volume 33, number 3 summer 2008 summer 2008 · optometric education vol. 33 contents no. 3 summer...

Volume 33, Number 3 Summer 2008

The Journal of the Association of Schools and Colleges of Optometry

Volume 33, Number 3 Summer 2008

76 Optometric Education

BOARD OF DIRECTORSExecutive Committee

OFFICERS AND MEMBERS

Association of Schools and Colleges of OptometryThe Association of Schools and Colleges of Optometry (ASCO) represents the professional programs of

optometric education in the United States. ASCO is a non-profit, tax-exempt professional educational associationwith national headquarters in Rockville, MD.

PresidentJohn F. Amos, O.D.DeanUniversity of Alabama at Birmingham,School of OptometryBirmingham, AL 35294-0010

President-Elect Melvin D. Shipp, O.D., MPH, Ph.DDean & ProfessorThe Ohio State UniversityCollege of OptometryColumbus, OH 43210-1240

At Large MemberThomas L. Lewis, O.D., Ph.D.PresidentPennsylvania College of Optometryat Salus UniversityElkins Park, PA 19027-1598

Secretary-TreasurerEarl L. Smith, III, O.D., Ph.D.DeanUniversity of HoustonCollege of OptometryHouston, TX 77204-2020

Immediate Past-President*Hector Santiago, O.D., Ph.D.DeanMidwestern UniversityArizona College of OptometryGlendale, AZ 85308

Executive DirectorMartin A. Wall, CAE

BOARD MEMBERS

Kevin L. Alexander, O.D., Ph.D.,PresidentSouthern California College ofOptometryFullerton, CA 92831

Arol R. Augsburger, O.D.,PresidentIllinois College of OptometryChicago, IL 60616

Elizabeth Chen, MBA, President The New England College of OptometryBoston, MA 02115

* Larry J. Davis, O.D., DeanUniversity of Missouri at St. LouisCollege of OptometrySt. Louis, MO 63121-4499

*George E. Foster, O.D., DeanNortheastern State University, Oklahoma College of OptometryTahlequah, OK 74464

David Heath, O.D., Ed.M., PresidentState University of New YorkState College of OptometryNew York, NY 10036-8003

Elizabeth Hoppe, O.D., M.P.H., DrPHFounding DeanWestern University of Health SciencesCollege of OptometryPomona, CA 91766-1854

Dennis M. Levi, O.D., Ph.D., DeanUniversity of California at Berkeley,School of OptometryBerkeley, CA 94720-2020

*David S. Loshin, O.D., Ph.D., DeanNova Southeastern University, College of Optometry, Ft. Lauderdale, FL 33328

Andres Pagan, O.D., M.P.H.Interim DeanInter American University of Puerto RicoSchool of OptometryBayamon, PR 00957

Nancy Peterson-Klein, O.D.Interim DeanMichigan College of Optometryat Ferris State UniversityBig Rapids, MI 49307-2738

Richard W. Phillips, O.D., PresidentSouthern College of OptometryMemphis, TN 38104

P. Sarita Soni, O.D., M.S.Interim DeanIndiana University, School of OptometryBloomington, IN 47401

Jennifer Smythe, O.D., M.S.DeanPacific University, College of OptometryForest Grove, OR 97116

*Past Presidents

ASCO Affiliate Members

Dr. Jacques Gresset, DirectorUniversity of Montreal — OptometryMontreal, Quebec H3C 3J7

Dr. Thom Freddo, DirectorUniversity of Waterloo — OptometryWaterloo, Ontario, Canada N2L 3G1

Ms. Pamela Happ, Exec. Dir.College of Optometrists in

Vision DevelopmentAurora, OH 44202

Mr. Robert Williams, Exec. Dir.Optometric Extension Program

FoundationSanta Ana, CA 92705-5510

Dr. John Townsend, DirectorVA Optometry ServiceDepartment of Veterans AffairsBaltimore, MD 21202

Dr. Jairo H. Garcia, DeanUniversidad de la SalleFacultad de OptometriaBogota, Colombia

Editorial Review Board

Editor: Elizabeth Hoppe, O.D., M.P.H., Dr. PH.

ASCOTECH Coeditors:Dominick M. Maino, O.D., M.Ed.Geoffrey W. Goodfellow, O.D.

Communications Editor: David Damari, O.D.

Diane T. Adamczyk, O.D.Norman Bailey, O.D., M.S., M.P.H.John Baker, O.D., M.S.Ed.Etty Bitton, O.D., M.Sc.Nancy B. Carlson, O.D.N. Scott Gorman, O.D., M.S., Ed.D.Michael G. Harris, O.D., J.D., M.S.Christopher W. Lievens, O.D.Nada J. Lingel, O.D., M.S.Richard E. Meetz, O.D., M.S.Jeffrey Nyman, O.D.Doug Penisten, O.D., Ph.D.Hector Santiago, O.D., Ph.D.Paulette P. Schmidt, O.D., M.S.Julie A. Schornack, O.D., M.Ed.Leo P. Semes, O.D.Marlee M. Spafford, O.D., M.Sc., Ph.D.Mark Swan, O.D., M.Ed.Timothy Wingert, O.D.

OPTOMETRICEDUCATION

CONTENTSVOL. 33NO. 3

SUMMER2008


ISSN 1521-4230

FEATURES AND DEPARTMENTS

Industry News 79Editorial: Thinking About ThinkingElizabeth Hoppe, OD, MPH, DrPH 81Guest Editorial: Putting Critical Thinking Into ActionAurora Denial, OD, FAAO 82Think Tank: What Are the Challenges to Encouraging Student Development of Critical Thinking Skills in the Optometric Educational Environment and How Can These Challenges BeOvercome? 83My Best Day in Optometric Education:Getting to Know Students and Watching Them LearnNancy B. Carlson, OD, FAAO 87

ARTICLES Critical Thinking: The Nuts and Bolts of EducationLinda Elder, PhDRichard Paul, PhDThere are three primary intellectual sets that critical thinking offers us: tools for the analysis of thinking, tools for the assessment of thinking and tools for fostering intellectual dispositions of mind. The authors describe each of these sets and discuss their implications for teaching and education. 88

The Teaching of Skillful Thinking: Lifelong LearnersT. Bridgett Galvin, PhDThe purpose of this article is twofold: first, to provide information on the learning process and skillful thinking and, second, to provide educators with tangible suggestions on how to change the learning environment to enhance skillful thinking. 92Critical Thinking and Clinical JudgmentNoreen C. FacionePeter A. FacioneLives depend on competent clinical reasoning. Thus it is a moral imperative for health care providers to strive to monitor and improve their clinical reasoning and care related judgments. 97

www.dailies.com

(Continued on page 78)

Contents (Cont'd)VOL. 33NO. 3

SUMMER2008


OPTOMETRIC EDUCATION is published by the Association of Schools and Colleges of Optometry (ASCO). Managing Editor:Stephanie Dean. Art Director: Carol Nansel, The Darwin Group, Inc.. Business and editorial offices are located at 6110 ExecutiveBoulevard, Suite 510, Rockville, MD 20852 (301) 231-5944. JOE is published three times per year. As of the Fall 2007 issue, JOE is freeto both members and the general public. To access JOE online please go to www.opted.org. Postage paid for a non-profit, tax-exemptorganization at Rockville, MD. Copyright © 2008 by The Association of Schools and Colleges of Optometry. Advertising rates areavailable upon request. OPTOMETRIC EDUCATION disclaims responsibility for opinions expressed by the authors. Indexed inCurrent Index to Journals in Education (ERIC).

Association of Critical Thinking Skills With Clinical Performance in Fourth-Year Optometry StudentsAurora Denial, OD, FAAOThe goal of optometric education is to produce a clinician who exhibits entry-level competencies in knowledge base, skills, and attitudes by the time of graduation. The author addresses the following research question: Is there an association between critical thinking scores, as measured by a standardized test, and evaluations of clinical performance in fourth-year optometry students? 103Changes in Critical Thinking After the Final Year of Clinical EducationAurora Denial, OD, FAAOThe final year of optometric education may provide the ideal opportunity to become more skilled at critical thinking. The author evaluates changes in standardized critical thinking scores between the start and end of the final year of study in 36 students. 107

Cover: courtesy of Rick Clapper, Director of Graphics andBranding, Western University of Health Sciences

Volume 33, Number 3 / Summer 2008 79

OPHTHALMIC

The following companies support ASCO’s national programsand activities benefiting theschools and colleges of optometryin the U.S. and Puerto Rico.*

Benefactors ($25,000 - $49,999)Alcon LaboratoriesCIBA Vision CorporationEssilor of AmericaTransitions OpticalThe Vision Care InstituteTM of

Johnson & Johnson VisionCare, Inc.

Supporters ($15,000 - $24,999)Advanced Medical OpticsCarl Zeiss VisionHoya Vision Care, North AmericaLuxottica / EyeMed Vision CareM&S TechnologiesVision Service Plan

Friends ($10,000 - $14,999)Allergan, Inc.Bausch & Lomb, Inc.Compulink Business SystemsCooperVisionGenzymeOptos North AmericaVolk Optical

Contributors ($5,000 – $9,999)Marchon EyewearNidek, Inc.Ophthonix, Inc.Optovue, Inc.Safilo GroupTLC VisionVision Source!Vistakon® Division of Johnson &

Johnson Vision Care, Inc.Wal-Mart Stores, Inc.

————————————————*As of August 1, 2008

New DAILIES® AquaComfortPlusTM Contact Lenses FeatureCIBA VISION Triple-ActionMoisture

CIBA VISION has announced theU.S. introduction of DAILIESAquaComfort Plus, an innovativenew contact lens that takes comfortto a new level for DAILIES. The firstand only CIBA VISION lens withTriple Action Moisture, DAILIESAquaComfort Plus lubricates, mois-turizes and refreshes the lens foroutstanding comfort throughout theday. This new lens includes a lubri-cant for instant comfort at the startof the day, a wetting agent that,together with the third comfortagent, provides moisture throughoutthe day, and an optimized blink-acti-vated moisturizing agent thatrefreshes the lens through the end ofthe day.\

Three material components con-tribute to the Triple Action Moisture:HPMC (Hydroxypropyl methylcel-lulose) lubricates the lens, PEG(Polyethylene glycol) moisturizesthe lens, and PVA (Polyvinyl alco-hol) refreshes the lens throughoutthe day. Studies have shown that inindividuals who quit wearing theircontact lenses, 47 percent cite dis-comfort as the main reason behinddiscontinuation of use.

In other news from CIBAVISION, the company hasannounced the launch of its latestsilicone hydrogel innovation – AIROPTIXTM AQUA breathable contactlenses. AIR OPTIX AQUA lensesdeliver an advanced combination ofoxygen and moisture, and excellentinitial as well as all-day comfort,contributing to a healthy lens-wear-ing experience. AIR OPTIX AQUAlenses start and stay comfortablewith the new AQUA MoistureSystem, which includes: a uniquemoisture agent that helps lubricate

the lens for initial comfort, a patent-ed lens material that helps maintainmoisture by minimizing the rate oflens dehydrationi for comfort allday, and an ultra-smooth surfacewith superior wetability and excel-lent deposit resistance for comfortevery day. According to studies, sev-enty percent of patients who experi-ence eye irritation from their contactlenses never mention it to their eyecare professional. To help encouragehealthy lens wear and higher patientcompliance, CIBA VISION is recom-mending a monthly replacementschedule for AIR OPTIX AQUAlenses.

Eye Allergies Nothing toSneeze at this Fall“Eye Health and Allergies” Brochurefrom Asthma and Allergy Foundation ofAmerica Offers Advice for Eye AllergySufferers; Includes Seasonal Strategiesfor Contact Lens Wearers

Come late summer, some 10 to 20percent of Americans begin to sufferfrom ragweed allergy, or hay fever.In addition to symptoms of sneez-ing, stuffy or runny nose, allergicreactions. To help eye allergy suffer-ers better understand and handlethe condition, the Asthma andAllergy Foundation of America(AAFA) is offering a free educationalbrochure, “Eye Health andAllergies.” The brochure can beviewed or downloaded atwww.aafa.org. “This brochure offersuseful information on how eye aller-gies occur, common signs and symp-toms, and practical advice on how totreat and prevent eye allergies.

Fifty-four percent of those whowear contact lenses find it veryuncomfortable to wear their lenseswhen they have allergy symptoms,according to a 2006 survey of 500adult contact lens wearers with ocu-lar allergies. The vast majority copeby increasing their use of wettingdrops, wearing their lenses less oftenor removing their lenses during the

INDUSTRY NEWS

(Continued on page 80)


day. A significant minority (42 percent) say they stopwearing lenses and switch to glasses.

In a three-year study2 comparing the clinical perfor-mance of daily disposables (1•DAY ACUVUE® BrandContact Lenses) with that of conventional daily-wearlenses replaced at 1 or 3 months (n=126), frequent replace-ment lenses replaced every 2 weeks (n=144) and daily dis-posable wearers (n=68), single-use lens wearers reportedfewer symptoms of redness, cloudy vision, and grittiness;at the same time, they reported better vision and overallsatisfaction, and had fewer lens surface deposits, compli-cations, or unscheduled doctor’s visits than conventionaldaily lens wearers.

To help allergy sufferers who would like to start wear-ing or continue wearing contact lenses, the brochure,along with a free trial-pair certificate* for 1•DAY ACU-VUE® MOIST® Brand Contact Lenses, is available atwww.acuvue.com/seasons.

Medical and Optometry Schools Turn toEyemaginations for Education Tools

Eyemaginations continues to be embraced as the pre-ferred source for animated education solutions for highereducation institutions. Nearly all of the nation’s optome-try schools and many leading medical schools haveturned to Eyemaginations to develop training tools fortheir residents and students.

Most recently, the Yale School of Medicine and theGeorge Washington University School of Medicine andHealth Services implemented Eyemaginations’ flagshipsoftware product, 3D-Eye Office, as a new tool for stu-dents to use in the classroom and as a supplemental train-ing resource. Many schools also use 3D-Eye Office soft-ware in their clinics to educate patients about conditionsand procedures. The majority of the optometry programsin the North America currently use Eyemaginations.Selected clients include The Pennsylvania College ofOptometry at Salus University, the State University ofNew York College of Optometry, Pacific UniversityCollege of Optometry, and Illinois College of Optometry.

Eyemaginations, most known for developing state-of-the-art patient education solutions that help eye care pro-fessionals inform their patients about conditions and pro-cedures, expanded its core business to focus on highereducation institutions over the last 18 months.

Volk H-R Wide Field Laser Lens

High-resolution lens allows visualization of details approachingthe ora serrata

Volk Optical, the leader in aspheric optics, has releaseda revolutionary new pan retinal lens for diagnosis withthe addition of the H-R Wide Field Lens. Its high-resolu-tion imaging, coupled with an extremely wide field capa-

bility, provides highly detailed views for pan retinal diag-nosis. The H-R Wide Field is a contact type of lens andrequires a coupling solution when contacting the eye.Although this may add a step to the examination, itensures that the optometrist can clearly visualize retinaltears or lesions across the entire retinal surface, all theway to the ora serrata. Most important, it is distortion freeacross the entire viewing area. The combination of Volk’spatented double aspheric glass design with low disper-sion glass, ensures the highest resolution imaging acrossthe entire viewing field. This superior viewing powerwith a 0.50x magnification is contained in a low-profile,reduced-size housing to simplify manipulation of the lenswithin the orbit.

Volk Optical is an industry leader in the design andmanufacture of aspheric optics. Glass lens constructionand the company’s patented double aspheric technologyresult in the highest resolution imaging with the beststereopsis for precision diagnostic, therapeutic and surgi-cal work.

Vision Source, a network of private practice optometrists,has added four executives to its management team as itadds Office Number 1,800 to its network. Joining VisionSource, LP are, Kelly Kerksick, O.D., Director ofProfessional Services, Jason Morris, O.D., GeneralManager of Vision Source Canada, Derrick Artis, O.D.,Vice President of Vendor Relations, and Hans Kell, O.D.,Vice President of Network Administration. Coincidentalwith the announcement of its new executives, VisionSource also added its 1,800th member office in Krugerville,Texas. Founded in 1991, Vision Source provides its mem-bers with cost of goods savings, practice managementsupport and a forum for sharing experiences and ideas.Each office is owned and operated by an independentdoctor of optometry.

Industry News(Continued from page 79)

We have!Have you thought about the future of optometry?

The Partnership Foundation for Optometric Education is planting, cultivating, and nurturing. Together,

this “true partnership” is making a long-term investment in tomorrow.


This special theme issue of the journal seeks tohelp answer the question, “When we think aboutthinking, what should we be thinking about?” Asconvoluted as that question sounds, it points out

the importance of seeking a deeper understanding of thethought processes and thinking skills required to be agood optometric practitioner and an effective optometriceducator. Critical thinking skills are something everyonewants students to have, but not everyone is using thesame definition of critical thinking. Perceptions andassumptions about thinking vary, and many differenttechniques are being used in health profession educationto teach our future health care providers “how to think.”

There have been a number of recent publicationsabout critical thinking in journals devoted to higher edu-cation and health profession education. Willingham hasmade the point that it is time to ask the fundamentalquestion, “Can critical thinking actually be taught?”1 Headvised that many people assume that critical thinking isa skill like riding a bicycle and that, once learned, it canbe applied in a variety of situations. In re sponse to thisassumption, Willing ham made the argument that theapplication of critical thinking is context dependent andthat specific strategies, knowledge, and practice arerequired to improve the ability to think critically.1

Beyond the classroom, Delany and Watkin haveasserted that clinical education emphasizing experientiallearning may not be sufficient to develop many of thecomponents of critical thinking. In particular, they haveidentified that flexibility, self-awareness, and an under-standing of alternative perspectives require supplemen-tal programs to enhance the development of these skills.2

Further research has supported the idea that a favor-able disposition toward critical thinking is also veryimportant for optometric educators. Research byProfetto-McGrath et al. found that nurse educators whohad a higher score on the California Critical ThinkingDispositions Inventory were also more likely to utilizeresearch in the delivery of patient care and student edu-cation. They asserted that these characteristics are vitalfor improving patient and systems outcomes.3,4

This theme issue represents one of the first occasionsthat articles about critical thinking have been publishedin a journal devoted to optometric education. In thisissue, we present articles representing the range fromtheoretical and conceptual ideas to practical applications

and assessments of thinking skills in the context of opto-metric clinical education.

Elder and Paul set the foundation for our contempla-tion of critical thinking by describing their working defi-nitions and perceptions of critical thinking and by pro-viding a common framework. Galvin brings in theperspective of classroom education, with examples ofimplementation from a teacher’s perspective. Her workemphasizes the learning process and environment in theeducational setting and how that can translate into thedevelopment of lifelong learners. Faccione and Faccionebring a clinical perspective by translating critical think-ing skills into the patient care environment. Denial pro-vides research that links optometry students’ criticalthinking skills and clinical skill–building within theoptometric curriculum.

This issue’s “Think Tank” continues the theme, as con-tributors share their thoughts about overcoming chal-lenges to encouraging student development of criticalthinking skills. Optometric educators from the classroomand the clinic provide us with a variety of perspectives.Carlson reminds us of the joys of watching students learnand grow when she tells us about her “Best Day” in opto-metric education.

Each of these pieces should help us gain a deeperunderstanding of the complexities of skillful thinking,and together they showcase important themes that willhelp us in our roles as educators. We are, after all, creat-ing the next generation of critical thinkers.

References1. Willingham, DT. Critical thinking: Why is it so hard to teach? Arts

Educ Pol Rev. 2008;109(4):21-9.2. Delany C, Watkin D. A study of critical reflection in health profes-

sional education: “learning where others are coming from.” AdvHealth Sci Educ Theory Pract. 2008 (June). DOI: 10.1007/s10459-008-9128-0. Available from http://www.springerlink.com/ content/v05423601p317432/

3. Profetto-McGrath J, Smith KB, Hugo K, Patel A, Dussault B. Nurseeducators’ critical thinking dispositions and research utilization.Nurse Educ Pract. 2008, August 11: [Epub].

4. Profetto-McGrath J, Hesketh KL, Lang S, Estabrooks CA. A study ofcritical thinking and research utilization among nurses. West J NursRes. 2003;25:322-37.

EDITORIALThinking About Thinking

Elizabeth Hoppe, OD, MPH, DrPH

Dr. Hoppe is founding dean of Western University of Health Sciences Collegeof Optometry. E-mail: [email protected].


The teaching and learningof critical thinking skillshave gained prominencein higher education in

recent years. In many fields suchas medicine, nursing and optom-etry the attainment of criticalthinking skills has become alearning objective for the curricu-lum. Educators in all fields haverecognized the need to cultivatecritical thinking ability withintheir domain of students as well

within the context of the curriculum.I first became interested in teaching critical thinking

through my involvement in the Integrative Seminar Tract(IST) at the New England College of Optometry. In 2003, Iwas named co-course master and developer of the IST. Thetract, which consisted of two courses for first and secondyear students, was dedicated to teaching the skills associat-ed with clinical thinking and integration of knowledge.Case analysis, problem based learning and other activitieswere used to achieve the goals. However, it soon becameapparent that students in the early stages of learning clini-cal thought process, especially in a didactic setting, neededto learn a strategy for thinking.

The more I learned about critical thinking skills, themore I saw the connection between critical thinking abilityand clinical thinking. I began to think of developing criticalthinking skills as the key strategy needed to drive clinicalthinking. Therefore, it made sense to more formally teachcritical thinking concepts. However, our students needed alittle more convincing. Most students felt that when theyarrived at optometry school they demonstrated good think-ing skills and therefore teaching these skills was redundant.All they needed to learn was the knowledge and technicalskills associated with the profession. Most of their support-ing evidence came from high academic achievement in col-lege and good scores on standardized testing. The evidencethey presented only supported being a good student, butnot necessarily a good thinker. In reality, even those stu-dents who possessed excellent thinking skills could alwaysbenefit by taking those skills to a higher level.

In everyday life, we constantly engage in thinking, prob-lem solving and decision making. In most cases, the conse-quences of our thinking have relatively low stakes. Whenwe are preparing students for a profession that deals withthe responsibility of caring for another person’s eyesight orin some cases their lives, the consequences of our student’sthinking have much higher stakes. In class, I use the

analogy of driving a car. If we are driving around a turn at20 miles per hour and make a mistake in most cases theconsequences are not severe. If we are driving at 200 milesper hour and make an error the consequences are signifi-cant. Even if you have good skills driving at slower speedswhen you engage in driving at fast speeds you need addi-tional training.

The teaching of critical thinking has been an adventurefilled with many challenges. The first challenge was increas-ing my knowledge in critical thinking and the second chal-lenge was changing the student’s perception of criticalthinking. My first step was to get formal training in the con-cepts that I felt were so important to our students’ educa-tion. My first conference was the 26th InternationalConference for Critical Thinking by the Foundation forCritical Thinking, Dillon Beach, California. This conferenceprovided an excellent foundation. Exposure to key conceptsrelated to critical thinking and teaching with active learningwere highlights. The foundation has many resources avail-able such as books, articles, workshops and speakers. Ispent the following year reading, researching and talking toother people, who were more expert than I. The next sum-mer I attended the Summer Institute on Teaching CriticalThinking by the National Center for Teaching Thinking, inNewton, Massachusetts. This conference was very produc-tive as it provided more information on how to implementcritical thinking concepts into content. The Center also pro-vided many valuable resources.

This past academic year, to help students value the theo-retical concepts related to critical thinking I emphasizedteaching in context and active learning. Volunteers from thecommunity who served as “patients” were included in thecourse in a non-clinical interaction. These volunteers pro-vided the context to learn critical thinking in relation topatient care. To engage students in an active manner,instead of lecturing to students about critical thinking con-cepts, the students extrapolated the strategy for problemsolving by watching the movie “Apollo 13”. Students wereassigned to work in groups of 3 to 4 to encourage brain-storming and peer support. Peer teaching as well as selfdirected learning were also incorporated into the course.

Helping students develop good thinking skills givesthem independence and self reliance. Information, knowl-edge and techniques can change over time. Developinggood thinking skills will last a lifetime. An optometrist’sthought process is the best tool they can bring to theirpatients.

GUEST EDITORIALPutting Critical Thinking into Action

Aurora Denial, OD, FAAO

Dr. Denial is associate professor of optometry at the New England College ofOptometry. E-mail: [email protected]


What we really want is for our students to apply criticalthinking skills, clinically. Attempting to teach criticalthinking skills in general terms may not seem relevant

to our students. If we put an emphasis on heuristics as they enterclinic, it will seem more meaningful. Successful clinicians useheuristics—conceptual rules of thumb—that allow them to siftthough information quickly and efficiently to answer diagnosticquestions. If we want our students to effectively use heuristics,faculty need to be aware of how they apply them. Faculty and stu-dents both need to be aware of the common pitfalls of heuristicsand how common errors and cognitive biases can lead themastray. One example is the error of availability—the tendency tojudge the likelihood of an event by the ease with which relevantexamples come to mind. Another example of a cognitive error isanchoring, where the clinician latches on to one single answerand doesn’t consider other possibilities.

Jerome Groopman has written an excellent book, How DoctorsThink (Houghton Mifflin; 2007). In it he introduces the topic ofheuristics. The book is written for a lay audience; therefore, evenstudents who are early in their clinical career would benefit fromhis presentation. Experienced clinicians use heuristics withoutever analyzing the process. Clinical faculty need to be acquaintedwith heuristics enough to be conversant in the subject and be ableto model for students their own clinical thinking.

Melanie A. Crandall, OD, MBA, FAAOAssociate ProfessorNova Southeastern University College of Optometry

C ritical thinking cannot beexpected to develop on its ownbut, like every other skill,

needs to be required and practiced. Ithink optometric education falls short inthe area of requiring it and then givingstudents genuine opportunities to prac-tice it. In large classrooms, most mater-ial is delivered by lecture andPowerPoint, and even when we querythe class, we either don’t wait longenough for them to think, much lesswork up the courage to speak, or weaccept one or two answers from a shortlist of outspoken individuals and thenmove on. Solutions for the classroominclude waiting longer after we ask theclass a question (such as silently countingto 10) and reformulating queries asmultiple-choice questions, demandingthe class vote for one, and having thepatience and courage not to move onuntil most of the students have voted.Personal experience with both methodssuggests that they work, albeit imper-fectly. In the clinical setting, the urge onthe part of the preceptor to give answersis almost irresistible, especially whenthere is time pressure in a busy clinic,but the best way to help students developtheir thinking skills is to demand it ofthem and then give them time, andmore time, to formulate and expresstheir thoughts. The recurrent themesare to demand critical thinking fromstudents and then to give them time todo it.

————— • ————

Daniel Kurtz, PhD, OD, FAAOAssociate Dean of Academic Affairs

Western University College of Optometry

“What Are the Challenges to Encouraging Student Developmentof Critical Thinking Skills in the Optometric EducationalEnvironment and How Can These Challenges Be Overcome?”

Think Tank . . .

Think Tank . . .

Although, egocentrically speaking, it is uplifting tocreate small images of ourselves in the form ofstudents, the better good is realized by an instruc-

tor who refuses to impose the intellectual box on the sur-rounding student population, offering instead a generalknowledge of systems that can then be expanded toinclude the details. Classical approaches of instructionand testing have rewarded the students who memorizelarge lists of facts. We can all recount individuals whotopped the class in written tests but were mediocre inclinical application of this knowledge.

Rather than scholastically supporting the “cram-ming–regurgitation–brain dump” cycle, could we noteffectively facilitate our students’ learning and under-standing by routinely requiring the students to engage inthe holistic, creative application of the multitude ofdetails in a problem-solving activity? This approach notonly requires a thorough knowledge of the facts, found asan emphasis in the classical model, but advances creativi-ty both in thought and application of the minutiae, basedon a thorough knowledge of systemic function. Thegreater the knowledge of body systems, for instance, themore variables that can be called into the solution or intoclinical and research science and the greater the complex-ity of the problems that can be solved. Internships, extern-ships, residencies, postdoctoral fellowships, and the likeeffectively instruct using systemic assessment in problem-solving experiences. Why not incorporate this same effec-tive method into the initial years of professional instruc-tion?

Nothing here is news to any educator, but an increasein initial emphasis on the picture or system as a whole—to which is added detail versus instruction, and testing ofdetail, even in the initial stages of the learning process—enhances not only learning but creativity of thought andmastery of the subject material. From my first-year med-ical students all the way to the residents, all are asking formore of this instructional approach. The educational jour-ney through the training of health professionals is notinexpensive. As the old song says, “Who could ask formore?” Well, perhaps we all could and most likely should.

Clifford D. Brown, OD, MPH, FAAOChief of the

Crow North Cheyenne Hospital Eye Services

Critical thinking does not begin in optom-etry school but is used by students inother environments long before the

onset of their optometric training. It cannot betaught in isolation but is facilitated by a strongknowledge base within the discipline in which itis used. The challenge to enabling critical think-ing in optometric training, therefore, is to createan educational environment where knowledge istaught in the service of clinical practice.

Information must be taught in a clinically rele-vant fashion from the beginning of the curricu-lum. Rather than solely regurgitating coursecontent, students must learn to transform andapply classroom material into clinical practice.Development of critical thinking skills necessarilylags behind content learning earlier in the edu-cational process. As the student’s knowledgebase expands, critical thinking assumes a moresignificant role in optometric training.

Critical thinking skills are advanced in the clinicsetting, as patient encounters progress fromthose more heavily involving information gather-ing to those with greater emphasis on clinicaldecision making. One barrier in this process isstudent anxiety. Beginning interns are unaccus-tomed to working with patients and highlyfocused on technical performance. This inter-feres with their ability to view the big picture, asit relates to their cases. Starting patient interac-tion early in the optometric curriculum works todesensitize students and relieve some of thisanxiety. The student gains experience in per-forming an examination not solely in the labora-tory on a fellow student but on a clinic patient.Clinical instruction must require that interns gothrough the process of, and demonstrate com-petency in, critical thinking in their patientencounters. This is fostered by support andencouragement on the part of the supervisorand working through the clinical decision-makingprocess with the student.

Leon Nehmad, OD, MSW, FAAOState University of New York College of Optometry



In this age of increased healthcare costs, there arepressures for every mode of practice to be as effi-cient as possible. Taking the time to allow students

to perform the exam and still providing good clinicaleducation is not necessarily more efficient than seeingthe patients on your own. There are numerous articlesin the literature on how to make clinical teaching costeffective, but it is not easy to do. Generally, the stu-dents need to present their explanation to the licensedpractitioner and discuss it before any discussion withthe patient. That gives the opportunity for discussionof other possible ways to analyze the findings and pro-vides feedback to the student. However, the time thelicensed practitioner saves in testing time is sometimesused up in rechecking findings, documentation, andteaching the students.

Students need to learn how to change their wordingto customize their approach based on the particularcharacteristics of the patient in subjective testing andin speaking to the patients. The wording they learnedfrom practicing on fellow optometry students may notyield the same examination results in the general pop-ulation without specific knowledge of the subjectivetests and questions asked of the patient. It takesrepeated patient exposures for them to learn how tomodify their wording to adapt to the patient. I usuallytell the students that if the patient does not give reli-able results, the examiner needs to change the instruc-tions. Time needs to be allocated to discuss alternativeways to request the subjective information of thepatient.

When the students take the patient-education por-tion of the exam, they may end up taking longer than

an established practitioner to adequately confirmpatient understanding. Students need the practice inpresenting the case to the patient. This can decreasethe efficiency of patient care in a busy, multi-specialtyclinical environment where being efficient is necessary.However, this is also the type of environment with thepatient base that is unique enough to be a great educa-tional experience. My preference is to have themwatch the techniques I use for these explanations and,then, when the clinic is running on time, have the stu-dents present to patients, with the licensed practitionerstill in the room to observe and fill in any gaps. Thisallows the students to observe the unique differencesin each clinical environment.

During their clinical education, students build rap-port by talking to the patients about things that maybe peripheral to the examination, which can be timeconsuming. There is a fine line between bonding withthe patient and getting off-task. It is difficult to directa patient back to the examination without them feelinglike they are being rushed. To be efficient, I usuallydemonstrate to the student how to repeat the patient’slast comment and then direct them back to the examrather than allowing the patients to take the conversa-tion off the task at hand.

Clinical education in this era of spiraling healthcarecosts will continue to challenge the quality and theefficiency of patient care. This challenge is well worththe satisfaction of seeing the clinical confidence of stu-dents’ handling difficult cases improve in front of you.

Debbie L. Hettler, OD, MPH, FAAOHarry S. Truman Memorial Veterans Affairs Hospital

In my role as a clinical preceptorduring my residency, I had theopportunity to work closely with

optometry students at all levels ofclinical development. There are manychallenges to encouraging the devel-opment of critical thinking skills instudents, but I saw three specificchallenges common to most stu-dents. First, students do not alwaysget enough opportunities at an earlystage to have the number of patientencounters necessary to reinforcethe importance of critical thinking.Students need to have a largeenough number of encounters with abroad diversity of patient populationsand clinical settings so that theyquickly develop the technical confi-dence to move beyond the tendencyto spend their mental energy on tech-

nique rather than on the significanceof findings. Second, clinical precep-tors do not always make time toeffectively model and encourage thecritical thinking process. Clinical pre-ceptors need to be empowered (andmotivated) to spend the time neces-sary to discuss each case with stu-dents for the students to understandthe practitioner’s thought process inapproaching the case and to receivevaluable, constructive feedback.Third, students do not always viewthe critical thinking process as a pow-erful tool that can improve your abilityto care for your patients and your effi-ciency. Often, students sacrifice thetime necessary to develop good criti-cal thinking skills in the rush to getthrough the exam quickly enough toplease their clinical preceptor by hav-

ing data for all the important points ofan encounter. It is critical that stu-dents spend the time before and out-side of clinic to practice their efficien-cy and work toward better timemanagement so that they have thetime to stop and think about how thepatient encounter findings fit into thebig picture of the patient’s health.This allows a practitioner to preventwasted time by approaching prob-lems in a targeted fashion and allowsthem to better care for their patientsas a whole.

Justin Smith, ODPediatric Optometrist

Harvard Vanguard Medical Associates

Think Tank . . .

The ongoing challenges among optometric educatorsto continually expand the curriculum as our scopeof practice grows but still maintain the optometric

curriculum’s finite length will always persist. Greater scopeof practice not only entails acquiring new diagnostic andmanagement skills but the basic science knowledge thatforms the basis of those techniques, procedures, and/or treat-ments.

There will always be inadequate time to convey to stu-dents the evolution of basic/clinical science knowledge withregard to every clinical test, procedure, or treatment. Yet, anadequate amount of didactic knowledge must be acquired,as it is the foundation for its application to clinical care. Thehistorical approach has been to teach the basic sciences (e.g.,geometric optics and ocular motility) and subsequentlybuild on this knowledge base with clinical science courses(e.g., ophthalmic optics and binocular vision). Althoughthis is logical and students should indeed retain all ofknowledge they have acquired cumulatively in a curriculum,it is often challenging for students to recall the details ofthe basic-science coursework while learning the clinical sci-ence coursework.

While the historical approach has already been improvedon by initiating clinical science courses earlier into the cur-riculum, supplementing with or implementing courses thathave as their explicit goal to integrate basic and clinical sci-ence will have an impact on the challenge presented here.Of course, no traditional didactic course could accomplishthis easily. So-called problem-based learning and/or self-directed learning approaches have already been implementedat some schools and colleges of optometry. These courses askstudents to think critically about how an ocular conditionaffects the ocular anatomy/physiology, how the signs andsymptoms manifest themselves due to the alterations in theanatomy/physiology, and the scientific basis for how a pro-posed intervention would ameliorate the condition. Thisthought process is intended to be much more in-depth thanthat involved in a typical optometric exam.

Of course, a closely related, but perhaps more challeng-ing, aspect of this issue is developing critical thinking skillsfor direct patient care. Didactic coursework is often filledwith lab reports and written tests, which students have a,relatively speaking, “adequate and uninterrupted time” towork on. On entering clinical care, students suddenly haveinadequate and interrupted time to care for a patient.Clinical care in the optometric education model puts pres-sure on the students not only from the standpoint of “get-

ting a grade,” just as in basic or clinical science coursework,but the very real pressure of caring for patient sitting in thechair (and staring at you) is present. The unique anxietythat clinical care represents can easily overwhelm studentsso that the critically thinking skills become secondary to thedata collection.

The present shift in among all schools and colleges ofoptometry to integrate students into clinical care as soon aspossible will address part of this challenge. Early in a pro-gram, students shadowing more senior students should beactive observers in the decision-making processes internsand faculty work through on each and every patient.Transitioning from these observation assignments to clinicalinterns will hopefully allow students to acquire a good graspof the critical thinking skills involved in the majority ofprimary care exams. Of course, part of the challenge inlearning this way is that the student has not necessarilyacquired the basic knowledge to understand the full process,but as more coursework is undertaken students can relatethese experiences to their coursework at the time of instruc-tion (rather than the other way around).

Critical thinking skills for patient care really must devel-op from devoted students and faculty to treat each patientencounter as a learning experience. The demands (and sur-prises) that patient care presents to new optometric internscoupled with the “rush hour” atmosphere that clinical facul-ty may experience are stressful. Nevertheless, stu-dent–faculty ratios need to be optimized and time should beallocated to reviewing patient cases the same day so that thestudent and faculty feel satisfied that each patient encounterwas a useful learning experience, and the decision-makingprocesses that lead to a primary diagnosis from a chief com-plaint need to be obvious from both standpoints.

The challenge of developing critical thinking skills dur-ing optometric education will continue. The good news isthat every year, optometric graduates are more highly edu-cated than previous classes. Diversity in the optometric cur-ricula (e.g., problem-based learning, grand-round seminars)sparks students’ motivation to develop critical thinkingskills earlier in the curricula, but, ultimately, the enrollmentof talented, passionate, and self-motivated students coupledwith devoted faculty will allow the graduating classes to bethe most highly educated and caring doctors every year.

Jason Ng, OD, PhD, FAAOAssistant Professor

Southern California College of Optometry

Think Tank . . .


My best day in optomet-ric education isThursday—not a spe-cific Thursday, but just

about every Thursday since the fallof 1982 when I started teaching first-year optometry labs. Over the years,the name of the course has changedfrom Optometric Methods, toOptometry: Theory and Methods, toPrinciples and Practice ofOptometry, but my lab assignmenthas somehow remained onThursdays. The content has changedsome too, but what has not changedis that teaching lab is a great oppor-tunity to get to know students per-sonally and to see learning takingplace during every session.

The first lab of the year is alwaysfun for me. The students come innervous and unsure. They spend 30minutes attempting to measure visu-al acuity with a projected Snellenchart on a classmate who speakstheir language, is obviously intelli-gent, and who most likely has 20/20vision. They are confused when the

patient cannot read the near chartand amazed to see vision improveseveral lines by simply directing theoverhead lamp onto the near card.Even in that first hour, learning canbe seen not only by me but by thestudents too. The second patienttested in the first lab only takes 15minutes and the third takes about 10minutes. The students lose theirawkwardness and start to look likeclinicians. In just six weeks, the samestudents come in for their first profi-ciency exam. They dress up so thatthey look like doctors, and they areable to complete nine tests in addi-tion to Snellen acuity in less than 25minutes. It is an amazing transfor-mation.

Working with a small group ofstudents in a lab is much less formalthan lecturing to the whole class.Students become individuals in lab;their personalities and their learningstyles become very evident. There istime to talk to the students, find outabout where they are from, wherethey went to school, where they areliving in the Boston area, how theyspend their free time, and all abouttheir families. Over the years, stu-dents have told me about greatrestaurants in the Boston area,advised me on vacation destinations,recommended great novels they arereading and want to share, andother fun, free-time activities. I haveattended weddings, christenings,and (sadly) funerals of students andtheir family members.

Because of the relationships that Ihave made in lab, I have been ableto help students who are havingproblems in understanding materialin my course who I might not haveknown about otherwise. Studentswho are not keeping up in lab standout because of the “up close andpersonal” nature of lab. Sometimes,just a short discussion in my office

with a few extra examples straight-ens out the problem and the stu-dents find that they can succeed.Sometimes a referral for tutoring orfor help in sorting out personalproblems is warranted. And some-times a recommendation to workharder is the right thing for a stu-dent. It is a privilege to be a part ofhelping students find what theyneed to do to succeed.

Lab teaching has been great feed-back for me on how well the lectureportion of the course is going. Ifthings are not clear in lecture, pre-cious lab time is wasted going overthings that should have already beenunderstood. Working with individu-als in lab has also given me ideasabout better ways of presentingmaterial to the whole class in lec-ture.

Why would any senior facultymember continue to teach first yearlabs year after year? Surely, this isone of those dreadful assignmentsthat are usually delegated to newfaculty who move on to bigger andbetter things as soon as it is possible.I have chosen to continue to teachlabs because it is such a great oppor-tunity to get to know my future col-leagues and because, over the years,I have learned at least as much frommy students as I have taught them.It may be the same topics year afteryear, but the students are fresh, new,and eager to learn when they arrivein the fall of their first year. It isgreat to be so much a part of theireducation, and I plan to continueteaching labs for the rest of mycareer.

Dr. Carlson is a professor of optometry atthe New England College of Optometry. E-mail: [email protected]

My Best Day in Optometric EducationGetting to Know Students and

Watching Them LearnNancy B. Carlson, OD, FAAO


FEATURE

Critical Thinking1

To think within a discipline is tothink within the system of meaningsthat constitute the discipline. Whatwe call knowledge are systems of inter-connected ideas, ideas that togethercreate a logic: the logic of biology, thelogic of chemistry, the logic of mathe-

matics. Yet most students think ofwhat they are learning as disconnect-ed sentences from a textbook or lec-ture. By the time they reach the col-lege level, they have successfullymislearned what it means to learn.They have successfully constructed amisconception of knowledge. Theydo not see the need for thinking theirway through the content, or for find-ing connections within and across dis-ciplines. They see subjects and disci-plines as atomic facts, bits, and piecesof meaning to store in their minds fora test, and then to forget to makeroom for more bits and pieces foranother test, and so on. It is our job todisabuse our students of their carica-tures of knowledge and learning. It isour job to teach them how to think:clearly, accurately, precisely, relevant-ly, deeply, broadly, logically, signifi-cantly, fairly. Enter critical thinking.

“Critical thinking is that mode ofthinking—about any subject, content,or problem—in which the thinkerimproves the quality of his or herthinking by skillfully analyzing,assessing, and reconstructing it.Critical thinking is self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposesassent to rigorous standards of excel-lence and mindful command of theiruse. It entails effective communica-tion and problem-solving abilities, aswell as a commitment to overcomeour native egocentrism and sociocen-trism.”2 It is an abiding concern withthe problems in thinking.

Critical thinking provides the intel-lectual tools students need to reasonwell within every subject and disci-pline, within every mode of humanthought. Critical thinking offers intel-lectual tools for the analysis andassessment of thinking within andacross disciplines. It enables studentsto see the interconnected logic of anysubject or specialty and to think withdiscipline and skill within that logic.In short, it provides a vehicle for edu-cating the mind.

There are three primary intellectualsets that critical thinking offers us:

1. Tools for the analysis of think-ing—the elements of reasoning.

2. Tools for the assessment of think-ing—universal intellectual standards

3. Tools for fostering intellectualdispositions of mind—intellectualvirtues

The purpose of this article is todescribe each of these sets and discusstheir implications for teaching and

AbstractCritical thinking provides a vehicle for educating the mind. Although most

educators strive to teach and foster critical thinking skills in their students manydo not have a clear understanding of the concepts and tools of critical thinking.Critical thinking provides the intellectual tools students need to reason wellwithin every subject and discipline, within every mode of human thought.Critical thinking offers intellectual tools for the analysis and assessment of think-ing. It enables students to see the interconnected logic of any subject or specialtyand to think with discipline and skill within that logic. It entails effective com-munication and problem-solving abilities, as well as a commitment to overcomeour native egocentrism and sociocentrism. There are three primary intellectualsets that critical thinking offers us: tools for the analysis of thinking, tools for theassessment of thinking and tools for fostering intellectual dispositions of mind.The purpose of this article is to describe each of these sets and discuss their impli-cations for teaching and education. With a clear and accurate understanding ofcritical thinking concepts, educators will be able to lay the foundation for learn-ing and education. This article represents a review and consolidation of originalwork by Drs. Linda Elder and Richard Paul. The concepts presented in this arti-cle incorporate text which has been previously published and was specificallycompiled to provide foundational information for the optometric educator. Itreflects years of thinking about thinking – about what it entails, about where itgoes wrong, about how it can be improved.

Key Words: critical thinking, education, reasoning

Dr. Linda Elder is an educational psychologist anda prominent authority on critical thinking. She isPresident of the Foundation for Critical Thinkingand Executive Director of the Center for CriticalThink ing. Dr. Richard Paul is the Director of Re -search and Professional Development at the Centerfor Critical Thinking and Chair of the NationalCouncil for Excellence in Critical Thinking.

Critical Thinking: The Nuts and Bolts ofEducationLinda Elder, PhDRichard Paul, PhD



education. With a clear and accurateunderstanding of critical thinkingconcepts, educators will be able to laythe foundation for learning and edu-cation. This article represents a reviewand consolidation of original work byDrs Linda Elder and Richard Paul.The concepts presented in this article,incorporate text that has been previ-ously published and was specificallycompiled to provide foundationalinformation for the optometric educa-tor. It reflects years of thinking aboutthinking—about what it entails, aboutwhere it goes wrong, and about howit can be improved.

The Analysis of Thinking3

“Everyone thinks; it is our natureto do so. But much of our thinking,left to itself, is biased, distorted, par-tial, uninformed, or downright preju-diced. Yet the quality of our life and ofwhat we produce, make, or builddepends precisely on the quality ofour thought. Shoddy thinking is cost-ly, both in money and in quality oflife.”3,4 If we want to think well, wemust understand at least the rudi-ments of thought, the most basicstructures out of which all thinking ismade. We must learn how to takethinking apart.

All Thinking Is Defined by theEight Elements That Make ItUp3,5

“Eight basic structures are presentin all thinking: Whenever we think,we think for a purpose within a pointof view based on assumptions leadingto implications and consequences. Weuse concepts, ideas and theories tointerpret data, facts, and experiencesin order to answer questions, solveproblems, and resolve issues.”3,5

“Thinking, then:• generates purposes• raises questions• uses information• utilizes concepts• makes inferences• makes assumptions• generates implications• embodies a point of view”3,5

The figure to the right illustratesthe “Elements of Thought”(Copyright 2007 by the Foundationfor Critical Thinking. Reproducedwith permission.3)

“Each of these structures has impli-cations for the others. If we changeour purpose or agenda, we changeour questions and problems. If wechange our questions and problems,we are forced to seek new informationand data.”3,5 If we collect new infor-mation and data, we are forced to con-sider alternative inferences or conclu-sions. And so forth. When weunderstand the elements of reason-ing, we realize that all subjects, all dis-ciplines, have a fundamental logicdefined by the structures of thoughtembedded in them.

“Therefore, to lay bare a subject’smost fundamental logic, we shouldbegin with these questions:

• What is the main purpose orgoal of studying this subject?What are people in this field try-ing to accomplish?

• What kinds of questions do theyask? What kinds of problems dothey try to solve?

• What sorts of information ordata do they gather?

• What types of inferences orjudgments do they typicallymake? (Judgments about...)

• How do they go about gatheringinformation in ways that are dis-tinctive to this field?

• What are the most basic ideas,concepts or theories in this field?

• What do professionals in thisfield take for granted orassume?

• How should studying this fieldaffect my view of the world?

• What viewpoint is fostered inthis field?

• What implications follow fromstudying this discipline? Howare the products of this fieldused in everyday life?” 3,6

“These questions can be contextu-alized for any given class day,chapter in the textbook anddimension of study. For exam-ple, on any given day you, oryour students, might ask one ormore of the following questions:

• What is our main purpose orgoal today? What are we tryingto accomplish?

• What kinds of questions are weasking? What kinds of problemsare we trying to solve? Howdoes this problem relate toeveryday life?

• What sort of information or datado we need? How can we getthat information?

• What is the most basic idea, con-cept or theory we need to under-stand to solve the problem weare most immediately posing?

• From what point of view shouldwe look at this problem?

• What can we safely assume aswe reason through this prob-lem?

• Should we call into question anyof the inferences that have beenmade?

• What are the implications ofwhat we are studying?” 3,7

The Assessment of Thinking3

To reason well within any disci-pline also presupposes our ability toassess our reasoning within the disci-pline. One of the fundamentals of crit-ical thinking, then, is the ability toassess one’s own reasoning. “To begood at assessment requires that weconsistently take apart our thinkingand examine the parts with respect tostandards of quality. We do this usingcriteria based on clarity, accuracy, pre-cision, relevance, depth, breadth, log-icalness, and significance,”3,4 to namesome of the important standards forthought.

As we have said, “Critical thinkersrecognize that, whenever they are rea-soning, they reason to some purpose(element of reasoning). Implicit goalsare built into their thought processes.But their reasoning is improved whenthey are clear (intellectual standard)about that purpose or goal. Similarly,to reason well, they need to knowthat, consciously or unconsciously,they are using information (element

Figure 1Element of Thought

of reasoning) in thinking. But theirreasoning improves if and when theymake sure that the information theyare using is accurate (intellectual stan-dard).”3,4

“Put another way, when we assessour reasoning, we want to know howwell we are reasoning.”3,4 We want toavoid the negative consequences offailing to do so.

“In assessing reasoning, within anysubject or discipline, we recommendthese intellectual standards as mini-mal:

• clarity • relevance • logicalness• accuracy • depth • significance• precision • breadth • fairness”3,4

“These are not the only intellectualstandards a person might use. Theyare simply among those most funda-mental.”3,4 Additional standardsmight be needed for high-quality rea-soning within a particular discipline.However, these universal standardswill always apply when relevant to aparticular issue or context.

“In this respect, the elements ofthought are more basic, because theeight elements we have identified areuniversal—present in all reasoning ofall subjects in all cultures”3,4 for alltime. “On the one hand, one cannotreason with no information about noquestion from no point of view withno assumptions. On the other hand,there is a wide variety of intellectualstandards from which to choose—such as credibility, predictability, fea-sibility, and completeness”3,4— inaddition to those we have alreadynamed.

“As critical thinkers, then, we thinkabout our thinking with these kindsof questions in mind: Am I beingclear? Accurate? Precise? Relevant?Am I thinking logically? Am I dealingwith a matter of significance? Is mythinking justifiable in context?Typically, we apply these standards toone or more elements.”3,8

“Reasonable people, then, judgethinking by intellectual standards, nomatter the subject, discipline, ordomain in which they are thinking.When students internalize these stan-dards and explicitly use them in theirthinking, their thinking becomesmore clear, accurate, precise, relevant.Their thinking becomes deeper,broader and more fair.”3,9

The Intellectual Virtues: The Keyto Fair-minded Critical Thinking1

“It is possible to develop as athinker, and yet not to develop as afair-minded thinker. In other words, itis possible to learn to use one’s skillsof mind in a narrow, self-serving way.Many highly skilled thinkers do justthat. Think of politicians, for example,who manipulate people throughsmooth (fallacious) talk, who promisewhat they have no intention of deliv-ering, who say whatever they need tosay to maintain their positions ofpower and prestige. In a sense, thesepeople are skilled thinkers becausetheir thinking enables them to getwhat they want. But the best thinkersdo not pursue selfish goals. They donot seek to manipulate others. Theystrive to be fair-minded, even when itmeans they have to give somethingup in the process. They recognize thatthe mind is not naturally fair-minded,but selfish. And they recognize that tobe fair-minded, they must also devel-op specific traits of mind, traits suchas intellectual humility, intellectualintegrity, intellectual courage, intel-lectual autonomy, intellectual empa-thy, intellectual perseverance andconfidence in reason.”1

“Critical thinking, then, can beused to serve two incompatible ends:self-centeredness or fair-mindedness.As we learn the basic intellectualskills that critical thinking entails, wecan begin to use those skills either in aselfish or in a fair-minded way.”1

“Liberals see mistakes in the argu-ments of conservatives; conservativessee mistakes in the arguments of lib-erals. Believers see mistakes in thethinking of nonbelievers; nonbeliev-

ers see mistakes in the thinking ofbelievers. Those who oppose abortionreadily see mistakes in the argumentsfor abortion; those who favor abortionreadily see mistakes in the argumentsagainst it.”1

“We call these thinkers weak-sensecritical thinkers. We call the thinking‘weak’ because, though it is workingwell for the thinker in some respects,it is missing certain important higher-level skills and values of criticalthinking. Most significantly, it fails toconsider, in good faith, viewpointsthat contradict its own viewpoint. Itlacks fair-mindedness.”1

“Another traditional name for theweak-sense thinker is found in theword sophist. Sophistry is the art ofwinning arguments regardless ofwhether there are problems in thethinking being used, regardless ofwhether relevant viewpoints arebeing ignored. The objective insophistic thinking is to win. Period.Sophistic thinkers generally uselower-level skills of rhetoric, or argu-mentation, by which they makeunreasonable thinking look reason-able and reasonable thinking lookunreasonable. This form of thinkingcan be easily seen in unethicallawyers, prosecutors, and politicianswho are more concerned with win-ning than with being fair. But all of ussometimes think in this way.”1

“We believe that the world alreadyhas too many skilled selfish thinkers,too many sophists and intellectualcon artists, too many unscrupulouslawyers and politicians who special-ize in twisting information and evi-dence to support their selfish interestsand the vested interests of those whopay them.”1

“To think critically in the strongsense requires that we develop fair-mindedness at the same time that welearn basic critical thinking skills, andthus begin to ‘practice’ fair-minded-ness in our thinking. If we do, weavoid using our skills to gain advan-tage over others. We treat all thinkingby the same high standards. Weexpect good reasoning from thosewho support us as well as those whooppose us. We subject our own rea-soning to the same criteria we applyto reasoning to which we are unsym-pathetic. We question our own pur-poses, evidence, conclusions, implica-tions, and point of view with the samevigor as we question those of others.”1

It is important for students to inter-nalize the intellectual virtues and to

Figure 2Intellectual Traits and Virtues


(Copyright 2002 by the Foundation for CriticalThinking. Reproduced with permission.1,3)


work toward fostering these disposi-tions in their own minds, so that theylearn to function more fair-mindedlyin their lives in general. Moreover,every professional discipline has anobligation to foster fair-mindness, sothat students learn to reason, with asense of justice, through any issueswithin their profession that have anethical dimension. In other words,when the rights and needs of peopleor sentient creatures are relevant todecisions and behavior within a field,we have an obligation, as instructorsto foster ethical reasoning abilities instudent thinking.

Critical Thinking and theEducated Person

We cannot be educated personswithout possessing the skills andtraits of the critical mind. Educatedpersons are able to enter viewpointsalien to them and think within thoseviewpoints clearly and accurately ingood faith. They change their positionwhen faced with reasoning betterthan their own. Educated persons areable to consider alternate conclusionswhen reasoning through a complexissue, to think logically, and to thinkwith bread and depth when the ques-tion at issue requires them to do so.

Educated persons are able to formu-late their purposes clearly and accu-rately, to check multiple purposes forconsistency, to determine how theirpurposes relate with the question atissue. They are able to perseverethrough the difficulties in issues. Theyapply the same standards to theirown thinking and behavior that theyexpect of others. They have thecourage to examine their beliefs andto stand alone, using disciplined rea-soning, when opposed by others.Implicit in all of these skills, abilities,and dispositions are the elements ofreasoning, intellectual standards, andintellectual virtues discussed herein.

Critical thinking is not now a cul-tural or educational value, as is evi-denced by the sad lack of it in ourschools, colleges, and universities atall levels and in all subjects. In ouropinion, students are now leaving our“educational” institutions without theability to reason well through com-plex issues, to reason with skillthrough the subjects and disciplinesthat have been the focus of theirschooling, or to read, write, and thinkdeeply, broadly, logically, and signifi-cantly. Only when institutions beginto take critical thinking seriously and,thus, foster it systematically withinand across departments and divisions

will we begin to educate the mind inthe true sense of the word.

References1. Paul R, Elder L. Critical thinking: tools for

taking charge of your learning and your life,2nd ed. Upper Saddle River, NJ: PearsonPrentice Hall; 2006.

2. Our concept of critical thinking. RetrievedMay 23, 2008, from http:// www. critical-thinking.org/aboutCT/ourConceptCT.cfm

3. Elder L, Paul R. The Thinker’s guide to ana-lytic thinking. Dillon Beach, CA: Foun -dation for Critical Thinking Press; 2006.

4. Paul R, Elder L. Critical thinking: tools fortaking charge of your professional and per-sonal life. Upper Saddle River, NJ: FT Press;2002.

5. Analyzing and assessing thinking. Re -trieved May 23, 2008, from http://www.cr i t i ca l th inking . org/ courses/Elements_standards_model.cfm

6. Elder, L. & Paul R. A Miniature Guide ForStudents and Faculty To The Foundations OfAnalytic Thinking. Dillon Beach, CA: TheFoundation for Critical Thinking; 2003.

7. Elder L, Paul R, Hiler W. The miniatureguide to the art of asking essential ques-tions. Dillon Beach, CA: The Foundation forCritical Thinking; 2005.

8. An interview with Linda Elder about usingcritical thinking concepts and tools.Retrieved June16, 2008, from http:// www.criticalthinking.org/articles/ an-interview-linda-elder.cfm

9. Paul R., Elder L. Critical thinking com pe -tency standard. Retrieved June16, 2008,from http://www.udlap.mx/promueve/ciedd/CR/pensamiento/criticalthinkingcompetencies.pdf

The Case for Skillful Thinking

As educators it is importantto begin a new dialogueabout teaching and engag-ing students in skillful

thinking. For the last several decades,students have come from an educa-tional system that has emphasized therole of teaching and placed theresponsibility of learning on theteacher instead of the student. Thissystem has encouraged students toexpect a passive learning environ-ment in the college classroom.1

Educators have become increasinglyresponsible for providing studentswith information necessary to com-plete graduation requirements and oncompletion, to pass, with high marks,a deluge of standardized tests.2

From grade school to graduateschool, the No Child Left Behind Actseems to have taken hold of our edu-cational system and prompted a driveto cover material on the tests. In fact,the too often asked question, “Willthis be on the test?,” is one that noweven the teachers seem to be asking.3

Student passivity and the emphasison testing have shifted the learningprocess toward more shallow process-ing of information and away fromdeveloping deeper skillful thinking.3

It is time to explore the learningprocess and create a learning environ-

ment that is more conducive to skill-ful thinking. Changing the classroomexperience, creating a course map (thesyllabus), and reevaluating how wemeasure progress are starting pointsin creating a different environmentfor learning. The purpose of this arti-cle is twofold: first, to provide infor-mation on the learning process andskillful thinking and, second, to pro-vide educators with tangible sugges-tions on how to change the learningenvironment to enhance skillfulthinking.

The Learning Process: A Knowledge Triangle

Ideally, the learning process con-sists of three components: the teacheror expert in the discipline, the stu-dent, and the learning environment,which includes the content of the dis-cipline. At the most basic level, eachof these components plays a signifi-cant role in the acquisition, applica-tion, and understanding of knowl-edge necessary to pass the tests.However, these components play aneven larger role in establishing theskills necessary for our students tobecome lifelong learners.

The TeacherThe first integral part of this

process is the teacher. In higher edu-cation, this role has traditionally beenone of dispenser of knowledge.Historically, college students havelooked for the teacher to provide thecontent of the discipline through well-defined classroom lectures. Ironically,teachers have also followed the sameline of reasoning. With due diligence,we have prepared our lectures basedon the text material and supplementalreadings. We have even incorporatedtechnology and provided extensivePowerPoint lectures to our students,complete with detailed lecture notes.We have gone so far as to eliminatethe need for active note-taking by thestudents. We have been sure to pro-vide adequate definitions for termsand been proficient in “covering” themost important material to be includ-ed on our own exams. In fact, we havecontributed to the very passive styleof learning evident in many collegeclassrooms today.

With respect to identifying thebody of knowledge our studentsshould acquire, teachers are responsi-ble for establishing course content.We are, in fact, hired because of our

The Teaching of Skillful Thinking:Lifelong Learners

T. Bridgett Galvin, PhD

AbstractAn educational history of stu-

dent passivity in the classroom andthe emphasis on testing have shiftedthe learning process away fromskillful thinking. It is time toexplore the learning process andcreate a learning environment thatis more conducive to the develop-ment of skillful thinking. Changingthe classroom experience, creating acourse map (the syllabus), andreevaluating how progress is mea-sured are starting points in creatinga different environment that is moreconducive for deeper learning andunderstanding. The purpose of thisarticle is twofold: first, to provideinformation on the learning processand skillful thinking and, second, toprovide educators with tangiblesuggestions on how to change thelearning environment to enhanceskillful thinking.

Key Words: education, pedagogy,skillful thinking, critical thinking

Dr. Galvin is professor of psychology and codirectorof the Center for Excellence in Teaching,Scholarship, and Service at Framingham StateCollege, Framingham, MA. Email: [email protected]


expertise in the discipline. We areresponsible for deciding what tocover in a given semester. However,we must make sure the informationwill be useful to students, who aresure to face some form of competencyexam. However, with knowledgedoubling every five years, this taskhas become daunting.4 With each newtextbook edition, the expanse of infor-mation that we could cover in a giventerm increases. The decision as towhat to leave out becomes as impor-tant as what to include with respect tocontent. The dilemma only adds tothe burden of fully engaging studentswith the material.

At the pace and quantity of changein the knowledge base in any givendiscipline, the teacher can no longerbe a dispenser of information butmust become the guide in helpingstudents learn how to learn on theirown. It is our responsibility to estab-lish key concepts that will become thefoundation for dialogue and skilldevelopment necessary for our stu-dents to become lifelong learners. Asexperts in our disciplines, we mustdemonstrate that expertise in theselection of content more now thanever before. At the most basic level inmeeting this requirement, we mustmaintain a current knowledge base inour discipline by keeping abreast ofnew findings. In addition, we must beaware of the prerequisite thinkingskills necessary for students to engagein a meaningful way with the contentwe select. If for no other reason thanthere is too much information tomemorize in one term, our interac-tions with students need to shift fromtelling to skill-building using the con-tent as our platform. In so doing, wemust also develop ways to evaluatethe learning process or measures ofstudent learning.

The StudentThe second part of the learning

process focuses on the student.Students bring a rich history thatincludes years of attending classesthat have reinforced their being pas-sive recipients of knowledge. Thosestudents who traditionally have beenable to memorize facts and repeatback information to which they havebeen exposed constitute the bulk ofour student population. To date, stu-dents who know how to take testsand find the correct answer have beenrewarded with good grades and pass-ing competency scores. Their educa-

tional experiences have fostered anexpectation that they can attend aclass and experience an absorptionmodel of learning, as if they aresponges soaking up information torepeat later. When our students areasked to evaluate a new clinical orwork procedure, they may not havethe necessary thinking skills torespond effectively and efficiently.They often believe that they need onlylisten, memorize, and repeat to learnthe material. However, when studentsare asked to solve problems or think“outside the box,” they are often sur-prised when test performance indi-cates a more shallow level of process-ing, as are their instructors. Thisshallow level of processing shouldcome as no surprise, when studentsarrive in our courses with minimaldevelopment of good thinking skills.5

At the same time that students maybring few developed thinking skills,they do bring a good deal of pastknowledge to our courses. Unfor -tunately, they have never developedthe awareness that their own knowl-edge base can be useful in acquiringnew knowledge and solving prob-lems. In short, they have not learnhow to learn. Although they mayhave completed 16 years or more offormal education, they have notlearned how to actively engage in thelearning process. They have notdeveloped skillful thinking habits.

The Learning EnvironmentThe third part of the learning

process is the learning environment,which includes the daily classroomexperiences. In this context, theinstructor has a significant role in con-structing this environment. Elementsinclude the content base, usually froman established text, and ancillaryreading materials. In addition, thereare the rules for engagement in theclass on a daily basis, such as partici-pation requirements, procedures forhanding in coursework, gradingrequirements, and so forth. Typically,the syllabus becomes the tool forinforming students about this envi-ronment.

For this environment to be effec-tive, it should also include a transpar-ent set of thinking skills necessary tounderstand concepts the instructorhas identified as being central to thecourses. In addition, this environmentshould include activities designed topromote a deep level of understand-ing of concepts. Last, a clearly defined

process for evaluation of these activi-ties should be indicated.

Creating a LearningEnvironment That PromotesSkillful Thinking: What IsSkillful Thinking?

In designing and coordinating thelearning process that promotes skill-ful thinking, we, as mentors andguides, must also take some firststeps. First, we must begin the processof evaluating and improving our ownthinking skills. If asked, each of uswould argue that we use skillfulthinking, or critical thinking, on adaily basis. However, if asked for adefinition of those characteristics ofskillful thinking, many of us would behard-pressed to provide one. Thedevelopment of skillful thinking inthis case is much akin to the bela-bored topic of critical thinking. Muchof the literature in the 1980s focusedon the need to develop critical think-ing skills in our students. However,over the past two decades and intothe present one, educators haveengaged in debate over a simple,agreed-on definition of critical think-ing. For the purpose of this article, Ihave chosen to focus on three relatedareas of skillful thinking. RichardPaul and Linda Elder have a devel-oped a model of critical thinking thatstresses the importance of developinga process of thinking using elementsand standards.5 Walcott and Lynchhave provided a developmentalframework for understanding andpromoting skillful thinking.6 ArtCosta has proposed that skillfulthinking is a set of habits of mind thatmust be cultivated and practiced.7 Allthree of these perspectives assert thatstudents must be actively engaged inthe development of thinking skills,must be given opportunity to practicethem on a routine basis, and must begiven appropriate feedback so as toimprove their skills throughout theirlifetime. An even more basic premisefor all of these theorists is that, beforewe can guide our students in thisprocess, we must first work to devel-op them in ourselves.

As a practitioner of skillful think-ing, our job is to model skillful think-ing for our students on a daily basis.Moreover, our course design shouldalso model this type of thinking in themost transparent of ways. For exam-ple, Paul and Elder have argued that



teachers must ask questions abouttheir purpose, assumptions, and theirown teaching/learning perspectives.5

We must ask ourselves soul-searchingquestions: What do we want our stu-dents to learn? What assumptions arewe making about their previouslearning experiences or their existingknowledge base? What questions dowe want our students to be able toanswer? Why is this informationimportant? The questions are as infi-nite as the answers. Not only must weask these questions but we must do sowhile adhering to standards of skillfulthinking, such as relevance, accuracy,clarity, breadth, and depth. In begin-ning to think clearly about theseissues, we can help to guide our stu-dents in this process in our class-rooms. In summary, we must modelskillful thinking in our daily lives ifwe are to expect our students todevelop these same skills.

As we develop these skills in think-ing, Costa would argue that we mustguide our students effectively bymaking connections between devel-oping skillful thinking and learningcontent.7 One method of accomplish-ing this task involves relating read-ings, activities, assignments, and eval-uations to concepts and thinkingskills in such a way that awareness ofthe process begins to develop.Typically, students are not aware thatthe major component in the learningprocess is the practice and applicationof skillful thinking to the content. Bymaking this process transparent inrelating the course activities and con-cepts to thinking, students can devel-op an awareness of a set of strategiesfor learning, thereby improving theirmeta-cognition skills. Moreover, thispractice of skillful thinking can, intime, become a mental habit thatresults in more disciplined, produc-tive thinking in both our and theirdaily lives.

Last, it is important to recognizethat skillful thinking, like other lifeskills, may follow a developmentalprogression.6 Students must be sup-ported when engaging in skillfulthinking and reinforced for activelyengaging in the material, not merelymemorizing it. Moreover, they mustbe given feedback so that they canmonitor their skill development. Byincreasing student responsibility forlearning, we are actually increasingtheir capacity to learn.

Several assumptions underlie thebasic premise that we can build a bet-

ter learning environment that empha-sizes the development of skillfulthinking. Wolcott and Lynch pro-posed that skillful thinking developsin a sequential manner and includes aset of skills necessary to be an effec-tive problem solver and powerfulthinker.4 Moreover, it is imperativethat the environment be structured toinclude support for the developmentof those skills. The environment mustalso include a strategy for allowingstudents to take responsibility fortheir learning and provide a mecha-nism for evaluation and feedback oftheir learning. The question thenbecomes, how do we, as educatorswho may only have students for oneterm, embark on this task? Where dowe start?

Charting the Course: TheClassroom Experience

In structuring the classroom envi-ronment we can start at a basic level.It can be helpful to provide studentswith aids to developing more skillfulthinking. For example, bookmarkswith brief definitions of the skillful-thinking standards, such as clarity,relevance, breadth, depth, accuracy,and precision, can provide studentswith cues for better thinking.Reinforcement of the standards canoccur with each assignment. Forexample, it is helpful to verbalize thethinking skill that students are prac-ticing. Thinking skills can become realfor students when we provide cuesfor them to recognize the skill. If theyare engaging in brainstorming, besure to identify with them what itsounds like, looks like, and feels liketo brainstorm. Compare and contrastthat experience with one of activelylistening. Give them physical cues toaccompany the skills they are work-ing on. When they are working on anactivity that requires them to evaluatedata, provide them with a map ortemplate for establishing the reliabili-ty and validity of the data. Createtransparency between your objectivesand the students’ behaviors you wishto develop.

In creating a learning environmentin the classroom, we must rethink theroles and responsibilities of both ourstudents and ourselves. As statedbefore, we serve as guides and men-tors. Our students will be responsiblefor their own learning. For students tofunction in this type of environmentas active learners, we need to prepare

them with the skill set needed to crit-ically read the content of our disci-pline on their own. Often, we assumestudents have a set of skills needed toaccomplish reading and higher ordertasks. For example, we may ask ourstudents to compare and contrast twotheoretical perspectives on an exam.However, they may not have the pre-requisite skills of identifying similari-ties and differences or sequencing. Itis imperative that we take a develop-mental approach to helping our stu-dents to develop more skillful think-ing. Again, if we have skillfullythought about our assignments wewill also have identified pre-requisiteskills as well.

Numerous classroom activitiesexist which will help to ensure ourstudents are reading and understand-ing the material assigned as content.One activity proposed by Paul andElder requires students to read select-ed material ahead of time and thenprocess in class with a peer. First, stu-dents are assigned selected readingmaterial. Second, they summarize itby paraphrasing in their own words,elaborate on the information, and pro-vide an example. Third, they illustrateit with an analogy or a metaphor. Thisprocess of summarizing, elaborating,providing an example, and illustrat-ing is known as the SEEI method.8

Next, they would actively engagewith the material again by participat-ing in a think, pair and share processwith their peers. Pairs of studentswould be asked to share their SEEIprocess with each other using thematerial they had been assigned toread. An activity such as this onerequires that students be responsiblefor reading the material but at thesame time ensures that they process itat a level that would promote deeperunderstanding.

A key element in ensuring studentsbecome more responsible for theirown learning requires a shift in themethod of acquiring knowledge andbasic information. This shift in knowl-edge transmission moves away fromtraditional lecture format andtowards the creation of understand-ing information through processingwith another peer. The instructor’srole is to guide and promote the shar-ing of information as the activity isprocessed in a larger group. In thelarger group the instructor may usereciprocal teaching and question-response cuing as effective strategiesin place of lecturing.9 Providing stu-

dents with cues for types of questionssuch as those requiring recall, exam-ple, or evaluation helps them engagemore actively with the material and tomonitor their own thinking early inthe term. Starting the term with thesetypes of activities informs studentsthat the responsibility for reading andlearning rests squarely on their shoul-ders. It also sets the standard foractive participation during the classtime. The more students are interact-ing with the content, the less timeteachers will be lecturing. This aspectof the learning environment allowsstudents to process information andconstruct their own understanding insuch a way that memorization is notthe sole method for storing the infor-mation.

In addition to creating an activeenvironment for students to processinformation, we need to build intoour course multiple ways of engagingstudents with the material both in andoutside of the classroom. In additionto the think, pair, and share with apartner, small-group assignments arealso of value. Working collaborativelyin groups is another skill that stu-dents seem to be lacking. As mentors,we can help to define this skill for stu-dents by establishing clear roles,responsibilities, and outcomes forgroup work. When students areworking in groups, it is imperativethat the purpose of the group be clear-ly defined. In addition, procedures fordiscussion and workload sharing, aswell as clearly defined evaluationmethods, need to be established priorto group work. Outside of the class-room, students who engage in jour-naling and practice self-reflectionregarding the content have beenshown to process information at adeeper level. A number of additionalactivities and suggestions to promoteactive and cooperative learning canbe found in a miniature guide createdby Hiler and Paul.10

In summary, several strategies canbe used to aid the student and theinstructor in creating an active learn-ing environment. These include thefollowing:

• Provide concrete aids• Verbalize thinking• Provide a map or template for

data evaluation• Encourage self-directed learning

and reflection on the learningprocess

• Identify prerequisite thinkingskills needed for assignments

• Summarize, elaborate, providean example, and illustrate (SEEI)

• Engage students with materialin and outside of the classroom.

Creating a Map: The SyllabusAs stated earlier, this process

should begin by first improving ourown thinking skills and modelingskillful thinking for our students. Tothat end, our interactions with ourstudents will be modified as well.Given that we will always be workingon our own thinking, a more pressingquestion becomes, “What do we do inour classrooms?” or “How can westructure our courses to promote skill-ful thinking?”

One practical, first step is to devel-op a comprehensive syllabus thatincludes a description of the thinkingskills that are required to do well inthe course. In refining your syllabusfor teaching skillful thinking, it is use-ful to consider the following ques-tions:

• What are some of the functionsthe syllabus plays in my courses?

• What is my first step in buildingmy syllabus?

• At what stage in syllabus devel-opment do I choose the coursecontent?

• What is the most importantinformation students need frommy syllabus?

• What is the most importantinformation I need to have inmy syllabus?

• How can I make sure my stu-dents and I agree on the mostimportant information in mysyllabus?

The answers to these questionsmay be surprising to some. Many ofus prepare our syllabus the way ourinstructors prepared theirs. We thinkback to a syllabus format we liked asa student and often adopt that format.Or, as a new faculty member, we mayrely on models of syllabi from our col-leagues who teach a similar course. Ineither case, rarely do we take the timeto skillfully think about and examinethe purpose of our syllabus.

The traditional model for compos-ing a syllabus is shown in Figure 1.

As instructors, we often fail toengage in skillful thinking at the basiclevel of evaluating the purpose of thecourse and the concepts or contentbefore we design our syllabus. A

thinking-based model for syllabusdevelopment is depicted in Figure 2.

In the process of developing oursyllabus, we naturally exercise ourexpertise in identifying the key con-cepts. We might begin by makingclear the major concepts studentswould need to understand to allowthem to think skillfully in our disci-pline. For example, in a class on visu-al development, the concepts centralto understanding the content in thiscourse might include anatomy andphysiology of the visual system,development of the brain, linkbetween the nervous system andvision, and visual development underabnormal conditions. These conceptswould constitute the bulk of the con-tent for the course. A set of key ques-tions would be developed aroundthese concepts. Next, objective learn-ing outcomes would be developed.The expectation of previouslyacquired knowledge would be identi-fied (i.e., what knowledge the stu-dents entering the class should haveacquired). All assignments and activi-ties would be designed to providestudents with a clear understandingof each of these concepts and howthey interact with each other. The textitself and material in the text wouldthen need to be selected for its valuein adding to the understanding ofthese concepts. Clear evaluation andfeedback measures would be identi-fied and attached to the syllabus.

Assessment and Evaluation:How Do We Measure Progress?

When we choose to have a learn-ing-centered classroom, anxiety oftenarises regarding the amount of mater-ial covered in a term and the assess-ment of mastery for our students.Basic questions, such as, “How will Icover everything?” and “How can Iguarantee the students will be pre-pared for my exam let alone thosetests beyond my classroom?,” are cer-tain to be raised. The answers are notsimple. At best, we can hope that wehave used our expertise in designingthe classroom experience to fullycover the material needed for ourcourse. If we have practiced skillfulthinking in preparing our course andguiding our students, a positive out-come is probable. However, we stillmust evaluate the student learningthat has occurred.

For each assignment created, feed-back and evaluation procedures


should be clearly defined at concep-tion. By asking clear questions aboutthe purpose of an assignment or activ-ity, we can also begin to devise clearmethods of assessment. It is impera-tive that students be informed of theassessment methods prior to complet-ing any task or assignment. When stu-dents are aware of evaluation orassessment guidelines for any givenactivity, their thinking process willalso be modified. Prequizzing of thematerial is another way to motivatestudents to come to your class pre-pared for active engagement.Prequizzes of basic material allowstudents to engage in meaningful dis-cussion with the instructor instead ofpassively listening to a lecture. Scoreson prequizzes can be used to monitorfactual understanding and free uptime for engaging in more conceptualprocessing.

Creating rubrics for grading andevaluation also provide a clear map

for students to follow in assessingtheir own thinking. Evaluationrubrics are useful in clarifying objec-tives, providing feedback, inspiringstudents, improving self-awareness,and improving communicationbetween the instructor and the stu-dent. Moreover, they can also serve astools for motivating curriculumimprovement if used beyond theclassroom, as we evaluate our choiceand delivery of course material. Agood understanding of develop -mentally based rubrics for assessingthinking in the classroom can befound at www.wolcotlynch.com.11

Generic tem plates are available on theWeb site for designing rubrics forassessing thinking for any subject. Insummary, the instructor should clear-ly define the evaluation procedure,inform students of the assessmentmethod prior to giving the task orassignment, give a prequiz, and createa rubric.

ConclusionMaking the shift from content-

based instruction to teaching forthinking is not an easy process. Itrequires a leap of faith in believingthat students can and should beresponsible for their own learningprocess. It also requires instructors tomodify traditional classroom strate-gies and establish a norm of collabo-rative learning in the classroom. Thetraditional focus on mastery of con-tent must shift to include a focus onthe development of skillful thinkingas a mental habit. When instructorsand students demonstrate the habit ofskillful thinking, all learning and per-formance on measures of learning arecertain to improve.

References1. Howell C. Facilitating responsibility for

learning in adult community college stu-dents. ERIC Digest. Accessed April 2007.Available from: http://www.ericdigests.org/ 2001-4/adult.html

2. Morse J. Is that your final answer? 2000,June, accessed December 3, 2007. Availablefrom: http://www.time.com/ time/ magazine/ article/0,9171,47123,00.html

3. Sacks P. Standardized minds: the high priceof America’s testing culture and what wecan do to change it. Cambridge, MA:DaCapp Press; 2000, pp. 1-16.

4. Grunwald N, Schott D. Challenges in revo-lutionizing mathematical teaching in engi-neering under complicated societal condi-tions. Global J Eng Educ. 2000; 4:235-43.

5. Paul R. Why students don’t reason well.2006. Accessed December 3, 2007. Availablefrom: http://www.criticalthinking.org

6. Wolcott SK, Lynch CL. Critical thinking inthe accounting classroom: a reflective judg-ment developmental process perspective.Account Educ: J Theory, Pract Res.1997;2:59-78.

7. Costa A. Habits of mind book 1: discoveringand exploring habits of mind (ch.1-3).Alexandria, VA: Association for Supervisionand Curriculum Development; 2000.

8. Paul R, Elder L. How to read a paragraph.Dillon Beach, CA: Foundation for CriticalThinking; 2003, pp. 18-9. Available from:www.criticalthinking.org

9. Piercy TD, Piercy W. Chaos in the class-room: the new science applied to instruc-tional practice. In D Fasko (Ed), Criticalthinking and reasoning: current researchtheory and practice. Cresskill, NJ: HamptonPress; 2003, pp. 187-206.

10. Paul R, Hiler W. The miniature guide: prac-tical ways to promote active and coopera-tive learning. Dillon Beach, CA: Foundationfor Critical Thinking; 2002. Available from:www.criticalthinking.org

11. Wolcott S. Developmental rubrics for assess-ing. Accessed April, 2007. Available from:h t t p : / / w w w. w o l c o t t l y n c h . c o m /EducatorResources.html

Learning Skill Set Thinking Skills

Identified

Contemplate Material Consider Key Concepts/Questions

Develop Learning Objectives

Choose Course Materials

Exercises/Activities Projects/Interaction Styles

Guests, Trips, Resources

Class Population/Existing Knowledge

Process Elements: Student Work to Show Progress

Evaluation/Feedback Elements Wr ite Syllabus

Choose a text Choose Chapters Create Timeline Write syllabus

Figure 1. Traditional Model for Syllabus Development

Figure 2. Thinking-Based-Learning Syllabus Development


Lives depend on competentclinical reasoning. Thus it is amoral imperative for healthcare providers to strive to

monitor and improve their clinicalreasoning and care related judgments.Knowing that this is the agreementowed to the public trust, agenciesresponsible for the accreditation ofprofessional training programs andfor the oversight of health care deliv-ery have mandated the need todemonstrate competence in clinicalreasoning in health care clinicians andstudents. This focus on competentreasoning and problem solving is notunique to health care. Sparked by ameeting of the United StatesGovernors in the late 1980’s, educa-

tional mandates to teach and assessthinking and problem-solving havebecome increasingly pervasive. In thiseffort, the health sciences and militaryscience have led the way. Nearly allperformance based credentialing pro-grams and performance based fund-ing initiatives require thinking andproblem solving as one of the educa-tional outcomes worthy of assessment(Ackerman, Rinchuse, & Rinchuse,2006). This focus on assessing compe-tence in reasoning and problem-solv-ing is also becoming a standard in theworkplace.

The Language of ThinkingCritical thinking and reflective

problem-solving are two commonterms for the cognitive processesinvolved in clinical reasoning.Excellence in professional judgment isthe result of the sound use of criticalthinking skills and the reliable andstrong disposition to use those criticalthinking skills. The alternative (actingwithout adequate analysis of theproblem, repeating a previous caredelivery behavior unreflectively, orcontinuing to carry out a care deliverybehavior without evaluating its effect)is not a standard of practice any of uswould uphold. The discussion belowoutlines what has been learned to dateabout how humans engage high risk

problems and arrive at competentjudgments about what to believe andwhat to do. It also explores the chal-lenge we face as researchers and edu-cators to facilitate improvements inclinical reasoning for ourselves, ourstudents and our peers.

There are many prior accounts ofthe development of a consensusdescription of critical thinking,research carried out as a Delphi Studyin the late 1980’s (AmericanPhilosophical Association, 1990). andreplicated by an independent study atPenn State University (Jones &Ratcliff, 1993). We recommend thatthose unfamiliar with this literatureseek out any of these previous papers(Facione & Facione, 1996a; 2006;Facione, Facione & Giancarlo, 2000).All of our work in instrument devel-opment and in the theoretical andpractical study of human reasoningstems from this seminal study focusedon the importance of everyday com-petence in reasoned judgment. Herewe offer a brief overview integratingour research on defining and measur-ing evidence of everyday reasoningand judgment with the emerging con-sensus of research attempting toexplain human reasoning processes.The result is informative for trainingcritical thinking and clinical reason-ing.

We begin with a definition of criti-cal thinking derived from a consensusof disciplines, and used widely toground teaching and assessment ofcritical thinking:

“Critical thinking is theprocess of purposeful, self-regu-latory judgment. This processgives reasoned consideration toevidence, contexts, conceptual-izations, methods, and criteria.”(American Philosophical Asso -cia tion Delphi Report, 1990).

In other words, critical thinking is ajudgment process. Its goal is to decidewhat to believe and/or what to do ina given context, in relation to theavailable evidence, using appropriateconceptualizations and methods, andevaluated by the appropriate criteria.One way of describing how criticalthinking relates to clinical judgmentwould be: Critical thinking is the processwe use to make a judgment about what tobelieve and what to do about the symp-toms our patient is presenting for diagno-sis and treatment. This language is dis-cipline free, because it refers to

Critical Thinking andClinical Judgment

Noreen C. Facione and Peter A. Facione

This material is reprintedfrom: Noreen C. Facione andPeter A. Facione, “CriticalThink ing and ClinicalJudgment,” from Critical Think -ing and Clinical Reasoning in theHealth Sciences: A TeachingAnthology, 2008. Published byInsight Assessment/The Cali -fornia Academic Press: MillbraeCA. pp. 1-13. (c) 2008 NCFacione & PA Facione, HermosaBeach, CA. URL: www.insightassessment.com


cognitive capabilities that can be gen-eralized to all problem frames and allsituational contexts. Here our interestis applying this terminology to thehealth sciences. To arrive at a judg-ment about what to believe and whatto do, a clinician should consider theunique character of the symptoms(evidence) in view of the patient’s cur-rent health and life circumstances(context), using the knowledge andskills acquired over the course of theirhealth sciences training and practice(methods, conceptualizations), antici-pate the likely effects of a chosentreatment action (consideration of evi-dence and criteria), and finally moni-tor the eventual consequences ofdelivered care (evidence and criteria).

Adequate Time to ThinkNewell (1990) provided us with

some concrete data on how long itactually takes to process a novelobservation or a novel problemdemanding of a response. Whenhumans are queried on a novel issueor problem they require eleven to six-teen seconds to interpret the situationat hand and formulate even the mostrudimentary reflective response. Withforewarning they can summon rele-vant memories and content knowl-edge to inform their response, butotherwise processing time is required.Humans also frequently rely onheuristic maneuvers in an attempt tooptimally address high stakes issues.Heuristic reasoning is believed to bemost prevalent in time limited situa-tions that do not admit of more reflec-tive thinking, and in uncertain con-texts when reflective thought fails toresolve ambiguities in the direction ofa seemingly certain judgment(Gilovic, Griffin & Kahneman, 2002).More on this topic in the sectionbelow entitled ‘Two systems of rea-soning’ but for now we return to theissue of ‘time to think.’

Sixteen seconds is far longer thanwe are accustomed to waiting for aresponse after we pose an importantquestion to a clinician, or even a stu-dent who is supposed to be preparedfor the clinic. Both may feel the desireto respond thoughtfully and providethe optimal opinion, but far moreoften they first feel the pressure torespond quickly. So, what is forthcom-ing usually begins as only half-thought-out, with late breakinginsights and necessary edits cominglater as additional ideas are formulat-

ed. If the problem we pose is novel,and the clinician values accuracy andcomprehensiveness as a component ofthe response, we may hear, “Now letme think about that for a moment.”Hearing this response should engen-der confidence, but often instead itengenders doubt.

Learning to ‘think aloud,’ supply-ing evidence of the process of one’sthinking and subsequent judgment(the assumptions made, the evidencebase applied, the logical framing)offers a way for the listener to bothevaluate the quality of the judgmentand to learn to reason better them-selves, This is demonstrated in discus-sions of think aloud exercises in someof the chapters to follow.

The accuracy of Newell’s findings(the need for time to think) can bereadily observed by asking anyone anovel question that requires reflectivethought, and recording the time to aresponse. This is true regardless ofexpertise level, when the question orproblem is truly novel. The physiolog-ical realities of human thinking makeit important for educators to controlthe tempo of teaching and learningsessions if they are to effectively leadto improved clinical reasoning. Thosewho answer too quickly may have notthought well.

Clinical Reasoning andExpertise

When clinical problems are famil-iar we can rely on externally devel-oped protocols and internal ‘mentalscripts’ to assist us in deciding whatto believe and what to do about theproblem. The externally developedprotocols are elaborate and rise to thestatus of standards when the conse-quences of error are high and societyis concerned with safety. There is stillneed for reflective thought whenusing protocols to assure that they areremain appropriate to the case andthat expected results occur.

Internally developed ‘mentalscripts’ are a function of expertise.The Dreyfus and Dreyfus model ofexpertise, which has been adapted byBenner for Nursing, (Benner 1994,2004) is a phenomenological modelthat provides a description of theincreasing sense of ease experiencedover time by the clinician, movingfrom novice practice to more expertpractice. Most models of expertisedescribe the novice who encounters aproblem as attending indiscriminately

to data in an attempt to recognize keyrelationships that will then allow theapplication of knowledge they believeto be relevant. The expert, in contrast,recognizes most problems by pattern,and resolves them without a signifi-cant awareness of reflective thinking.An expert does this through theretrieval of similar cases examplesstored in episodic memory, a largerarray of relevant knowledge stored insemantic memory, and the use ofother heuristic thinking processes.

Benner’s work describing the‘lived experience’ of clinical reasoningnotes the seeming inability to reflecton the thinking process that occurs inthe expert clinician, describing it as‘intuiting.’ In contrast, other cognitivescience models of human reasoningexplain this lack of conscious reflec-tion as a function of several cognitiveprocesses: heuristic reasoning (think-ing maneuvers and shortcuts dis-cussed below), automatic thought (theability to accomplish an array of taskswithout conscious attention), and theabsence of perception of meta-cogni-tion (listening to or thinking aboutyour thinking). In the case of automat-ic thinking, familiarity with the tasksrequired frees cognitive resources tofocused more specifically on only theunique aspects of the situation or per-haps even a different problem alto-gether. Recall the experience of dri-ving home from work rehearsingapproaches to resolving an interper-sonal issue. Possibly you exit the carrealizing that you really didn’t ‘see’the road and the other drivers for themajority of the thirty-minute drive.We even have language for this, ‘run-ning on autopilot.’ But clearly somecognitive process, outside of yourawareness, was monitoring your dri-ving, making lane changes, braking,using turn signals, seeing the othercars. It is not known how often theautopilot function impacts clinicalreasoning, nor what percentage ofthose impacts are negative.

Models of expertise help us tounderstand how different groups ofclinicians are likely to approach clini-cal problems. A high level of expertisedoes not assure flawless reasoning inthe clinician, any more than we can besure frequent errors will be made bythe novice. Novices are known to beslower to come to a judgment becausethey require more time for reflectivethought and additional data search-ing. Novices err through problemmisidentification and uncertainty



about knowledge application. Butexperts also err due to problemmisidentification, and they are moreprone to being inattentive to those dif-ferences in the problem which make itthe odd exception to the pattern andwhich render the modal responsesinappropriate.

Understanding the cognitive effortentailed by the novice or expert statesuggests several things about thetraining of clinical reasoning. Feelingsof comfort when working on familiarproblems in familiar contexts shouldnot be confused with genuine clinicalexpertise. A person may be comfort-able doing roughly the same thingover and over again, as demanding asthat may be, but not have the exper-tise to be able to resolve new prob-lems, to adapt old ways to new situa-tions, or even to recognize limitationsor shortcomings in the way he or shehas always gone about doing thosefamiliar things.

Expert clinicians are never beyondthe need to actively monitor thesoundness of their clinical reasoning.While we might allow ourselves tofold the laundry or cut the grass auto-matically, we can’t allow this type ofdisconnect when the life or health ofothers is at stake. Hence, we need tocontinuously build the cognitive skillsand habits of mind inherent in criticalthinking as the preferred tools of theclinical judgment process, the con-scious reflection about what to believeand what to do in the clinical context.Novice clinicians will have far morenovel problems to address, but thosewho have stronger critical thinkingskills will progress toward higher lev-els of competence and expertise.

Two Systems of ReasoningNewer research in human reason-

ing finds evidence of the function oftwo interconnected ‘systems’ of rea-soning. ‘System 1’ is conceptualizedas reactive, instinctive, quick, andholistic. System 1 often relies on high-ly expeditious heuristic maneuverswhich can yield useful response toperceived problems without recourseto reflection. By contrast, ‘System 2’ isdescribed in the cognitive science lit-erature as more deliberative, reflec-tive, analytical, and procedural.System 2 is generally associated withreflective problem-solving and criticalthinking. In its decision makingprocesses System 2 also uses someheuristic maneuvers. We offer a fuller

discussion in Thinking and Reasoningin Human Decision Making: The Methodof Argument and Heuristic Analysis,(Facione & Facione, 2007) but willrecap key elements here.

In humans these two systems neverfunction completely independently.One is not naturally “better” than theother; in fact there are situationswhere each offers something of a cor-rective effect on the other. Becauseboth systems rely on cognitive heuris-tics and because these maneuvers areknown to have the potential to intro-duce error and biases into human rea-soning, knowing something aboutheuristic reasoning is important tothose who are attempting to train orto measure clinical reasoning. There isa growing literature on this researchbut reading several of the foundation-al books and papers will provide theneeded insight into how we believehumans actually think and make clin-ical judgments (Gilovic, Griffin &Kahneman, 2002; Kahneman , Slovic& Tversky, 1982; Montgomery 1998).Here we provide only the briefestoverview.

Some hypothesize that lackingclaws, fangs, skeletal armor, protec-tive fur, poisonous secretions, naturalcamouflage, strength, or speed, thehuman species survived, because ofsome other evolutionary advantage.One factor was the fast, efficient, andeffective problem-solving made possi-ble by heuristic reasoning. When usedwell, heuristic thinking helps us sur-vive, but misuse of this type of rea-soning, when not overridden byreflective thought (System 2), leads topredictable error. For example, con-sider the influence on behavior of theaffect heuristic. This heuristic mightfunction well pre-consciously likethis: “unprotected needle –> BAD!(stop)” Twenty years after the AIDSepidemic, no reflective argumentshould be needed for a trained clini-cian to recognize the immediate dan-ger presented by an unshielded nee-dle. A misuse of this heuristic mightbe “comfort food –> GOOD,” depend-ing on how much one is trying to loseweight. Favoring choices that avoidloss, recognizing similarities, guess-ing about future events by playing amovie in your head of what will hap-pen, and assuming one is able to con-trol all threats, are examples of heuris-tic maneuvers that are typically belowthe level of conscious thought. Thissystem 1 thought has a powerfuleffect on behavior as documented in

these references here and others theend of this chapter. (Montgomery,1998; Tversky & Kahneman, 1973;Kahneman, Slovic & Tversky, 1982;Weinstein, 1982).

Perhaps the current preoccupationwith heuristic reasoning results frombeing relatively unaware of it in thepast. While cognitive and social psy-chology has been working to impactthe understanding of human reason-ing, many have been holding to earlydescriptions by Plato and Aristotle ofhumans as always striving to be delib-erative, reflective, and logical. Nottrue. Even when we are making highstakes clinical judgments, this is nottrue. The current conceptualization oftwo interacting and complementarysystems better explains the evolution-ary success of our species. A newmethod of argument analysis hasemerged that includes an examinationof the entire decision-making process,both System 1 and System 2 and theinfluences of cognitive heuristicsalong with argument making on deci-sion outcomes (Facione & Facione,2007). It’s likely that this method ofdecision analysis will bring newinsights about how some commonclinical errors occur. The importantthing to realize is that although youmay not as yet have heard muchabout this in the past, this is how wethink. Effectively mixing System 1and System 2 cognitive maneuvers toidentify and resolve clinical problemsis the normal form of mental process-es involved in sound, expert, clinicalreasoning. Misusing heuristic reason-ing maneuvers, in the context of poorlogic and misinformation is a descrip-tion of poor clinical reasoning. Figure1 below is a diagram locating thethinking processes we have been dis-cussing. Even good thinkers makeboth System 1 and 2 errors from timeto time. We misinterpret things, over-estimate or underestimate ourchances of succeeding, rely on mistak-en analogies, reject options out ofhand, rely too heavily on feelings andhunches, judge things credible whenthey are not, etc. And there is onemore strategy humans use to becomeconfident about their decisions whichneeds to be factored in before thestory of clinical reasoning is fully told.

Dominance StructuringRichly considered judgments about

what to believe or do are typicallystructured around one dominant con-

clusion. In the case of a clinical judg-ment made under risky and uncertainconditions, that judgment emerges asa function of eliminating possiblechoices based on the evidence avail-able. Subsequently, even when newevidence becomes available thatchanges the value of the chosen alter-native, it proves difficult to override

one’s original conclusion. Thisremains true, even when new infor-mation renders the supporting rea-sons for the initial decision question-able at best. Creation of a ‘dominancestructure’ (Montgomery, 1989) aroundone’s choice of action (or inaction) cansustain confidence in the judgment

even when the negative consequencesof error are extremely high.

We all do this. We need to do this,actually, to attain significant confi-dence to act under uncertain condi-tions. Otherwise we would be morelikely to delay a needed judgment orfail to maintain our resolve, thus mak-ing errors of omission. This wouldconstitute a breech in the trust placedin us as health care providers. Butthere are dangers here. We can allthink of situations where an ineffec-tive plan of care was continued toolong to be optimal, and was evenharmful for a given individual. If weadd the realities surrounding theinterpersonal power structure neces-sary for the function of a medicalteam, there is an added pressure ofresponsibility on team leaders to beaware of dominance structuresaround particular diagnostic or treat-ment decisions which they may besustaining long past their utility forimproving the health of individualpatients. The same situation could bedescribed in relationship to the reten-tion of policies and practices wellbeyond their appropriate application,or negative judgments against co-workers because initial negativeimpressions are wrongly sustained.

Problem ParametersWhen we interpret presenting

symptoms, we explore their charac-teristics (frequency, severity, persis-tence, duration...), knowing that thesecharacteristics modify the symptoms’meaning. So it is with the characteris-tics of clinical problems, or all of life’sproblems for that matter. A problem’sattributes pose differing challengesfor the thinking skills and habits ofmind required for successful problemresolution. We have already men-tioned above that new, or novel, prob-lems and situations are approacheddifferently than familiar ones. Otherkey characteristics of problem situa-tions are the associated risk, the prob-lem’s complexity, the spontaneity ofits occurrence, accompanying timeconstraints, and the need for special-ized knowledge or collaborationrequired to address a response.Reflect on the likely characteristics ofthe typical problems presented in clin-ical practice and recall your own ini-tial clinical experiences as a student.When you were a health science stu-dent yourself, many of the problemsyou encountered in the clinical setting

Figure 1:The Argument and Heuristic Analysis Model of Decision-Making


appeared to you to be: 1) novel, 2)complex, 3) high stakes, 4) time con-strained, 5) spontaneous, and 6)requiring of more specialized knowl-edge than you had at your fingertips.Finally, in spite of being a trainee,often you probably felt you had toresolve problems individually ratherthan relying on collaboration. Yourresponses to those same problemsnow will depend in part on the natureof your current practice and theexpertise you have developed. Theperceived risk attached may be simi-lar, as most clinical judgments arehigh stakes for you as well as yourpatients. But there are probably ahigher proportion of those problemswhich are now, for you, highly famil-iar, less complex, more anticipatable,more within your knowledge base,where time to think is less of an issue,and you can rely on collaborationwith other members of the health careteam.

Training clinical judgment acrossall of these possible problem parame-ters requires a careful pedagogicalapproach. We need to remember toprovide time for trainees to think.Scaffolding the complexity of prob-lems presented to students and novicestaff will improve their ability to thinkwell. Debriefing case outcomes as tothe embedded clinical reasoning (sur-facing assumptions, preliminary diag-noses, suspected interacting factors)externalizes the reasoning process sothat it can be critiqued or praised. Inthe end, training health professionalsto think well in clinical practice is adelicate dance, balancing the need tofunction in swiftly evolving realworld cases with the need to allowevery promising student time todevelop their critical thinking skills.

The emphasis here is on ‘promis-ing.’ One thing we have learned in thecourse of our work in critical thinkingmeasurement is that many studentsadmitted to health science programsdo not have the requisite thinkingskills to become great or even compe-tent diagnosticians. We know this byexamining thousands of critical think-ing test scores from students acrossthe health science disciplines (Facione& Facione, 1997; Chirema, 2006) andfrom the research that has been doneto link critical thinking test scoreswith success on licensure examina-tions in the health sciences (Williams,Schmidt, Tilliss et. al., 2006).

Taking a critical thinking approachto clinical practice entails two linked

goals: accurate problem identificationand optimal problem resolution. Thefirst is essential. Taking action to solvethe wrong problem may work occa-sionally in politics, but will not workfor the sick and dying. The second isalso essential. What are the conse-quences of not taking a critical think-ing approach to developing a clinicaltreatment plan? If clinicians or ourhealth science students do not havethe possibility to think reflectivelyabout clinical situations, they will useother methods for problem resolution.Some alternatives to critical thinkingare: 1) to ask someone else what to do;2) to do nothing; 3) to keep on doingsomething which is failing to achieveour desired outcome; or 4) to dosomething, anything, new justbecause it has not been tried yet. Thefirst three are a recipe for mediocrityor failure through omission. Thefourth is perhaps most dangerous ifthe presumed diagnosis is mistakenor if the chanced upon trial treatmentturns out to be not simply ineffectualbut actually harmful.

At its best, a focus on reflectivethinking, and some attempt to meta-cognitively monitor our use of heuris-tic thinking, allows one to be thought-ful about intellectual honesty,analytically anticipating what hap-pens next, demanding the wisdom ofmaking decisions in a fair-mindedand timely manner, and the attempt toeliminate personal biases. Thesehabits of mind have been identified asthose of the ideal critical thinker(Facione, Facione & Sanchez, 1994;American Philosophical Association,1990).

Multiple MeasurementModalities

The assessment of critical thinkinglends itself to the full array of mea-surement methods. Here as in allareas of measurement, multiple mea-sures allow the assessment of criticalthinking in the many clinical practicecontexts. Multiple choice (Facione &Facione, 2006; Facione, 2000; Watson& Glaser, 1980; Ennis, Millman &Tomko, 1985) or short answer essaytests (Ennis & Weir, 1985), can be usedto take one measure of critical think-ing skill. These are particularly usefulas diagnostic tests for reasoning com-petence for newly hired clinicians,health science students, and evenhealth care clients who are not cogni-tively impaired. Some of these instru-

ments use multiple choice questionsrequiring test-takers to apply criticalthinking skills not only to solve aproblem but to evaluate the quality ofthe solution and provide the evidencefor that quality. Likert-style attitudi-nal measures can gauge critical think-ing habits of mind (Facione & Facione1992; Giancarlo 1998). Others havereported the utility of the multiplechoice format to test reasoningprocess when the items are writtenwell (Leung, Mok & Wong, 2007).Rubrics can be constructed to assessparticular critical thinking skills or toobtain a holistic ratings of criticalthinking skills and disposition. Whencare is taken to train rater and assuretheir valid and reliable observation ofcritical thinking as it presents in realtime, these rubrics can be used toassess critical thinking exhibited byclinicians or students in routine caseconferences, planned classroom pre-sentations, written assignments, orimmediately after addressing a spon-taneous bedside situation (Facione &Facione 1996b; Facione & Facione,1994).

Each assessment device has differ-ent potential for assessing criticalthinking in relation to more or lessauthentic clinical judgment situations.Any test of critical thinking must callforth evidence of critical thinkingitself and not merely evidence of con-tent knowledge if they are to assess anindividual’s ability to think well.Psychological measures of criticalthinking disposition can provide abarometer for whether a given indi-vidual is disposed to use their criticalthinking skills rather than to rely onsome other way of dealing with prob-lems. These test an individual’s will-ingness to try to think well. We needclinicians who are both willing andable to think well.

SummaryThe focus on the need to training

clinical judgment per se is rather new.At every level from novice to expert,clinical judgment regarding diagno-sis, treatment, and on-going evalua-tion of patient outcomes is a funda-mentally complex reasoning processwhich is applied to problems charac-terized by a multiplicity of potentiallyvarying parameters, and which con-sumes cognitive resources includingtime to think as it relies upon core crit-ical thinking skills and habits of mind,integrating our two systems of deci-



sion-making, susceptible to the bene-fits and shortcomings of cognitivedominance structuring. How clinicalreasoning is experience, even d by theexpert, is not a reliable measure ofeither the complexity or the quality ofreasoning process. We would make ananalogy to the practiced use of cus-tomized software on a computer. Theapparent ease of the experience beliesthe cognitive, physiological andmechanical processes at work. Wecannot make this point stronglyenough, because the potential impli-cations of overconfidence in one’sexpertise in clinical reasoning couldnot be more grave for the sick anddying. Previously we were overlyconfident that students and noviceclinicians would somehow “natural-ly” advance in their clinical reasoningas they were introduced to typicalclinical case scenarios. But we havelearned that without a direct focus onthe critical thinking processes used tointerpret, analyze, infer, evaluate, andexplain what is going on, progress inclinical reasoning is an uncertain out-come. True, this progress may comeentirely from the learners own aware-ness of how she or he needs to goabout internalizing and growing theirclinical reasoning expertise. But whenwise instructors and mentors facilitatereflective problem-solving by prompt-ing meta-analysis and evaluation ofclinical reasoning through theircourse assignments and pedagogicalapproaches, the progress is more cer-tain. Changes in health science curric-ula to case-based pedagogies andproblem based learning are relativelyrecent, but we are already seeing evi-dence of improved outcomes as edu-cational researchers report that theirpedagogical efforts to improve clinicalreasoning skills and dispositions havebeen demonstrated in a variety ofhealth science disciplines and con-texts (Jenicek 2006; McAllister 2005;Tiwari, Lai, So & Yuen, 2006, Shin,Jung, Shin, & Kim, 2006; Torre, Daley,Stark-Schweitzer, Siddhartha, et al.,2007; Ozturk, Muslu & Dicle, 2007;Suliman, 2006; Velde & Wittman,2006). Expanding our knowledge ofhow to do this well will surely follow.

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IntroductionThe goal of optometric education is

to produce a clinician who exhibitsentry-level competencies in knowl-edge base, skills, and attitudes by thetime of graduation. To help clarifythis goal, the Association of Schoolsand Colleges of Optometry (ASCO)

recommended that new graduatesmust acquire “the critical thinkingskills needed to assess the patient’svisual and physical status and tointerpret and synthesize the data toformulate and execute effective man-agement skills.”1 This recommenda-tion has led the schools and collegesof optometry to strive to incorporatecritical thinking into their curriculaand into the various clinical settingswhere teaching and learning occur.

Critical thinking is a complex andmuch sought-after skill. The literaturereports many definitions of criticalthinking with varied emphasis. Pauland Elder’s definition emphasizes theart of analysis, evaluation, and assess-ment of thinking.2 Watson and Glaseremphasized an attitude of inquiry.3

The Delphi Report, which representsthe collective thinking of several hun-dred experts in a variety of disci-plines, defines critical thinking as,“Purposeful, self-regulatory judg-ment which results in interpretation,analysis, evaluation, and inference, aswell as explanation of the evidential,conceptual, methodological, criterio-logical, or contextual considerationsupon which that judgment is based.”4

In the healthcare professions, clinicalreasoning is the cognitive process thatinvolves critical thinking and reflec-tive problem solving.5

For more than three decades,researchers have been exploring thenature of clinical reasoning. Severalstudies in the healthcare professionshave linked good critical thinkingskills to good professional judg-ment.6-8 In the field of optometry, pre-vious research has demonstrated apositive association between evalua-tions of clinical performance and crit-ical thinking skills in students withminimal clinical experience.9

The education of optometrists andother healthcare professionalsrequires clinical experience to fullydevelop clinical reasoning skills. Thefinal year of optometric educationrepresents intense, full-time clinicaltraining in preparation for gradua-tion. At the New England College ofOptometry (NECO), fourth-year stu-dents, as they progress through theclinical curriculum, have a greaterdemand for efficient thought processbecause they make higher stakes deci-sions. They are exposed to more com-plex ocular and systemic patient carescenarios and are expected to exhibitindependence in decision making.

Association of CriticalThinking Skills WithClinical Performance in Fourth-YearOptometry Students


AbstractThe goal of optometric education is to produce a clinician who exhibits entry-

level competencies in knowledge base, skills, and attitudes by the time of gradu-ation. The purpose of this study was to address the following research question:Is there an association between critical thinking scores, as measured by a stan-dardized test, and evaluations of clinical performance in fourth-year optometrystudents?

Methods: Thirty-six students from the New England College of Optometrywere assessed at the end of their fourth year with the California Critical ThinkingSkills Test (CCTST).

Results: An association was found between critical thinking scores after oneyear of full-time clinical experience and clinical performance (p=0.0057, Kruskal-Wallis Test).

Conclusion: After intense clinical experience of full-time patient care, stu-dents who demonstrated the lowest clinical ability demonstrated low scores incritical thinking skills. This study suggests that evaluations of clinical perfor-mance are associated with critical thinking skills as measured by a standardizedtest. The identification of this trend may have potential impact on promoting theteaching of critical thinking, the early identification of clinically weaker studentsas an assessment tool for clinical education, and in customizing specific remedi-ation plans.

Key words: critical thinking, optometric education, clinical performance

Dr. Denial is associate professor of optometry at theNew England College of Optometry. She thanksDrs. Nancy Carlson and Elizabeth Hoppe for herhelp in editing the manuscript and Dr. Li Deng forher statistical support. E-mail: [email protected]


Educational research is needed toevaluate the relationship betweencritical thinking skills and clinicalabilities during optometric training.The purpose of this study was toaddress the following research ques-tion: Is there an association betweencritical thinking scores as measuredby a standardized test and evalua-tions of clinical performance infourth-year optometry students? Thisstudy may impact promoting theteaching of critical thinking, earlyidentification of clinically weaker stu-dents, and customizing specific reme-diation plans and serve as an assess-ment tool for clinical education.

MethodsThirty six students from NECO

were assessed with the CaliforniaCritical Thinking Skill Test (CCTST)10

at the end of their final year of opto-metric education. The sample sizeincluded 25 female and 11 male stu-dents between the ages of 25 and 30years. Participation in the study wasvoluntary and the participants wererandomly chosen. The students wereengaged in over 2,000 hours of direct,patient-specific and comprehensivecare by the end of their final year ofeducation.

The CCTST is designed to measurethe skills involved with critical think-ing. The CCTST is content neutral;questions are not related to science oroptometric knowledge base.Therefore, it possesses the ability tomeasure basic critical thinking skillsthat are not influenced by the test-taker’s knowledge base, educationalbackground, educational emphasis,or type of professional degree pro-

gram. The instrument is based on theAmerican Philosophical Association’sdefinition of critical thinking. 4 Theitems cover a variety of topics; someinclude concrete scenarios and someare more abstract in nature. The testcontains 34 multiple-choice questions,with a 45-minute time limit. Therange of scores is between 0 and 34.The test has demonstrated contentvalidity and has been successful indetecting growth in critical thinkingskills. 11 The alpha reliability of theCCTST ranges from .78 to .84.11 Thefive areas tested by the CCTST areanalysis, evaluation, inference,deductive reasoning, and inductivereasoning. The CCTST was adminis-tered using guidelines from InsightAssessment.12 The tests were scoredby Insight Assessment, which report-ed both a total score and individualsubsets.

The total CT scores were comparedwith evaluations of clinical perfor-mance in the final year of study,grouped as follows: Group 1, anygrade of remedial or fail at midtermor final; Group 3, three out of fourgrades of honors at the final; Group 2,all of the others (no remedial or failand less than three grades of honors).The evaluation tool for clinical perfor-mance consisted of a nine-domainrubric validated by expert consensus.The evaluation rubric is used by allclinical instructors at NECO. Thedomains evaluated were technicalskills, knowledge base, analyticalskills, diagnostic skills, managementand treatment, communication skills,efficiency, attitude, and professional-ism. A nonparametric analysis of vari-ance (ANOVA), the Kruskal-WallisTest, was used to analyze the relation-

ship between evaluations of clinicalperformance and critical thinkingskills.

ResultsClinical performance was grouped

into three groups representing high,medium, and low ability. An associa-tion was found between critical think-ing scores after one year of full-timeclinical experience and clinical perfor-mance (p=0.0057, Kruskal-WallisTest). The average CCTST score forthe lower performing group was 15.5;the medium group, 19.3; and thehigher performing group, 22.9 (Table1 and Figure 1).

DiscussionCritical thinking skills have been

associated with clinical reasoningskills in several health care profes-sions.6-8 The data from this study sup-ported a previous study that demon-strated an association between criticalthinking test scores and evaluationsof critical thinking in the field ofoptometry.9

The association between criticalthinking and clinical performance,along with the recommendationsfrom ASCO, supported the teachingand acquiring of critical thinkingskills in the optometric curriculum.Facione has shown that, with instruc-tion, critical thinking skills improvedin college students.11,13 However, with-out specific instruction, no improve-ments took place. The development ofcritical thinking skills is essential, butimplementation of teaching and fos-tering critical thinking in the curricu-lum is difficult.

Optometric faculty face the chal-lenge of teaching extensive amountsof knowledge and techniques whiledeveloping the critical thinking skillsof students. Administrators often findthemselves hindered by faculty andstudent time limitations and financialconsideration. The didactic curricu-lum builds a foundation of knowl-edge, thought process, and technicalskills that are used and expanded inthe clinical setting. Clinical educatorsface the dual role of taking care ofpatients and educating students. Thelecture format is one of the most cost-effective ways to deliver material.However, in most cases, in the lectureformat, students are left on their ownto analyze, prioritize, and structuretheir knowledge, thus hindering the


Clinical groups n Average critical thinkingscore

Variance

Group 1- low performing 7 15.57143 9.619048

Group 2 16 19.375 19.18333

Group 3- high performing 13 22.92308 24.41026

Table 1Average CT scores and Clinical Groups

Note: Group 1, any grade of remedial or fail at midterm or final; Group 3, three or more final gradesof honors; Group 2, all of the others (no remedial or fail and less than 3 final grades of honors).


development of critical thinkingskills.14

Although this study evaluated crit-ical thinking skills and clinical perfor-mance, the foundation for criticalthinking ability comes prior to entryinto the clinical setting and must bereinforced in the preclinical didacticcoursework. In the 1990s, manyhealthcare institutions moved awayfrom the traditional, lecture-based,single-discipline courses to a curricu-lum that incorporated the integrationof disciplines and small-group, prob-lem-based or case-based learning. 15-17

Curricula that incorporate problem-or case-based learning have theopportunity to foster and developclinic thought processes and criticalthinking.5,18

The small-group seminar providesa safe, nonthreatening environmentfor students to practice clinical prob-lem solving. 19 In addition, this settingpromotes the learning of criticalthinking skills by giving studentsimmediate feedback, the opportunityto brainstorm, and the encourage-ment to think reflectively.

Although small-group seminarsare one way to foster critical thinking,any teaching strategy that encouragesactive learning can be instrumental in

helping students think about theskills of evaluation, assessment, andanalysis. Hiler and Paul20 have severalteaching strategies that can easily beimplemented in a large lecture formator in the clinical setting. They havesuggested asking questions thatarouse curiosity, using study ques-tions that require thinking and appli-cation of knowledge, and being a rolemodel by thinking out loud.

Additional suggestions from Hillerand Paul may be directly applicable tothe clinical teaching environment andinclude the following four ways tointegrate critical thought processes:20

1. “Teach the principles of criticalthinking along with subjectmaterial.” Use the subject mate-rial as examples of analysis,evaluation, and assessment ofmaterial.

2. “Promote independent thinking,present students with a prob-lem/diagnosis that has severalpossible solutions/treatment.Have students defend their pro-posed solution/treatment planwith logical evidence.”

3. “Use Socratic questioning.”What do you mean? What evi-dence do you have? What does

that imply? How did you arriveat this conclusion?

4. “Teach for usefulness.” Teachconcepts as a functional tool forapplication in patient care. Ifstudents value the information,their learning will be deeper andbetter retained.

Critical thinking and clinicalthought process should be taught andencouraged in every clinical anddidactic teaching encounter. Studentsneed to become active in their learn-ing and develop inquisitive minds.Optometric education oversees thetransition of students from a “stu-dent” to a “doctor.” Acquisition ofknowledge involves more than mem-orization of information. Sound opto-metric, clinical, decision making issupported by the use of knowledgeand good problem-solving skills.Achieving these goals enables stu-dents to provide a high level ofpatient care and perform well in theclinical setting.

Most students acquire the neededskills to experience success within theclinical environment. However, eachyear a small percentage of studentsfind themselves under pressure andstruggling with clinical success. Areview of the midterm and final clini-cal evaluations of the students in thelowest performing group revealedthat 100% of the students obtainedtheir grades because of a weakness inan area associated with clinicalthought process. Examples of areasassociated with thought process arediagnosis, management, and analysis.Future studies should include the fea-sibility of testing critical thinkingskills before clinical rotations toenable educators to identify studentsat risk for weak clinical performance.

Students who are not achievingclinically hinder the efficiency of theclinical site to which they are assignedand suffer emotional stress. 20 Aneffective and efficient remediationprogram is beneficial to the student,faculty, clinical site, and ultimately tothe profession. The design of remedi-ation programs varies among institu-tions. In most institutions, deficien-cies are identified with a valid clinicalassessment and a specific plan is insti-tuted.22 In many cases, the plan is lim-ited to additional clinical experience.If critical thinking is associated withclinical performance, then a well-designed clinical remediation pro-gram may need to include specific

0

5

10

15

20

25

30

35

0 1 2 3 4

Clinical Groupings

CT

Scor

es

Figure 1Critical Thinking Scores/Clinical Groupings

course work in critical think-ing/problem-solving strategies andclinical experience.

Clinical experience is an essentialcomponent of the educationalprocess. The ability to accuratelyassess the quality of the clinical edu-cational experience is vital and diffi-cult. Variability in clinical sites,instructors, students, and patientsmakes evaluation of clinical educa-tion challenging. In most cases, clini-cal education is best assessed by mul-tiple measures. Currently, clinicaleducation is evaluated by severalstandards: students’ clinical perfor-mance, students’ subjective evalua-tions, independent site evaluations,and patient quality control. If weassume that students’ clinical perfor-mance is a valid measure of clinicaleducation, then tests that are associat-ed with evaluations of clinical perfor-mance are also a valid measure ofclinical education. This assumes thatwe have a motivated and capable stu-dent. The results of this study demon-strate an association between scoresof critical thinking and evaluations ofclinical performance. Therefore, criti-cal thinking scores may have thepotential to be used as an objectiveevaluative tool of clinical education.An objective evaluative tool of clinicaleducation allows for better qualityassurance, enables better studentplacement, and provides a basis forcomparative studies.

ConclusionAfter intense clinical experience

(over 2,000 hours), students whodemonstrated the lowest clinical abil-ity demonstrated low scores in criticalthinking skills. This study suggests

that clinical performance is associatedwith critical thinking skills, as mea-sured by a standardized test. Thisstudy supports previous research thatreported an association between lowcritical thinking scores and low clini-cal performance after limited clinicalexperience.9 The identification of thistrend may have potential impact onpromoting the teaching of criticalthinking and the early identificationof clinically weaker students as anassessment tools for clinical educationand in customizing specific remedia-tion plans. Although the results of thisstudy are promising, we can not infera causal relationship between criticalthinking and clinical performance.Additional studies are needed toadvance the knowledge of how tobest facilitate and enhance the teach-ing of critical thinking and, ultimate-ly, how to best apply these skills inpatient care.

References1. Heath D, Daum K, DiStefano A, Haine C,

Schwartz S. Attributes of students graduat-ing from schools and colleges of optometry.Opto Educ. 2000;26:15-8.

2. Paul R, Elder L. Critical thinking, tools fortaking charge of your learning and your life.Englewood Cliffs, NJ: Pearson Prentice Hall;2006, p. xvii.

3. Watson G, Glaser EM. Watson-Glaser criti-cal thinking appraisal. Dallas, TX:Psychological Corporation; 1980.

4. Facione PA. Critical thinking: a statement ofexpert consensus for purposes of education-al assessment and instruction. “The Delphireport.” Milbrae, CA: California AcademicPress; 1990.

5. Facione PA, Facione NC. Teaching criticalthinking and clinical reasoning in the healthsciences. Millbrae CA: California AcademicPress; 2007.

6. Brookfield S. On impostership, cultural sui-cide and other dangers: how nurses learncritical thinking. J Contin Educ Nurs.

1993;24:197-205.7. Case B. Walking around the elephant: a crit-

ical thinking strategy for decision making. JContin Educ Nurs. 1994;25:101-9.

8. Hill T. The relationship between criticalthinking and decision making in respiratorycare students. Resp Care. 2002;47:571-7.

9. Denial A, Pitcher M. Optometric GPA,NBEO and clinical performance comparedto critical thinking skills and dispositions.Opto Educ. 2007;32 (Spring).

10. Facione PA. The California Critical ThinkingSkills Test. Insight Assessment/CaliforniaAcademic Press; 2000.

11. Facione PA. California Critical ThinkingSkills Test technical report number 1: exper-imental validation and content validity.Millbrae, CA: California Academic Press;1990.

12. Facione PA, Facione NC, Giancarlo CA. TheCalifornia Critical Thinking Skills test man-ual. Millbrae, CA: California AcademicPress; 2002.

13. Facione PA. California Critical ThinkingSkills Test technical report number 2: factorspredictive of CT skills. Millbrae, CA:California Academic Press; 1990.

14. Meyers C. Teaching students to thinkingcritically. San Francisco: Josey-Bass; 1986.

15. Schmidt H. Integrating the teaching of basicsciences, clinical sciences, and biopsychoso-cial issues. Acad Med(Suppl).1998;73(9):S24-31.

16. Bruhn JG. Outcomes of problem basedlearning in health care professional educa-tion: a critique. Farm Comm Health.1997;20(1):66-74.

17. Murphy J. Optometry schools raise thegrade. Rev Opto. 2003;49-56.

18. Barrows H, Pickell G. Developing clinicalproblem solving skills: a guide to moreeffective diagnosis and treatment. NewYork: Norton; 1991.18.

19. Denial A, Zorn M. Student’s assessment ofan integrative seminar course. Opto Educ.2006;32:17-22.

20. Hiler W, Paul R. Practical ways to promoteactive and cooperative learning. Millbrae,CA: Foundation for Critical Thinking; 2005.Available from wwwcriticalthinking.org

21. Haskivitz L, Koop E. Students struggling inclinic? A new role for the patient simulator.J Nurs Educ. 2004;43:181-4.

22. Olewszewski SC. Designing clinical remedi-ation programs. Sum. 1989;14(4):111-113.


IntroductionCritical thinking is a component of

clinical thought process that is usedby clinicians to determine what tobelieve and what to do about apatient’s symptoms.1 Critical thinkingin the clinical setting involves consid-eration of the “unique character of the

symptoms (evidence) in view of thepatient’s current health and life’s cir-cumstances (context), using theknowledge and skill acquired overthe course of their health sciencetraining and practice (methods, con-ceptualization), anticipation of thelikely effects of a chosen treatmentaction (consideration of evidence andcriteria) and finally monitoring theeventual consequences of deliveredcare (evidence and criteria).”1 Criticalthinking skills reflect a clinician’s abil-ity to ask relevant questions and ana-lyze, evaluate, and assess relevantinformation. These skills can beacquired through learning and prac-tice.2

In a four-year optometric program,the final year of schooling representsintense, full-time clinical training inpreparation for graduation. Fourth-year students, as they progressthrough the clinical curriculum, havea greater demand for efficient thoughtprocess because they make higherstakes decisions. They are exposed tomore complex ocular and systemicpatient care scenarios and are expect-ed to exhibit independence in deci-sion making. The fourth year mayprovide the opportunity to becomemore skilled at critical thinking.

Optometric clinical preceptors mayuse a variety of methods to assess astudent’s ability to think critically inthe patient-care setting. Examplesinclude the use of clinical gradingrubrics, direct questioning, and chartaudits. To best assess changes in criti-cal thinking over time, it is mostappropriate to use a standardizedmeans to evaluate critical thinkingskills. The California CriticalThinking Skills Test (CCTST) is a vali-dated test of critical thinking.3 It iscontent neutral; questions are notrelated to science or optometricknowledge base. Therefore, the testpossesses the ability to measure basiccritical thinking skills that are notinfluenced by the test-taker’s knowl-edge base, educational background,educational emphasis, or type of pro-fessional degree program. The itemscover a variety of topics some includeconcrete scenarios, and some aremore abstract in nature.

A study of critical thinking scores,as measured by the CCTST suggeststhat, in optometric education, there isa moderate to high correlation amonga critical thinking test score, optomet-ric grade point average (GPA), andNational Board Examination in


Changes in CriticalThinking After the Final Year of ClinicalEducation


AbstractCritical thinking skills are reflective of a clinician’s ability to ask relevant

questions and analyze, evaluate, and assess relevant information. Critical think-ing skills can be acquired through learning and practice. The final year of opto-metric education may provide the ideal opportunity to become more skilled atcritical thinking. The purpose of this study was to evaluate changes in standard-ized critical thinking scores between the start and end of the final year of study.

Methods: Thirty-six students from the New England College of Optometrywere assessed at the end of their third year of optometric education and again oneyear later after being engaged in full-time clinical education, using the CaliforniaCritical Thinking Skills Test.

Results: The results indicated that there was no significant change in criticalthinking score after the final year of clinical experience (p=0.92, Wilcoxon SignedRank Test). The mean and standard deviation of the total score change were–0.083 and 3.65 respectively.

Conclusion: The cognitive skills needed to provide excellent patient care area much sought after commodity. The results from this study raise several ques-tions: What type, frequency, and consistency of clinical education may influencecritical thinking skills? What type, frequency, and complexity of patient encoun-ters could result in a change of critical thinking skills? Identifying where andhow students acquire critical thinking skills can be valuable in determining howto teach and foster this valuable attribute.

Key Words: critical thinking, clinical education, clinical thought process

Dr. Denial is associate professor ofoptometry at the New England College ofOptometry. She thanks Drs. ElizabethHoppe and Nancy Carlson for their helpin editing the manuscript and Dr LiDeng for her statistical support. E-mail:[email protected]

Table 1Types of Critical Thinking

Analysis Analysis as used on the CCTST means to comprehend and express the meaning or significanceof a wide variety of experiences, situations, data, events, judgments, conventions, beliefs, rules,procedures, or criteria, and to identify the intended and actual inferential relationships amongstatements, questions, concepts, descriptions, or other forms of representation intended toexpress beliefs, judgments, experiences, reasons, information, or opinions.

Evaluation Evaluation as used on the CCTST means to assess the credibility of statements or other represen-tations and “to state the results of one’s reasoning; to justify that reasoning in terms of the evi-dential, conceptual, methodological, criteriological and contextual considerations upon whichone’s results were based; and to present one’s reasoning in the form of cogent arguments.”

Inference Inference as used on the CCTST means to identify and secure elements needed to draw reason-able conclusions, to form conjectures and hypotheses, to consider relevant information and todeduce the consequences flowing from data, statements, principles, evidence, judgments,beliefs, opinions, concepts, descriptions, questions, or other forms of representation.

Deductive reasoning Deductive Reasoning as used in the CCTST sub-scale means the assumed truth of the premisespurportedly necessitates the truth of conclusion

Inductive reasoning Inductive reasoning as used in the CCTST subscale means an argument’s conclusion is pur -portedly warranted, but not necessitated, by the assumed truth of its premises.


Optometry (NBEO; Part 1) scores.4

Previous research has shown that crit-ical thinking scores demonstrated anassociation to clinical performance.4,5

The purpose of this study was to eval-uate changes in critical thinkingscores between the first year and theend of the final year of study.

MethodsThirty-six students from the New

England College of Optometry(NECO) were assessed with theCCTST at the end of their third year ofoptometric education and again afterone year of full-time clinical experi-ence (approximately 1,920 hours/year). The sample size included 25female and 11 male students betweenthe ages of 25 and 30 years.Participation in the study was volun-tary and the participants were ran-domly chosen. By the end of the thirdyear, students have completed theentire didactic curriculum. Thefourth-year clinical experience atNECO comprises four 3-month rota-tions. Each student rotates through aVeterans Administration Hospital, acommunity health center, a site thatdeals with special populations (e.g.,low vision, geriatrics, pediatrics), and

their choice of an elective site (tertiarycare, military base, private practice, orinternational site).

The CCTST was administeredusing the recommended guidelinesfrom Insight Assessment (Millbrae,CA).6 The CCTST is a standardizedpsychological test, designed to mea-sure the skills involved with criticalthinking. The test consists of 34 multi-ple-choice questions to be answeredin a 45-minute timeframe. The fiveareas tested by the CCTST are analy-sis, evaluation, inference, deductivereasoning, and inductive reasoning.The meanings of each domain aredefined by the Insight AssessmentInterpretation Document and are inTable 1.

The CCTSTs were scored by InsightAssessment, which reported both atotal score and individual subsets.The inductive and deductive scalesoverlap with the analysis, inference,and evaluation scales.6 Analysis,inference, and evaluation add up tothe CCTST total score.6 Induction anddeduction also sum to the CCTSTtotal score.6 The total scores and sub-sets for critical thinking skills werecompared before and after one year offull-time clinical experience; theWilcoxon Signed Rank Test was used

to analyze the data for changes in crit-ical thinking over time. The level ofsignificance was set at p<0.05. Thisstudy was reviewed by the Insti -tutional Review Board at the NewEngland College of Optometry. Par -ticipants were given an informed con-sent document.

ResultsAll 36 students completed the test

in the allotted time frame. The resultsindicated that there was no significantchange in critical thinking score afterthe clinical experience (p=0.92,Wilcoxon Signed Rank Test). Themean and standard deviation of thetotal score change were –0.083 and3.65, respectively. Table 2 shows totalscore and each subsection’s data.

DiscussionIt seems that the clinical character-

istics of the fourth-year experienceshould provide the ideal environmentto become more skilled at criticalthinking. However, the results of thisstudy suggest that the critical think-ing skills of the fourth-year studentsdid not change. Several potentialexplanations are discussed below in

an attempt to explain this potentiallycontradictory result. The discussionincludes the nature of the clinicalexperience, composition of the patientencounters, the development of criti-cal thinking skills, assessment tool,sample size, and student motivation.

Nature of the Clinical ExperienceThe clinical experience may have

given the students the opportunity touse critical thinking skills but did notprovide the intervention needed tochange the skills. Studies have shownthat, with instruction, critical thinkingskills can improve.8-11 However, with-out specific instruction designed toimprove critical thinking skills, noimprovements took place.8,9

What type of instruction is com-mon in the clinical setting? Socraticquestioning, role modeling withexplanation of thought process, andformal case presentation are threemethods commonly used to teachclinical thought process in the opto-metric clinical setting.12 In addition tothese methods, case studies, clinicalsimulations, clinical patient rounds,and small-group discussions arestrategies used by healthcare educa-tors to teach clinical and criticalthought processes in the clinical set-ting.13 Future studies need to explorethe optimal frequency, complexity,and consistency of instruction andmaterial needed to produce the bestenvironment that is conducive toincreasing clinical and critical think-ing skills.

Patient CompositionIn addition to optimizing the clini-

cal instructional environment, thecomposition of the patient encounterneeds to be evaluated to determinethe complexity, diversity, and fre-quency of patient-care encountersthat would enhance critical thinking.Enhancing critical thinking skillsrequires perceiving, remembering,thinking, and decision making.14

Applying these cognitive processes toa diverse and complex group ofpatients would give students theopportunity to advance their criticalthinking skills. If students are provid-ing care to a homogeneous group ofpatients, they may not be challengedto change their critical thinking skills.Even with a heterogeneous group ofpatients, the act of taking care ofpatients alone may not be sufficient tochange critical thinking skills. Thegrowth of critical thinking may needin-depth self-reflection, discussion,and analysis of thought process.

Development of Critical ThinkingSkills in the Didactic Environment

Another explanation for why criti-cal thinking skills did not appear tochange during the year of full-timeclinical education is that students’critical thinking skills are most influ-enced by the didactic education thattakes place prior to the final year. Itmay be that students experience themost rapid growth in critical thinkingability during the first 3 years of theeducational program and that further

improvements are negligible. Futurestudies need to address the changes incritical thinking over the first 3 yearsof optometric education.

Assessment ToolThe lack of change seen in this

study may indicate a lack of correla-tion with the assessment tool, CCTST,and clinical decision making. Criticalthinking is one component of clinicalthought process. Clinical thoughtprocess also involves a combinationof experience and knowledge base.The final year of optometry schoolmay provide an increase in experi-ence and knowledge base, whichleads to overall improved clinicalthought process but not necessarilybetter critical thinking skills. TheCCTST is a knowledge-neutral test ofproblem-solving skills. Several otherdisciplines have also used a knowl-edge-neutral test of critical thinkingto evaluate or predict clinical decision-making skills.13-16

Sample SizeThis study was limited by a rela-

tively small sample size. The numberof students recruited was largeenough to detect a change in criticalthinking ability scores. With a samplesize of 36, the study was sufficientlypowered to detect a change of twopoints on the total score. InsightAssessment advised that, after a non-specific intervention, a change of 2–3points is a reasonable expectation.17

Future studies should include a largersample size to capture smallerchanges.

Motivation LevelThe motivation level of the stu-

dents may have played a role in theoutcome of the study. The CCTST wasfirst administered at the end of thirdyear. At this point, students havecompleted their didactic courserequirements and have limited clini-cal experience. The students are antic-ipating their first full-time clinicalrotation with both excitement andstress. By the end of the fourth year,the students are awaiting graduationand are anxious to move on with theirlives and careers. Even though thestudents were chosen randomly andparticipation was voluntary, by theend of the fourth year, the studentsmay have been less attentive whiletaking the CCTST.

Discussing possible explanationsfor the lack of change in critical think-

Table 2Total Mean Critical Thinking (CT) and Subset Scores Before Clinical

Experience (3rd Year) and After Clinical Experience (4th Year)

Point type 3rd year 4th year p-value

Total CT score 20.00 19.91 0.89

Analytical 4.77 4.72 0.79

Inference 9.94 9.94 1.00

Evaluation 5.27 5.25 0.94

Induction 10.80 10.61 0.61

Deduction 9.19 9.30 0.80



ing scores provides insight for theteaching of clinical reasoning.However, it does not necessarily indi-cate a lack of adequate critical think-ing skills. Do students have adequatecritical thinking skills to providepatient care by the time they gradu-ate? Most students experience successwithin the clinical environment.Therefore, it is a reasonable assump-tion that their critical thinking skillsare adequate to provide entry-levelpatient care. However, each year, asmall percentage of students findthemselves under pressure and strug-gling with clinical success. In priorstudies, weak clinical performancehas been associated with lower criti-cal thinking skills.4,5 Clinical optomet-ric educators are often faced with thechallenge of finding efficient andeffective remediation strategies forweaker students. As educators, weshould strive to produce clinicianswho provide the highest level ofpatient care. Therefore, our goalsshould be to maximize the clinicalthought process of all students.However for weaker students,increasing critical thinking skills maybe vital to their success in the clinicalsystem and, ultimately, in their pro-fessional careers.

An effective and efficient remedia-tion program is beneficial to the stu-dent, faculty, and clinical sites .Thedesigns of remediation programsvary among institutions. In mostinstitutions, deficiencies are identifiedwith a valid clinical assessment, and aspecific plan is instituted. A well-designed remediation program mayneed to include specific coursework

in critical thinking/problem-solvingstrategies and clinical experience.

ConclusionThe results of this study indicated

that there was no significant changein critical thinking score after one yearof clinical experience. This study maycause optometric educators to ques-tion when and how students developcritical thinking skills. It may alsoprovide information that is helpful forthe design of remedial programs forstudents who are weaker clinically.The results raise several questions:What type, frequency, and consisten-cy of clinical education may influencecritical thinking skills? What type, fre-quency, and complexity of patientencounters could result in a change ofcritical thinking skills? The cognitiveskills needed to provide excellentpatient care are much sought-aftercommodities. Additional educationalresearch is needed to learn how tobest facilitate, teach, and enhancethese skills.

References1. Facione PA, Facione NC. Teaching critical

thinking and clinical reasoning in the healthscience. Chapter 1 (p. 2). Millbrae:California Academic Press; 2007.

2. Browne MN, Keeley S. Asking the rightquestions. A guide to critical thinking.Englewood Cliffs (NJ): Prentice Hall; 1990.

3. Soukup F. Assessment of critical thinkingskills in associate degree nursing students.presented at the graduate college of theUniversity of Wisconsin—Stout; May 1999.

4. Denial A, Pitcher M. Optometric GPA,NBEO and clinical performance comparedto critical thinking skills and dispositions.Opto Educ. 2007;32 (Spring).

5. Denial A. Association of critical thinkingskills with clinical performance in fourth-year optometry students. Opto Educ.2008;33.

6. Facione PA, Facione NC, Giancarlo CA. TheCalifornia Critical Thinking Skills Test man-ual. Millbrae: California Academic Press;2002.

7. Insight Assessment. Insight Assessmentinterpretation document. Millbrae, CA:Insight Assessment. Available from:www.insightassessment.com

8. Facione PA. California Critical ThinkingSkills Test technical report number 1:Experimental validation and content validi-ty. Millbrae: California Academic Press;1990.

9 . Facione PA. California Critical ThinkingSkills Test technical report number 1:Experimental validation and content validi-ty. Millbrae: California Academic Press;1990.

10. McMillian JH. Enhancing college students’critical thinking: a review of studies. ResHigher Educ. 1987;26:3-29.

11. Pascarella ET. The development of criticalthinking: does college make a difference. JCollege Student Devel. 1989;30:19-26.

12. Denial A. Teaching clinical thought processin the classroom and clinical setting. Paperpresented at the 16th Annual New EnglandCollege of Optometry’s PreceptorsConference, Boston; April 21, 2006.

13. Hill T. The relationship between criticalthinking and decision making in respiratorycare students. Resp Care. 2002;47:571-7.

14. Scott JN. Critical thinking: Change duringmedical school and relationship to perfor-mance in clinical clerkships. Med Educ.1998;32:14-8.

15. Williams KB, Glasnapp DR, Tilliss TS, et al.Predictive validity of critical thinking skillsfor initial clinical dental hygiene perfor-mance. J Dent Educ. 2003;67;1180-92.

16. Williams KB, Schmidt C, Tilliss TS, et al.Predictive validity of critical thinking skillsand disposition for the National BoardDental Hygiene Examination: a preliminaryinvestigation. J Dent Educ. 2006;70:536-44.

17. Personal Correspondence, Insight Assess -ment, Millbrae, CA. November 2006.

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