Developing Critical Thinking Skills in Pharmacy Students

Barriers to Critical Thinking

There are several challenges to students thinking critically: perceptions, poor metacognitive skills, a fixed mindset, heuristics, biases and because thinking is effortful. The first barrier is students’ perceptual problem – students believe they know how to solve problems, so often, they do not understand why they are being re-taught this skill. Educators teach students how to monitor their thinking and become better problem solvers by giving them a framework to be more thoughtful thinkers.

The next challenge is students’ weak metacognitive skills. The relationship between CT and metacognitive skills has been noted in the literature.¹⁵ Metacognition refers to an individual’s ability to assess his/her own thinking and actual level of skill or understanding in an area. Metacognition helps critical thinkers be more aware of and control their thinking processes.¹⁵ Students who are weak at metacognition jump to conclusions without evaluating the evidence, thinking they know the answer, which ultimately interferes with CT.

A third reason CT is difficult for students is that they may have a fixed mindset or a belief that their intelligence cannot change.¹⁶ If students believe CT is an innate skillset that occurs naturally, they may not invest the effort to develop it because they believe that no matter how hard they try, they will never get it.

Heuristics can get in the way of CT. Heuristics are our shortcuts to thinking – they are a strategy applied implicitly or deliberately during decision-making where we use only part of the information we might otherwise want or need. This results in decisions that are quicker and less effortful because the individual may be using the best single piece of data to make a more frugal approach.^17-19 In a classic study, participants were asked, “If a ball and bat cost $1.10, and the bat is $1 more than the ball, what was the cost of the ball?”²⁰ The most popular answer is $0.10, which is incorrect (the correct answer is the ball costs $0.05, the bat then is $1.05 or $1 more. If the ball was $0.10, the bat is only $0.90 more than the ball). We take cognitive shortcuts because thinking is effortful and if we can get a quick response that fits our current needs, we will do it. Kahneman referred to two systems of thought: System 1 and System 2.^19,21 System 1 is a fast decision-making system responsible for intuitive decision-making based on emotions, vivid imagery, and associative memory. System 2 thought processes is a slow system that observes System 1’s outputs, and intervenes when “intuition” is insufficient.²¹

Another challenge that makes CT difficult for students is their inherent biases. One major bias is confirmation bias or the tendency to search for information in a way that confirms our ideas or beliefs.²² Confirmation bias happens because of an eagerness to arrive at a conclusion, so students may assume they are questioning their assumptions when they are only searching for enough information to confirm their beliefs.²² When we want to think critically, we want the evidence against our view to better inform our decision. See Appendix 1 for a list of cognitive biases that may affect our thinking.

CT is difficult and does not develop automatically. It takes practice and effort. Experts think critically without conscious thought, which makes it effortless. However, developing expertise is estimated to take 10 years or 10,000 hours (or more) of deliberate practice, so it is a time consuming activity.^14,23 In a study of thinking using the game Tetris, it was shown that initial game learning resulted in higher brain glucose consumption compared to individuals with experience playing and those watching someone play.²⁴ Similar results are seen when comparing experts to novices. Functional MRI studies show that experts use less of their brain to solve a problem than novices, partly because a problem for a novice is not a problem for an expert.²⁵ It is experience that has led to muscle memory and heuristics. Students do not have a lot of experience thinking critically and therefore, do not want to do it because it is difficult and time consuming; they would rather do things that are automatic and effortless.

Developing Critical Thinking Skills

Developing CT skills is difficult but not impossible. CT is a teachable skill and is often discipline-specific because it relies on discipline-specific knowledge. Research and practice suggest several factors that improve thinking: a thoughtful learning environment (eg, integration), seeing or hearing what is actually done to executive cognitive operations one is trying to improve (eg, model behavior), guidance and support of one’s efforts until he or she can perform on their own (eg, scaffolding);²⁶ and prompting to question what is thought to be known (eg, challenging assumptions).²⁷ These are general, key points that instructors can do to help students develop CT skills.

Creating a thoughtful learning environment is not limited to just letting students make mistakes. Table 1 compares features of thoughtful classrooms to traditional classrooms that do not emphasize CT. The first piece of this thoughtful learning environment is helping students to integrate their knowledge. Integration allows students to build on previous experiences, provide developmentally appropriate opportunities for the individual to produce optimal performance, and lay a foundation for further development. By intentionally creating an environment that allows students to integrate previous and current knowledge, they can begin to evaluate how the concepts are related and make decisions on how to apply that knowledge to future, and likely different, situations. Integration can take many forms and does not necessarily mean courses need to be integrated or aligned in time. Integration can take the form of integrating the cumulative knowledge gained over the curriculum.

Modeling expert thinking is another way to help students see CT in action and begin to use these steps themselves. Instructors should verbalize their executive cognitive operations for students to hear or see when addressing a problem or issue that requires CT. No single step is too insignificant to point out. Learners are novice and assumptions should not be made that they understand or know how to perform a seemingly simple set in the thinking process. By watching the experts process information, learners begin to form those thinking skills as well.

Scaffolding is another general method that can facilitate development of CT skills. Scaffolding is a temporary support mechanism. Students receive assistance early on to complete tasks, then as their proficiency increases, that support is gradually removed. In this way, the student takes on more and more responsibility for his or her own learning. To provide scaffolding, instructors should provide clear directions and the purpose of the activity, keep students on task, direct students to worthy sources, and offer periodic assessments to clarify expectations. This process helps to reduce uncertainty, surprise and disappointment while creating momentum and efficiency for the student.

Thinking begins when our assumptions are violated. Driving to work requires little effort. We do it all the time and sometimes we may wonder how we got to work because our thoughts were elsewhere. On a daily basis, you assume your drive will be normal and unimpeded. Now imagine there is traffic. You move from auto-pilot to thinking mode because your assumptions were violated. When our assumptions are violated, we start to think and we see this thought process as early as a few weeks from birth.²⁸ In the classroom, we must identify and challenge students’ assumptions. As an example from self-care instructors, when students are asked to recommend a product for cough associated with the common cold, any student pharmacist with community pharmacy experience may answer “dextromethorphan.” This may be what they have seen in practice or what they received as a child from their parents. They have experience in this context. However, this answer is not supported by the guidelines,^29,30 but the students will argue it is correct because of their experience. The cognitive dissonance – not expecting something to happen that you thought would – starts the cognitive thinking process. From an instructional standpoint, it may be important to initiate the critical thinking process by having students make predictions on outcomes and showing how their predictions may be correct or incorrect.

Developing CT requires a 4-step approach.⁹ The first step is explicitly learning the skills of CT. The second is developing the disposition for effortful thinking. The third step is directing the learner to activities to increase the probability of application and transfer of skills. The final step is making the CT process visible by instructors making the metacognitive monitoring process explicit and overt. These four steps should be included both at the broad curricular level and down to the more discrete level of a lesson and a course.

Recommendations

A common model for the process of CT should be used in each pharmacy school curriculum. Ideally, a course should be required for all students early in the curriculum that addresses the definition, common model, and dispositions of CT and then provides an opportunity for students to actively practice these skills on general subject matter content. As students’ knowledge of pharmacy specific content grows, courses need to explicitly use the process outlined in the general course with application to the subject specific content. The repetition of these skills in multiple courses or course series will help students practice this skill. Additionally, all instructors should learn the model taught to students and learn how to create and facilitate activities to encourage CT in their content areas.

While there may be many templates for CT, we propose a 4-step cycle: generation, conceptualization, optimization and implementation.^37,38 In the generation phase, learners identify the problem and find facts. This is followed by the conceptualization phase when learners define the problem and draft ideas that could explain the defined problem. In the optimization phase, learners evaluate and select an idea then design a plan. Finally, the implementation phase involves accepting the plan and taking action. The cycle restarts with finding a new problem. For example, during a patient encounter, a learner would enter the generation phase, find all the problems and facts (laboratory values, past medical history, etc.). Then the learner would define the problem(s) and generate ideas as to why the problems are occurring. For example, the patient is complaining of fatigue and the learner would have to come up with reasons why fatigue might occur (anemia, lack of sleep, pregnancy, poor diet). The learner then uses the facts to evaluate each potential cause and consider what further tests may be necessary to exclude some of the potential causes. After selecting the cause, the learner formulates a plan and decides his or her next action. Once the learner discovers the patient is anemic, the cycle restarts with treatment options. This cycle can be used along with the Joint Commission of Pharmacy Practitioners Pharmacists' Patient Care Process.³⁹