MB-SH and ZKH carried out the analysis, interpretation of the data and drafting the manuscript. ZKH has been involved in revising the manuscript critically. All authors read and approved the final manuscript.

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Khoshgoftar, Z., Barkhordari-Sharifabad, M. Medical students’ reflective capacity and its role in their critical thinking disposition. BMC Med Educ 23 , 198 (2023). https://doi.org/10.1186/s12909-023-04163-x

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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.

We’ll keep you updated

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

Affiliations.

• 1 Shiraz University of Medical Sciences, Shiraz, Iran.
• 2 Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
• 3 Cardiovascular Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran.
• PMID: 32426391
• PMCID: PMC7188935
• DOI: 10.30476/jamp.2020.83053.1080

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.

Methods: 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.

Results: 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.

Keywords: Barriers; Critical thinking; Curriculum; Medical education; Thinking.

Copyright: © 2020: Journal of Advances in Medical Education & Professionalism.

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Flipped Classrooms in Medical Education: Improving Learning Outcomes and Engaging Students in Critical Thinking Skills

Adwait nichat.

1 Medical Education, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Nagpur, IND

Ujwal Gajbe

2 Anatomy, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Nagpur, IND

Nandkishor J Bankar

3 Microbiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Wardha, IND

Brij Raj Singh

Ankit k badge.

4 Microbiology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Nagpur, IND

The flipped classroom (FC) model involves students independently acquiring knowledge before in-person class sessions, during which they engage in active discussions and problem-solving. Various methods to implement FC are quizzes, e-content, case-based learning, problem-based learning, and reading assignments. The advantages of the FC approach included improved student preparation, active participation, and the promotion of critical thinking skills. Some disadvantages identified are technical problems like internet connection, improper planning and preparation, which increases teacher workload, and lack of self-motivation. This review underscores the potential of the FC approach to improve medical education by promoting independent learning, active participation, and deeper understanding. Consideration of factors such as curriculum design, faculty development, technological infrastructure, and student readiness is vital for successfully implementing the FC model. Balancing self-directed study with meaningful face-to-face interactions remains crucial to harnessing the full benefits of this innovative approach. By leveraging technology and student-centered methods, medical educators can create an enriched learning experience that positively influences future healthcare professionals.

Introduction and background

Medical education refers to teaching programs designed to serve the community in the near future. Good role models and learning environments which are examples of professional and organizational behaviors to be adopted, learning through practice, simulation programs, and educational tools such as electronic learning (e-learning) systems, good assessment and feedback systems, and portfolios that demonstrate and discuss professional progress are key elements of medical education programs [ 1 ]. Several advantages of traditional teaching involve face-to-face interactions between students and teachers. Face-to-face interactions provide a supportive learning environment with a positive psychological impact and motivate even less motivated students to participate [ 2 ]. Competency-based medical education (CBME) is a standardized framework for measuring student performance, focusing on the key learning components of good clinical practice. It also measures learning outcomes in training programs based on self-assessment, objective assessment, and multi-source assessment. It can be used for training in all medical fields [ 3 , 4 ]. One of the goals of CBME is self-directed learning, and flipped classroom (FC) is based on this concept, making FC an integral part of the CBME curriculum [ 5 , 6 ]. The main objective of CBME is to create competent Indian medical graduates (IMG) using a skill-based approach while also providing them with metacognition skills [ 3 , 7 ]. The objective of this review is to explore the effectiveness of FC in medical education.

Methods 

To conduct a comprehensive literature search, we used the PubMed and Google Scholar search. We searched for articles published between 2018 and 2023 using the following search terms: (Flipped classroom) OR (flipped classroom) AND (problem-based learning) AND (case-based learning) OR (virtual classroom) AND (traditional teaching). We applied the following inclusion criteria for the final review: (1) English language, (2) relevant to FC in medical education, (3) full text available, and (4) published in specified time frame.

Articles Screened

After conducting the initial search, we identified a total of (n=726) articles across the searched databases. We conducted an initial screening of titles and abstracts, which excluded (n=267) articles. After full-text screening of a total of (n=403) articles, we excluded (n=234) articles for not being retrieved. After screening (n=169) articles for eligibility, we excluded (n=150) articles that were not related to the topic and not in the English language leaving a total of (n=19) articles.

Duration and Number of Articles Included in the Final Review

The literature search was conducted in August 2023. The final review included a total of 19 articles from 2018 to 2023 (Figure ​ (Figure1 1 ).

n: number of studies; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis

The articles included in the review were each FC based on micro-video courses, self-learning-based online videos, texts, and traditional methods (Table ​ (Table1 1 ).

OSCE: objective structured clinical examination; FC: flipped classroom; NPE: near-peer education; NBME: National Board of Medical Examiners; ACLS: advanced cardiopulmonary life support

Nine studies [ 9 , 10 , 14 , 16 , 17 , 18 , 20 , 22 , 23 ] conducted pre tests and post tests. In each study [ 9 , 10 , 14 , 16 , 17 , 18 , 20 , 22 , 23 ], students were divided into two groups: one group was subjected to traditional teaching, while the other group was subjected to various methods to implement FC which were reading resources and video lectures [ 9 , 16 , 18 , 20 , 22 , 23 ], presentation [ 10 ], web-based learning [ 14 ], and e-content [ 17 ]. All studies [ 9 , 10 , 14 , 16 , 17 , 18 , 20 , 22 , 23 ] observed that FC is an effective tool. One study [ 25 ] divided students into two groups: one group was given micro-video lectures before class, while the other group was directly given theory lectures. Teacher-student interaction and questionnaires were used to assess the students, and it found that the FC model improved student performance. Six studies [ 7 , 8 , 13 , 15 , 19 , 21 ] assessed students based on final exam scores. In each study, students were divided into two groups: one group was subjected to traditional teaching, while for the other group, various methods were used including videos and resource materials [ 7 , 8 , 19 , 21 ], self-study [ 13 ], and PowerPoint [ 15 ]. Five studies [ 7 , 8 , 13 , 19 , 21 ] observed that FC is an effective tool for improving students' performance, while one study [ 15 ] did not observe any change in the students' performance. One study [ 11 ] conducted multilevel regression and observed that FC is an effective tool. In this study, the students were divided into two groups: one group was given videos and other resources via e-learning system, while lecture session was given to the other group. One study [ 12 ] observed the results based on OSCE (objective structured clinical examination) and NBME (National Board of Medical Examiners) scores and did not observe any change in students' performance. In this study, students were divided into two groups: one group was given only online instructions, while the other group was given both online and in-person instructions. One study [ 24 ] observed the result based on the composite learning score and found no significant difference. In this study, students were divided into two groups: one group was provided with theory notes beforehand, while the other group was directly subjected to training session.

Medical education

The systematic process of preparing interested and qualified people to become doctors is known as medical education. The Bachelor of Medicine, Bachelor of Surgery (MBBS) degree is considered capable of handling the responsibilities of a physician of first contact like patient care, medical practice, administrative duties, and ethical and legal duties [ 26 ]. The main objective of the National Medical Commission (NMC) project is to ensure that IMG are capable of serving as primary care physicians in their communities. The NMC project aims to improve the quality of medical education in India and enhance the practical skills of IMG. The NMC has taken an important initiative to introduce CBME to the undergraduate medical curriculum in India. The NMC clearly defined the competencies that an undergraduate medical student must have to become a globally competent IMG. The regulatory body has made significant efforts to design programs with the expert team and has also planned "training of trainers" from faculty at medical colleges throughout India, through the Curriculum Implementation Support Program (CISP) I and II, an implementation support program for schools across India [ 27 ]. Additionally, the project also seeks to bridge the gap between theoretical knowledge and hands-on experience, allowing IMG to confidently handle diverse medical cases and contribute to the overall development of the healthcare system [ 26 , 28 ]. The learning results and the competency of medical graduates are substantially impacted by the attitudes of both teachers and students. Medical educators' professionalism, management, and leadership abilities may be enhanced by well-crafted faculty development programs, which will help students become competent doctors [ 26 , 29 ]. Faculty members are primarily responsible for carrying out this significant duty. They are the most valuable resources and the foundation of any higher education institution. The role of the facilitator is to pay appropriate attention to the fields of competence, management, and leadership and to make accurate and comprehensive planning for students to become qualified future doctors in the role of therapists, managers, teachers, supporters, and researchers [ 30 ].

FC is a technique where knowledge is acquired independently by a student prior to a classroom encounter. This knowledge is then applied during in-person interactions taken by a teacher, often in the form of case-based discussions, helping to achieve higher-level problem-solving. FC is an effective way to promote active learning and critical thinking skills among students. Having students acquire knowledge independently before class makes them better prepared to engage in meaningful discussions and analyze real-life scenarios. This approach enhances problem-solving abilities and encourages independent learning and self-motivation. FC provides a valuable framework for bridging the gap between theory and practice in classrooms [ 31 - 33 ]. In a traditional face-to-face learning environment, fundamental concepts can be supplemented with online or asynchronous activities [ 31 , 34 ]. By using various forms of technology to share lecture materials outside of the classroom and with greater student-teacher interactions inside the classroom, FC focuses on student-centered learning rather than teacher-centered learning [ 9 , 35 ]. It is an inverted method of instruction that disseminates lecture materials outside of the classroom using videos, podcasts, or slides [ 36 , 37 ]. It can improve student learning efficiency and deepen student understanding, but teachers may lose the constraints on students [ 36 , 38 ]. In the field of medical education, FC serves as an excellent resource and is suitable for students so that they can participate more actively and focus on class interaction while using the pre-class time to acquire a lot of knowledge in their leisure time. The FC model allows students to watch pre-recorded lectures or read assigned materials before class. This way, students can grasp the foundational concepts at their own pace and have more time for critical thinking and problem-solving during in-person sessions. Additionally, FC promotes self-directed learning and encourages students to take ownership of their education, resulting in a deeper understanding and retention of the material [ 9 , 39 , 40 ]. Figure ​ Figure2 2 shows the concept of FC.

PPT: PowerPoint presentation

References: [ 9 , 31 - 40 ]

Various methods used for implementing FC

Video is the most common type of e-content which can be viewed anytime and at a desired pace [ 41 ]. Video-based learning provides an avenue to tackle a lot of educational issues. As most of the people have mobile phones and access to the internet, video lectures can help deliver lectures more easily [ 42 ]. Virtual reality helps in improving students' understanding of the topic [ 43 ] and is emerging as a new technique for presenting simulation [ 44 ].

Medical quizzes often follow one of the two formats: case-based or image-based. This method aids in bridging the knowledge gap between standard classroom instruction and clinical application. The quiz is a simple tool that enhances didactic lectures by helping students learn and understand more. Being an interactive tool centered on students, it promotes regular feedback mechanisms and encourages active student participation. Web-based quiz games can also be used to summarize the key content [ 45 ].

Team-Based Learning (TBL) and Case-Based Learning (CBL)

The pedagogies of CBL and TBL share characteristics such as the use of a real clinical case, active small group learning, activation of prior knowledge, and application of newly learned knowledge. In CBL, teachers guide students as they apply new knowledge to these real-world clinical issues and engage in peer learning. Unlike problem-based learning (PBL), which is intended to allow teachers to criticize and guide students, CBL promotes an organized and critical approach to clinical problem-solving. CBL also encourages students to work collaboratively, fostering teamwork and communication skills essential in the medical field. The emphasis on real-world cases in CBL helps students develop a deeper understanding of how theoretical concepts apply to practical situations [ 46 , 47 ]. TBL provides active and structured small group learning methods and can be applied to large-scale classes. Students' responsibility is achieved through specific TBL steps, including preparatory preparation, preparation assurance tests, problem-solving activities, and immediate feedback [ 48 ].

Reading Assignments

Students should be provided with pre-class reading materials such as handouts or worksheets, instructor-developed texts, or other reading materials. They can also be assigned to read specific chapters or sections from textbooks or articles related to the topic. Research papers and scholarly articles help in promoting critical thinking among students. This approach allows students to engage with the material before coming to class, promoting a deeper understanding of the content. It also encourages independent research and analysis, as students must locate and read additional sources beyond the assigned readings. By incorporating research papers and scholarly articles, students are exposed to expert perspectives and encouraged to evaluate the information presented critically. This enhances their critical thinking skills and fosters a deeper appreciation for the subject matter [ 49 - 51 ].

Advantages and disadvantages of FC

FC helps to improve student engagement and encourages students in developing a deeper understanding of the topic. It helps in learning through projects, activities, and discussion which not only increases peer-peer interaction but also helps students to think out of the box. Knowing that each student has a different pace to acquire knowledge, FC helps students to learn at their own pace and do multiple revisions of the topic. As videos and class notes are provided beforehand to students, in-class time can be utilized for teacher-student interaction and to address students' doubts. FC gives flexibility to students by allowing them to learn anytime and anywhere and also helps to teach students time management and self-discipline [ 52 - 54 ].

Some students may not complete the pre-class assignments, and use of e-content which is not validated, internet issues, and the requirement of special software may cause problems. For the proper implementation of FC, thorough planning and preparation of both teachers and students is required which also increases the workload of teachers. Students may lack the motivation to self-study a topic beforehand or may not understand the topic on their own. Not all topics may be suitable to be taught using FC. Studying alone at home may lead to students feeling isolated or disconnected with the teacher [ 52 - 54 ]. The advantages and disadvantages of FC are listed below (Table ​ (Table2 2 ).

References: [ 52 - 54 ]

Conclusions

The emergence of the FC as a cutting-edge educational strategy holds promise for improving medical students' learning outcomes and experiences. The FC paradigm can benefit medical students' learning outcomes, learner engagement, and critical thinking skills. Careful consideration of variables such as curriculum design, technological infrastructure, faculty development, and student preparation is necessary for its successful adoption. The success of the FC approach depends on striking a balance between independent study and significant face-to-face contact, maximizing the advantages of both elements. Medical educators can continue to create a revolutionary educational experience that benefits both students and the future of healthcare by using technology, active learning, and student-centered techniques.

The authors have declared that no competing interests exist.

Author Contributions

Concept and design:   Adwait Nichat, Ankit K. Badge

Drafting of the manuscript:   Adwait Nichat, Ujwal Gajbe, Ankit K. Badge

Acquisition, analysis, or interpretation of data:   Nandkishor J. Bankar, Brij Raj Singh, Ujwal Gajbe, Ankit K. Badge

Critical review of the manuscript for important intellectual content:   Nandkishor J. Bankar, Brij Raj Singh

Supervision:   Nandkishor J. Bankar, Brij Raj Singh