Critical Thinking in Critical Care: Five Strategies to Improve Teaching and Learning in the Intensive Care Unit

Abstract

Critical thinking, the capacity to be deliberate about thinking, is increasingly the focus of undergraduate medical education, but is not commonly addressed in graduate medical education. Without critical thinking, physicians, and particularly residents, are prone to cognitive errors, which can lead to diagnostic errors, especially in a high-stakes environment such as the intensive care unit. Although challenging, critical thinking skills can be taught. At this time, there is a paucity of data to support an educational gold standard for teaching critical thinking, but we believe that five strategies, routed in cognitive theory and our personal teaching experiences, provide an effective framework to teach critical thinking in the intensive care unit. The five strategies are: make the thinking process explicit by helping learners understand that the brain uses two cognitive processes: type 1, an intuitive pattern-recognizing process, and type 2, an analytic process; discuss cognitive biases, such as premature closure, and teach residents to minimize biases by expressing uncertainty and keeping differentials broad; model and teach inductive reasoning by utilizing concept and mechanism maps and explicitly teach how this reasoning differs from the more commonly used hypothetico-deductive reasoning; use questions to stimulate critical thinking: "how" or "why" questions can be used to coach trainees and to uncover their thought processes; and assess and provide feedback on learner's critical thinking. We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit.

Keywords: cognitive errors; critical care; critical thinking; medical education.

Figure 1.

Five strategies to teach critical thinking skills in a critical care environment.

Figure 2.

The revised Bloom’s taxonomy. This schematic, first created in 1956, depicts six levels of the cognitive domain. Remembering is the lowest level; creating is the highest level. Adapted from Anderson and Krathwol (20).

Figure 3.

Schematic representations of deductive (1) and inductive (2) reasoning apropos to the clinical case. In deductive reasoning, one fact (F; hypotension) is used to generated multiple hypotheses (H), and then facts that pertain to each are retrofitted (red F*; fever). In inductive reasoning, facts are grouped and used to generate hypotheses. Adapted from Pottier (32).

Figure 4.

(A) A mechanism map of a 45-year-old man presenting with cough, shortness of breath. Found to have an increased BUN/Cr ration, a decreased hematocrit, and a normal white blood cell count. (B) A concept map of the clinical case. AFib = atrial fibrillation; BUN/Cr = blood urea nitrogen to creatinine ratio; CAD = coronary artery disease; CO/Q = cardiac output; CVP = central venous pressure; CXR = chest X-ray; GI = gastrointestinal; HR = heart rate; Hx HTN = history of hypertension; MAP = mean arterial pressure; RV = right ventricle; SV = stroke volume; SVR = systemic vascular resistance; WBC = white blood cell.