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The critical thinking skills toolkit was developed and written by linda s

The Critical Thinking Skills Toolkit was developed and written by Linda S. Behar-
Horenstein, Ph.D., Distinguished Teaching Scholar and Professor at the University of
.
Critical Thinking Skills Toolbox
Introduction
The need to teach dental students how to develop and use critical thinking skills (CTS) has been a dominant theme in dental education for more than a decade. However, an understanding of how faculty teach these skills as well as how well students demonstrate these skills in didactic basic science courses and the predoctoral dental learning environment is less widespread. The quality of teaching in dental classrooms and clinics has been infrequently studied. Examination of how faculty develop opportunities for students to demonstrate critical thinking suggests that dental educators and researchers have a unique opportunity to change the course of academic history. Teaching students critical thinking skills also has implications for patient care. As students take ownership of diagnosis and treatment planning and articulate the thinking that supports their decisionmaking, they are poised to become better teachers. That is, they will be able to teach patients about diseases, self-care, what symptoms to look for, and the role of compliance in promoting self-care. Patients who take primary roles in self-care are likely to have fewer dental and other health care visits. Aside from helping students transform learning so they can become competent practitioners, teaching students critical thinking skills has implications for the quality of oral health care, costs, and well being. Those who believe critical thinking skills are already taught and are skeptical of the need to strengthen CTS may wish to consider the following questions. Table 1. Checklist for Teaching Basic Critical Thinking Skills
1. What percentage of the time do I encourage students to explain or demonstrate what
they know?
2. What percentage of the time do I dominate teaching in the classroom or clinic with
teacher-talk?
3. What percentage of the time do I include teacher-student discussion in the classroom
or clinic?
4. What percentage of the time do I devote teaching time in the classroom or clinic to
having students provide rationale for “what” they think and to explain “how” and “why”
they know?
5. What percentage of the time do I use questions to check for student understanding?
6. What percentage of the time do I ask students to identify the cues that indicate or
contraindicate treatment and to explain why these cues are relevant to prospective
treatment outcomes?
7. What percentage of the time do I ask students to describe how their understanding of body systems, like the cardiovascular system and related diseases, impact oral health? 8. What percentage of the time do I ask students to rephrase what I have just told them? 9. What percentage of the time do I ask students questions in order to identify why a patient is not responding to treatment as he or she should? 10. What percentage of the time do I explicitly explain to students how they will be evaluated on their clinical skills? 11. What percentage of the time do I ask students to explain to me the differences between a poor and an excellent tooth preparation? If in response to questions 1–11 you find that you are talking for 50% or more of your instructional time, then you are likely to benefit from this toolkit. Distler has observed that patients are now being treated by a multitude of highly specialized health care professionals1. A recent Institute of Medicine report emphasizes interprofessional collaboration2. If dental professionals become more involved in systemic health and cooperating with other health care professionals, the problems dentists face are likely to become more complicated and ambiguous. Because of these changes, dental educators are likely to see more patients who are acutely ill and it is more likely they will need to coordinate care with other health care providers. The information explosion is yet another reason why it is important that dental students utilize critical thinking skills3. Technology is becoming more sophisticated, and methods of diagnosis and treatment continue to expand. The sheer amount of readily available information challenges faculty to teach students how to decide what information is credible and what to do with the deluge of data. Recognizing the need to make substantial changes in the dental education curriculum, the American Dental Educational Association (2004) established the ADEA Commission on Change and Innovation (CCI). This group serves as a focal point where dental educators and administrators, along with representatives from dental organizations, the dental licensure community, the Commission on Dental Accreditation, the ADA Council on Dental Education and Licensure, and the Joint Commission on National Dental Examinations, coordinate efforts to improve dental education and the oral health of the nation. To assist dental educators across the United States and Canada in making necessary curricular changes, ADEA and the Academy for Academic Leadership agreed to jointly sponsor the creation of a critical thinking skills toolkit. Dental education has a longstanding history of telling and showing students what they need to know. Today’s students may not receive the type of instruction that allows them to transform learning and make it their own4. Learning how to teach students to use critical thinking skills will require fundamental shifts in beliefs about and planning for teaching. Some dental educators ask, “What does critical thinking look like in the clinic? In the classroom? How do I successfully teach students to use critical thinking skills when they don’t read before class or attend class regularly?” An overview of the dental education literature shows how dental hygienists have effectively used instructional strategies to promote critical thinking skills5. Moore used a mnemonic (a memory aid denoting a series of steps) to help lower students’ initial cognitive load and better remember how to transfer the steps to new problem-solving settings. The mnemonic, INFORMED, was:
I Issues and Information known
N Need to know
F Find information
O teach and learn from Others
R Recycle, Reflect, and identify Real problems
M Make a list of solutions
E Evaluate solutions
D Decide, Deliver, and Debrief
However, because this study occurred in a highly structured, contextualized program, it is difficult to determine whether the results can be attributed to problem-based learning (PBL), teacher expertise, group dynamics, student expertise, or prior experience. Thamasitboon et al. found that there was a significant difference between students who engaged in problem-based learning experiences and those who had traditional learning experiences in their development of several skill sets, including critical thinking skills6. While these and other studies hold promise for enculturating the teaching of critical thinking into dental school curriculum, they are limited by small sample sizes and the use of single outcome measures. In addition, Thamasitboon et al.’s study was limited by a low response rate and the disadvantages inherent to using a questionnaire with a rating scale. There is little practice-based evidence suggesting how to implement critical thinking changes in dental education. Some studies with small samples of undergraduate students have shown that a moderate infusion of critical thinking instruction can enhance critical thinking skills without the instructor making considerable changes to the course. (See Teaching Students to Use CTS during Instruction). Similar studies have not yet been conducted in dental education. Perhaps without social demand and funding opportunities faculty are reluctant to take on these types of studies. Nonetheless, the importance of teaching dental students to develop and use critical thinking skills is not a question; it is necessary. The shift to teaching critical thinking will require an organizational commitment to understanding what critical thinking is, identifying what strategies can be used to effectively teach critical thinking, testing changes in students’ critical thinking skills, and providing continuous faculty development opportunities and places to discuss, implement, and examine the scholarship of teaching. As Hansten and Washurn point out, an educational organization can support and foster critical thinking, or hinder it by creating faculty who are apathetic and feel powerless to make the changes that will be needed7. Behar-Horenstein et al. describe how faculty development initiatives brought about changes in instructional practices8. Behar-Horenstein et al. (2005) and Behar-Horenstein et al. (2000) also describe the role of assessment in studying how teaching critical thinking skills affects student thinking and practice in the classroom and predoctoral clinical learning environments9,10. As dental educators seek to transform the nature of teaching from telling and showing to holding students accountable for explaining their understanding and thinking, dental educators will need to develop more robust research studies to build an evidence-based collective of studies that reflect how efforts directed at teaching critical thinking skills matter to the new dental professional, the dental school, and society. Overview of Critical Thinking Skills
What is Critical Thinking?
Many researchers, including Facione, Simpson and Courtneay, Banning, Brookfield,
Ornstein and Hunkins, Sternberg, Ennis, and Lipman, have defined critical thinking (CT).
Researchers debate whether critical thinking can be learned or if it’s a developmental
process regulated by motivations, dispositions, and personality traits. Despite differences
of opinion, many researchers agree that critical thinking is "Purposeful, self-regulatory
judgment which results in interpretation, analysis, evaluation, and inference, as well as
explanation of the evidential, conceptual, methodological, criteriological or contextual
considerations upon which judgment is based 11.
Critical thinking is also regarded as intellectually engaged, skillful, and responsible thinking that facilitates good judgment because it requires the application of assumptions, knowledge, competence, and the ability to challenge one’s own thinking. Critical thinking requires the use of self-correction and monitoring to judge the rationality of thinking as well as reflexivity. When using critical thinking, individuals step back and reflect on the quality of that thinking. Simpson and Courtneay point out that critical thinking processes require active argumentation, initiative, reasoning, envisioning and analyzing complex alternatives, and making contingency-related value judgments 12. According to Banning, critical thinking involves scrutinizing, differentiating, and appraising information as well as reflecting on information to make judgments that will inform clinical decisions 13. Brookfield asserts that identifying and challenging assumptions and analyzing assumptions for validity are essential to critical thinking skills. He also suggested that because critical thinkers possess curiosity and skepticism, they are more likely to be motivated to provide solutions that resolve contradictions 14. Others such as Ornstein and Hunkins suggest that critical thinking and thinking skills refer to problem-solving and other related behaviors 15. For a number of years, dental educators thought teaching problem-solving skills was akin to teaching critical thinking skills. While teaching problem-solving skills is important to the process of learning how to use critical thinking skills, in the absence of other learning activities it may not be enough. Sternberg, Ennis, and Lipman assert that critical thinking skills are not a fixed entity but a form of intelligence that can be taught 16-19. The ability to develop critical thinking skills may be likened to Piaget’s concrete and formal operations. If students have not yet reached the formal operations stage, their ability to use critical thinking skills may be limited by an inability to handle abstract ideas. It is important to remember that Piaget’s stages of cognitive development are also linked to intellectual potential and environmental experiences. If the learning environment is crucial to the development of critical thinking skills, what instructional strategies can be used to promote critical thinking? Sternberg asserts that critical thinking involves complex mental operations that cannot be broken into discrete styles of thinking. He claims that CT involves students’ total intellectual functioning, not a narrowly defined set of skills. He postulates that there are three mental processes fostering critical thinking: meta-components, performance components, and knowledge-acquisition strategies 20. Meta-components refer to higher-order mental processes that individuals use to plan, monitor, and evaluate what they do. Performance components refer to the actual steps taken or strategies used, while knowledge-acquisition strategies refer to the ways in which individuals relate old to new material and apply new material. Sternberg does not specify a “how” approach to teaching and learning critical thinking skills. Instead, he provides general guidelines for developing or selecting a program or curriculum that will foster CTS. Interestingly, although not surprisingly, Sternberg states that students are not adequately prepared for the problems and critical thinking tasks they will face in everyday life because they are not taught these skills in their formative years 21. Tasks that stress right answers or truth telling or use objectively scored tests are generally removed from real-world relevance. Thus, it is particularly important that all aspects of dental educational curriculum stress real-world practice, the importance of oral health care, and the relationship of overall oral health care to systemic health by teaching students how to use critical thinking skills. Lipman, like Sternberg, does not specify a “how to” approach. However, he makes clear distinctions between ordinary thinking and critical thinking. He explains that ordinary thinking is simplistic thinking because it does not rely upon the use of standards or criteria. Examples of ordinary thinking are guessing, believing, and supposing. Lipman describes critical thinking as a complex process based on standards of objectivity, utility, or consistency in which students can reflect upon the certainty of their thinking because critical thinking is self-correcting 22. In order words, students can defend their thinking with evidence. Ennis asserts that to help students develop critical thinking skills, teachers must understand the cognitive processes that constitute critical thinking and use instructional activities that will develop these processes. He recommends instructors teach students how to define and clarify information, ask appropriate questions to clarify or challenge statements or beliefs, judge the credibility of sources, and solve problems by predicting probable outcomes through logic or deduction. Ennis also suggests that critical thinkers demonstrate particular attributes. Critical thinkers tend to: (1) Be capable of taking a position or changing a position as evidence dictates (2) Remain relevant to the point (3) Seek information as well as precision in information (4) Be open minded (5) Take the entire situation into account (6) Keep the original problem in mind (7) Search for reasons (8) Deal with the components of a complex problem in an orderly manner (9) Seek a clear statement of the problem (10) Look for options (11) Exhibit sensitivity to others’ feelings and depth of knowledge (12) Use credible sources 23 Critical thinkers use these skills appropriately and usually without prompting. They are generally predisposed to think critically and to evaluate the outcome of their thought processes 24. Instructional Strategies and Critical Thinking
Researchers have asserted that how educators teach has a direct influence on what is learned 25. Thus, the instructional strategies selected must be appropriate to the desired outcomes. For example, strategies of inquiry are contingent upon the problem being investigated and the targeted concepts, so it is essential that they be integrated with the associated processes of inquiry in order for students to see how new knowledge evolves 26. Researchers have also recommended eliminating superfluous activities and repetitious content and expanding learner-centered active forms of experiences to promote critical thinking skills 27. If the goal is for students to use critical thinking skills, then the following opportunities should constitute the majority of learning activities: a) Engaging in problem-based learning b) Analyzing case-based scenarios c) Engaging in debates, role-play, argument mapping, thinking aloud, and simulation among others 28 The benefit of engaging students in learning experiences that utilize critical thinking skills is the public nature of their thinking. When students engage in CTS, they have an opportunity to examine tacitly held knowledge of one another, make knowledge and think explicitly, respond to questions and comments, and clarify their thinking processes 29. Several researchers stated the types of instructional strategies that may be used to promote students’ critical thinking skills. Weerts suggested that working in groups might reduce students’ stress while trying to answer difficult questions. She points out that working together may result in better answers than working alone 30. Many dental educators might eschew the notion of using groups. However, it is important to acknowledge that even in classes of 80 to 100 dental students, groups of six to eight students could be developed to facilitate learning and inquiry. These groups could be responsible for answering questions about readings by being called upon randomly during class time. For example, instructors can consider writing three to four focus questions that accompany the readings to guide student comprehension. Instructors could also tell students that they should to be able to answer those questions in class. In this way, students can be held responsible for learning some of this discrete information before class. Rather than having the instructor feel responsible for “telling” students what they should know, the instructor can elicit the key concepts from students. Class time can then be used to present a case where the concept is illustrated, and students can work in groups to analyze how that concept is operationalized rather than receiving discrete knowledge through a lecture. Weerts also suggests that student groups can work together and develop critical thinking skills by: • Identifying issues • Gathering authoritative sources • Identifying potential treatments • Presenting competing points of view • Weighing modalities in light of the presenting case and then agreeing upon the treatment plan31 To ensure that students are developing appropriate skills, the instructor and students can use a Likert scale to rate each other on the following criteria: • Accuracy and relevancy of supporting evidence • Credibility of authoritative knowledge • Depth and breadth of thought • Clarity and soundness of responses Hendricson et al. suggest several active learning strategies that can be used to develop students’ critical thinking skills. Table 2. Strategies to Enhance Critical Thinking Skills • Use questions that require students to analyze problem etiology, compare alternative treatment modalities, provide rationales for plans of action, and predict outcomes. • Critique cases and review decisions to identify excellent practices and to identify errors. • Write assignments that require students to analyze problem etiology, compare alternative treatment modalities, provide rationales for plans of action, and predict outcomes. • Analyze work products and compare how outcomes compare to best practices and compare student reasoning about problems to those of an expert panel 32 Van Gelder concurs with Hendricson et al. that critical thinking must be deliberately practiced with the intent to improve performance; however, he states that CT is hard and human beings are not naturally critical 33. Shermer agrees and describes human beings as “pattern-seeking, story-telling animals … [who] like things to make sense, and the kinds of sense we grasp most easily are simple familiar patterns or narratives” (p. 42) 34. This penchant for the familiar affects how curriculum is designed and implemented. As a type of thinking that eschews the uncritical acceptance of information, critical thinking should be a deliberate part of the curriculum. Moreover, exposing students to good examples is insufficient to developing critical thinking skills. Students must demonstrate the ability to transfer critical thinking skills from one situation to another. As Kuhn writes: The best approach . . . may be to work from both ends at once-from a bottom-up anchoring in the regular practice [of what is being taught] so that skills are exercised, strengthened and consolidated as well as from a top-down fostering of understanding and intellectual values that play a major role in whether these skills will be used (p. 24) 35. Kuhn’s point has implications for teaching critical thinking skills in the basic science courses as well. Even though students are heavily immersed in learning a tremendous amount of information, they should still be presented with critical thinking learning experiences that embed concepts in actual practice-based scenarios 36. Argument mapping Van Gelder suggests that students’ critical thinking skills improve faster when instruction is based upon argument mapping. He asserts that when arguments are presented in diagrammatic form, students are more capable of following critical thinking procedures. Because argument maps are visual and more transparent, they make the core operations of critical thinking more straightforward. Van Gelder cautions, however, that belief preservation is a human tendency. He states that individuals tend to make evidence secondary to beliefs. Thus, critical thinking runs counter to human tendencies. Humans tend to seek evidence that supports beliefs and ignore evidence that goes against beliefs. Ideally, critical thinkers will recognize this, put extra effort into searching for evidence that contradicts their own beliefs and cultivate a willingness to change when evidence to the contrary begins to mount37 To apply argument mapping to clinical reasoning, consider Case #1. Case #1—Differing Views on Patient Treatment
A 60-year-old woman has internal resorption of the left maxillary lateral incisor. Radiographic exams reveal that saving the tooth is questionable. The student dentist recommends to Professor Marlin that the patient receive a fixed partial denture (FPD). Marlin confers with Professor James, and James recommends a removable partial denture (RPD). 1. The students are instructed to use argument mapping to explain the phenomenon. 2. Next, students are asked to write about the contradictions that differentiate viewpoints about FPD and RPD and to write about the counterarguments. 3. Finally, students are to identify their treatment decisions and provide evidence that supports or justifies their assertions. Lee and Ryan-Wenger recommend the use of the “think-aloud seminar” as a teaching tool. Students are presented with a case and asked relevant questions regarding symptoms and presenting signs. Using this approach, students can exclude underlying pathologies based upon the presentation. This process of excluding potential diagnoses aids students’ critical thinking by encouraging them to openly verbalize the rationales behind their opinions 38. Wong and Chung used simulation to develop diagnostic reasoning skills among nursing students. Students were asked to consider the etiological factors, presenting symptoms, and clinical signs of a patient who presented with a particular condition. As they examined the underlying patholophysiology, the CTS they developed were “assessing duration” and “frequency of symptoms and additional triggers.” They also were expected to review their understanding of the possible pathophysiological significance. The next set of CTS they focused on was “considering the pros and cons of treatments” and “drug actions and the possible side effects on the patient.” Finally they explored the efficacy of the outcomes. CTS developed in this phase were “determining the success of the treatment,” “determining complications,” “considering the time it took to resolve the clinical signs and symptoms,” and “considering reasons for the development of symptoms.”39 Other strategies Other strategies that can promote critical thinking include particular behaviors, especially asking questions. Table 3. Strategies that Promote Critical Thinking • Reflecting on the use of critical thinking • Making the teaching of thinking explicit • Rewarding good critical thinking and challenging poor critical thinking • Providing diverse problem contexts that are likely to engage students in critical thinking (essential) (40) Asking particular types of questions also promotes critical thinking. Table 4. Questions that Promote Critical Thinking • What other treatment options have you considered? Why have you chosen this approach? • Can you provide some evidence that supports your recommendation? • Is there another way to look at this problem? Also, Facione and Facione (1996) recommend that students begin analyzing their own thinking. For example, “If you were teaching a colleague about this situation, how would you lead him or her through the issues?” (41) While faculty strive to develop students’ abilities to use critical thinking, it is also important to communicate the logical fallacies students may demonstrate in their writing or speaking. Engel provides an overview that illustrates the common fallacies.42 Three common types of fallacies are shown in Table 5. Table 5. Common Logical Fallacies (Adapted from Engel, 1990) Types of Fallacies
Examples
• Using words that endow human attributes (e.g., “the organization made people…” Fallacies of ambiguity—Argument is not • Using the same word to mean different understood in more than one sense • Poor • Using sweeping generalizations • Premature closure (using insufficient evidence or an isolated example to make a Fallacies of presumption—Argument is not generalization) sound because of unproven assumptions or • Begging the question (when a conclusion overlooking, evading, or distorting facts restates the premise using different words)• Applying either/or classifications and ignoring other alternatives Fallacies of relevance—Argument relies on • Appealing to pity (rather than presenting irrelevant premises or attempts to obscure • Appealing to ignorance (trying to prove a claim by focusing on the lack of evidence against it) • Appealing to fear • Appealing to authority (trying to persuade by citing authorities, opinion, and tradition, rather than evidence) • Ad hominem arguments (avoiding discussion of the issues by describing attributes of the people involved) Teaching students how to use critical thinking skills shifts teaching from a model that largely ignores thinking to an approach that renders it pervasive43 When content is didactically taught, it is treated as static and students are unlikely to question or think it through. They tend to rely on rote memorization without grasping the logic, supporting evidence and application of what they are trying to memorize. Students who learn through a critical thinking process truly learn content. At every level, students need to learn how to: Ask questions precisely, define contexts and purposes, pursue relevant information, analyze key concepts, derive sound inferences, generate good reasons, recognize questionable assumptions, trace important implications, and think empathetically within different points of view (p. 20) 44. Critical thinking is difficult and requires overt practice using a variety of learning activities across the dental curriculum. It is also important to recognize the role that reflection plays in its development. Students need time to think about what they are learning and reflect upon that information. However, what they are learning must have an impact on their feelings in order for critical thinking to occur. Emotions and Critical Thinking
The role of emotion in learning to use critical thinking skills is yet another area that necessitates research inquiry. As Zull suggests, if we want students to retain concepts we must allow them to put things into their own words, verbally and in writing 45. Give students time to think before speaking and better construct ideas in their own words. Processing information takes time; stating one’s thinking correctly also takes time. If a student cannot do this alone, we can give him or her the opportunity to discuss questions with others. Giving students time to reflect is giving them time to make connections. Zull explains the process that takes place within the brain. First, the sensory cortex receives sensory input or concrete experiences. Next, the back integrative cortex tries to create meaning and images during the human process of reflection. The frontal integrative cortex is responsible for short-term memory and problem solving, making decisions and language, and making judgments and evaluations. This activity is akin to how learners handle abstractions—manipulating images and language to create new mental arrangements. The motor cortex triggers all coordinated and voluntary muscle contractions. This matches with the action that completes the learning cycle—actively testing abstractions and converting ideas into physical actions. The brain visualizes items in small amounts and all information arrives at the same time, producing an outline of objects and features in the visual field46 Thus, the brain can fully see great detail and nuance. Converting ideas into images helps students learn. Images enhance recall and aid in discovery. Sometimes the best teaching is just showing the student how. To ensure that students learn, educators need to limit the amount of information they give. Instructors should limit or condense to three or four pieces the amount of information they want students to process. The amygdala is responsible for screening experiences 47. If something is recognized as dangerous, the amygdale will instinctively cause the body to “freeze.” When a student first encounters something new, he or she may have a somewhat negative reaction. The instructor needs to find a way for the student to move into a more positive emotional territory 48. Making suggestions or showing examples can remind the student what he or she already knows, and then the student can hang newly acquired knowledge on that “scaffolding.” The support given by the instructor allows the student some level of success. Recognizing his or her success helps the student feel more hope, interest, and curiosity. At this point, the student is able to assume more control of the learning process. Boyd (2002) concurs and states, “emotions … constantly regulate what we experience as reality.” She also points out, “The limbic system plays an important role in processing emotion and memory and therefore appears to be important in the transfer of short-term memory into long-term memory" 49. Engaging students emotionally and actively strengthens memory. Teaching students to use CTS during instruction
There is some empirical evidence that a four-year undergraduate experience contributes
to modest gains in overall CT. However, there is little scientific evidence that a single
course, other than a critical thinking skills course makes a positive measurable difference
50. Even in the case of a specific CTS course, the evidence is mixed 51.
Recent studies show that limited efforts to infuse critical thinking in instruction can lead to improved scores on the Cornell Critical Thinking Test Level Z, a test that is aimed at a sophisticated audience and measures six common critical thinking skills 52. Allegrettti and Frederick (1995) reported pre- to post-test gains on the Cornell Z for a group of college seniors (n = 24) who took a capstone integrated psychology and philosophy course 53. Solon (2001) found that a partial treatment group of psychology students (n = 26) improved their scores on the Cornell Z compared to a group of untreated humanities students (n = 26). The results were statistically significant (beyond .001). In 2003, Solon studied three groups to compare coursework effects and reported that the full treatment group (n = 25) significantly outscored both the partial (n = 25) and non-treatment (n = 25) groups on the Cornell Z test 54. Solon (2007) reported that a group of introductory psychology students (n = 25) received a moderate infusion of critical thinking skills (10 hours instruction and 20 hours homework). Compared to the non-treatment group (n= 26), the experimental group significantly improved their scores on the Cornell Z test 55. These findings suggest that even a moderate infusion of critical thinking skills instruction can result in enhanced reasoning skills without requiring a significant investment from the instructor 56. Collins and Onwuegbuzie reported significant relationships between overall CTS and achievement in a graduate level research methodology course at the midterm (r = .34, p < .01) and final (r = .26, p < .01) stages 57. Onwuegbuzie compared the CTS of master’s and doctoral level students. He reported that doctoral level students (n = 19) obtained statistically higher overall CTS using the California Critical Thinking Skills Test than the masters’ degree students (n = 101, t = -3.54, p < .01). The effect size (d = 0.92) associated with this difference was extremely large 58. Teaching CTS requires instruction that uses higher order taxonomic skills. These skills require student demonstration or teacher usage of behaviors classified as analysis, evaluation, and creation (levels 4, 5, and 6 on Bloom’s revised taxonomy). When teaching takes place at higher levels of learning, lower order behaviors such as remembering, understanding, and applying are subsumed within instruction. The following table lists behaviors common at each level of learning and examples of related dental education activities. Table 6. Revised Bloom’s Taxonomy, Sample Verbs, and Related Learning Activities 59 A prosthodontics patient, age 62, has two fixed mandible bridges that have deteriorated over the last two years due to poor hygiene. These bridges now need replacement. You are a recent dental graduate in practice with two senior partners. The senior partners suggest taking impressions and replacing the fixed arrange, blend, create, bridges. You have read the recent literature on dental implants and would offer the patient this option. You also recognize that implants are more appropriate to the patient’s needs and that over time they represent a cost savings. However, the senior partners are not really familiar with state of the art information about implants. Develop a plan for responding to the senior partners in which you provide an evidence-based rationale for suggesting the use of dental implants. Two patients, aged 18 months and 10 years, have cleft palate. Neither patient has been seen by health professionals or treated for this condition until now. Based on a complete summary of the dental, medical, social, and psychological health of each child, develop a treatment plan using authoritative and credible sources. A 32-year-old white male arrives at your office and presents with pain and swelling over the “upper right canine tooth” for the past three days. His medical history is remarkable for GERD, for which he takes Prilosec daily, and a generalize, categorize, penicillin allergy (rash over his torso and fever intraoral and extra oral swelling over tooth #6. A radiograph reveals radiolucency with caries under the crestal bone (nonrestorable). What are your concerns? How would you treat and prescribe? Convert, demonstrate, After completing textbook readings about the basics of periodontology, explain with images the progression of periodontal disease from the perspective of pathogenesis. Choose lay terms Differentiate, fill in, find, group, outline, State four or five reasons that rubber dam predict, represent, trace, isolation is essential during endodontic Understanding compare, demonstrate, procedures. draw, find, match, read, From a list of 10 options, choose the five items
Making Critical Thinking Explicit
Teaching for critical thinking is a rational and intentional act. Typically, instructors cannot suddenly decide to teach CTS and develop an appropriate learning activity. An instructor must have a clear understanding of what CTS is, how it is implemented during instruction, and what strategies should be used during particular classroom and predoctoral clinical learning activities. Developing a repertoire of well-honed CTS activities appropriate to your specific discipline is advisable. Also crucial to the teaching of CTS is an educator announcing to students he or she will teach CTS, how he or she intends to do so, and what will be required of the students as learners. It is important to have an explicit conversation with students about what CTS is, what it looks like, and how educators will model it so students can differentiate the teaching of CTS from lower level learning. Effective teaching of university-age students is characterized by collegial and collaborative processes, not instruction that is ambiguous. In ambiguous instruction, the learner does not know what to expect next or have a clear understanding of what behavioral or skill changes he or she should demonstrate as a result of teacher-student interaction. Teaching explicitly helps ensure that less re-teaching will be necessary. Both teachers and students know their responsibilities as instructors and learners. Stages of Critical Thinking
Paul and Elder claim that individuals progress through predictable stages of unreflective, challenged, beginning, practicing, advanced, and master thinking60. They state that unless educators help students develop an intellectual vocabulary for discussing their thought processes and challenge them to identify the problems in their thinking, the students’ cognitive processes will remain invisible to them. The implication for curriculum development: If instructors want students to develop critical thinking skills, then critical thinking must be integrated into the foundations of instruction. It is also important to recognize that when patient care is task focused, it can obscure the bigger picture and become a barrier to the development of critical thinking skills. Individual personality, background, and position might also limit one’s ability to think critically. Additionally, gender, age, religion, and socioeconomic status might influence the development of critical thinking skills. One of the biggest barriers to the development of CTS is our educational system. Although it is important to recognize these attributes as potential barriers, it is more important that dental educators establish the kind of learning environments that will foster the development of CTS. Case #2—Why Are Mrs. Connor’s Teeth Yellow?
Mrs. Connor, a 74-year-old white female, comes to your office as a new patient. She presents you with a complaint that her teeth have become yellowed and unattractive. Her husband died one year prior, and since then she has been drinking 8-10 cups of coffee daily. Her internist diagnosed anemia and high blood cholesterol. She is taking iron and Lipitor. She feels better since she began taking Lipitor, but feels her teeth are too yellow. She recently met a widower who invited her to dinner next week. She is worried about the appearance of her teeth. 1. Working in groups of six, students are asked to write at least four hypotheses about why Mrs. Connor’s teeth are yellow. 2. Students must also determine if whiter teeth are important to the health and well being of geriatric patients. 3. Students must discuss if there a relationship between the need of care and the use of dental services by older patients. 4. A student group will then outline its recommendations and a rationale for the treatment plan to be presented to Mrs. Connor at her next dental appointment. Teachers must recognize that not all students will apply critical thinking skills at the same rate they learn these skills. Thus, instructional methods and objectives need to match students’ cognitive and experiential abilities while trying to stretch students to their growing edge 61. Students’ capacity for self-directed learning (SDL), which is required to implement reflective judgment, underlies many of the critical thinking skill dispositions 62. There is evidence that the students who routinely use the “learn by doing” approach to explore problems develop more sophisticated SDL than students in lecture-based curricula 63. The reflection element of critical thinking is considered essential to clinical judgment 64. Tanner asserts that using the skills associated with reflective thinking prepares students for ill-structured or ambiguous problems that they are likely to encounter in clinical practice 65. Problem-based learning (PBL) is a popular instructional strategy for promoting collaboration and reflection and negotiating different and individual constructions of knowledge. Some researchers assert that PBL is best used when problems are unsolvable or when they generate many individual constructions of knowledge that appear valid66. However, using only problem-based learning to teach critical thinking skills may not be enough. This instructional strategy does not necessarily equip students with the ability to analyze or critique a given situation or the information with which they are been provided. A variety of instructional strategies that give students the opportunity to think aloud, role play, prioritize alternatives, communicate conclusions effectively, simulate, or defend the logical basis of their thinking is recommended to foster students’ ability to use critical thinking. Asking students to apply their understanding of dental and medical knowledge to treatment planning and diagnosis is not an example of CTS. However, asking students to determine differential diagnoses of caries and periodontal disease among patients at various stages of lung cancer requires the ability to reason and justify particular treatment plans or demonstrate critical thinking skills. Habits of the students who demonstrate critical thinking are: (a) Making logical inferences (b) Offering opinions with reasons (c) Evaluating (d) Grasping principles (e) Classifying (f) Making criteria-based judgments (g) Making evidence-based decisions (h) Reflexivity Case #3—Female with Erythroplakia
Mrs. Jacklin, a 40-year-old female, presents you with a history of SLE and erythroplakia on the left lateral border of the tongue. She states she is experiencing a burning sensation on her tongue. She asks why she is having this discomfort and what she can do to make the sore on her tongue go away. The oral exam shows that Mrs. Jacklin has poor oral hygiene and mild dry mouth (xerostomia) but is otherwise not in danger for oral health concerns. 1. Working in groups of four, students are asked to locate the four most recent references on oral lesions. 2. Using those resources, they are asked to write five or six reasons that the patient is experiencing a tongue lesion and determine what questions they should ask the patient about her personal and social history. 3. Next, they identify questions to ask her about her medical history. 4. Using the information they have acquired, they are asked to generate a list of potential treatment plans and the benefits and limitations of each plan. 5. What should they tell the patient and why? Critical thinking is not:
(a) Applying what you have learned in decisionmaking and treatment planning (b) Keeping students awake, interested, and motivated (c) Linear or step-by-step thinking Critical thinking cannot be taught in a learning environment where the dental educator always lectures, tells students what ought to be undertaken during patient treatment, or shows students how to do a procedure correctly. Some habits of students who do not use critical thinking skills are: (a) Disorganization (in thought processing, preparation, and behaviors) (b) Overly simplistic thinking (“I had enough information. There was no need to ask for additional information.”) (c) Use of unreasonable criteria (“If my belief is sincere, evidence to the contrary is irrelevant.”) (d) Erratic use of facts (Looking only at the area of interest, he offered biased interpretations of the radiographs.) Critical thinking skills can be developed with frequent practice and the use of ill-structured problems and situations that require the ability to recall useful knowledge quickly, use pattern recognition, discern pertinent information, think ahead, and anticipate outcomes and problems while remaining composed so that emotions do not hinder decisionmaking skills. However, it is important to recognize CTS do not develop spontaneously or with maturation. Since strong personality components underlie CT dispositions, what happens if students admitted to colleges of dentistry do not already possess these traits? Teaching Observations
It cannot be assumed that all dental faculty members have global thinking skills themselves. Thus, it is also important to assess faculty members’ critical thinking skills and offer professional development opportunities so that faculty can develop expertise in teaching critical thinking skills 67. These practices should apply to current faculty as well as newly recruited faculty. The goal of teaching critical thinking skills is to raise the level of student instruction and ultimately patient care. A convenience sample of dental faculty was recruited for participation in videotaping their instructional practice. In exchange for their service, participants received written peer observations of their teaching. Faculty in pediatric dentistry, periodontology, oral medicine, and facial pain were recruited. Videotaped Examples of CTS in the Clinic
Observation #1
Looking in: A Pediatric Dentist and a Dental Student
Keep the following questions in mind as you view Observation #1. 1. In what ways does the professor promote the student’s critical thinking? 2. What strategies does the professor use? 3. What other strategies could have been used to promote the student’s ability to use critical thinking? 4. What have you learned about the teaching of critical thinking skills in the clinical learning environment from viewing this video clip? 5. How could CT be further expanded in this scenario? Observation #2
Looking in: A Periodontologist and a Dental Student
Keep the following questions in mind as you view Observation #2. 1. In what ways does the professor promote the student’s critical thinking? 2. What strategies does the professor use? 3. What other strategies could have been used to promote the student’s ability to use critical thinking? 4. What have you learned about the teaching of critical thinking skills in the clinical learning environment from viewing this video clip? 5. How could CT be further expanded in this scenario? Videotaped Examples of CTS in the Classroom
Observation #3
Looking in: Oral Medicine
Keep the following questions in mind as you view Observation #3. 1. In what ways does the professor promote the student’s critical thinking? 2. What strategies does the professor use? 3. What other strategies could have been used to promote the student’s ability to use critical thinking? 4. What have you learned about the teaching of critical thinking skills in the classroom environment from viewing this video clip? 5. How could CT be further expanded in this scenario? Observation #4
Looking in: Craniofacial Anomalies
Keep the following questions in mind as you view Observation #4. 1. In what ways does the professor promote the student’s critical thinking? 2. What strategies does the professor use? 3. What other strategies could have been used to promote the student’s ability to use critical thinking? 4. What have you learned about the teaching of critical thinking skills in the classroom environment from viewing this video clip? 5. How could CT be further expanded in this scenario? Vignettes
Vignette #1
Looking in: Structure and Function of Body Systems
The professor is chewing gum, and class has not yet begun. Students are milling around
the room, conversing with one another. The professor lowers the screen, and the slide
titled "Motor Systems: Pyramid" appears.
Although class has officially begun, the professor states, "We are actually stalling for time and waiting for more handouts. There is a practical exam for neuroscience coming up, but not until the last day of the course. We will meet in the wet lab on Friday at 8:30 and will cut up some brains; there will be lot for your family. This will be mainly for amusement; we're just going to cut them up. So watch for that email announcement about the lab. We only have one brain per group. Take some precaution. Formaldehyde is fairly toxic, especially to your eyes and skin.” The professor begins the presentation. “Today we are going to talk about motor systems, mainly the anatomy of the ears and eyes and voluntary movement, all of which can be broken up into voluntary reflexes. Everything begins in the cortex.” He describes the pre-central gyrus and states he'll cover the structures and functions involved in voluntary movement, show the neural pathways, and the entrance and exit points. First, he shows the transverse brain stem. "This is the most difficult part of the brain; it is interrupted by lots of fiber." He does not face students while he shows slides. The professor continues to explain what structures appear in the brain and how the angle of cut will reveal specific structures. He quickly explains the functions of selected structures in the brain. “If you are following along in the book on page 104, here you will see the cerebral peduncle.” He shows the longitudinal fiber of the pons and highlights on the slide the pontine nuclei. The professor tells students that rather than using the term "superior peduncle," it is now called the “longitudinal fibers of the pons.” He shows them another, larger slide of the previous slide, and then he draws an illustration on the board, but he does not identify the structures. Throughout the lecture, the side of his body faces the audience. “The left side of the brain controls the right side of the body. Everything crosses over, and not everything has this arrangement in the visual space.” He continues to explain the structure of the brain and illustrate on the white board. “You rarely have control of the individual muscles, because it is all organized at a neuronal level,” the professor states. He shows a slide that illustrates the basal ganglia and points outs the subthalamic nucleus and the substantia nigra, "which appears white and is always in the same place." He compares "substantia nigra" to moon pie and asks the students, "Do you know what a moon pie is?" Next, he discusses sensory cerebellum input. “When you talk about motor systems, you have to think about the cerebellum. No one knows much about it, but the cerebellum is important to programming muscles to move at certain rates and velocities in movement.” He continues, “The primary fissure separates the cerebellum into anterior and posterior lobes, sometimes called hemispheres.” He points out nodules, explains their functions, and continues to disseminate information rapidly while facing the screen. "So the cerebellum is going to get a lot of sensory input.” He continues to provide an overview of structures and functions of the brain without pause. "We talked about this earlier.” His voice trails off. “Remember that the cerebella peduncles connect the brain stem. The other source of cerebellum input is the cerebral context. All of this information isn't very good until we do something with it. Then there is the cerebellum output. The Purkinye cells are going to relay this information, and the output path of the cerebellum is the superior cerebellum peduncle that crosses over the path and passes into the red nucleus. Some of the other passes over into the ventro-lateral nucleus.” He concludes. Following the presentation, the professor presents five slides (without identifying information) and asks students to identify structures that he discussed during this session. He pauses between each slide, yet none of the students respond. 1. Describe the way in which the teacher provides instruction. 2. What are some instructional strategies that the instructor could have used to promote critical thinking skills? After you answer these questions, you may wish to review Appendix A. Vignette #2
Looking in: Evaluation of Clinical Judgment
The professor dims the lights in the classroom and says, “This month we are going to talk about dental malpractice." He tells students that he does dental malpractice with about ten firms around the state. "I've got a case that I’m going to pass out to you at the end of the class for your homework. As you read this, you'll get a sense of how these things unfold. Bear with me. I am going to discuss some basic law information first." He reviews types of public and private law, and he shows the purpose and characteristics of public and private law on PowerPoint slides. He points out different types of private laws (contract, property, and tort) and defines tort as "a civil wrong against an individual.” He describes negligence: "duty of care." He continues to read from slides and asks, "Are there any questions?” Without pausing, he continues, "If you have any questions, OK, but don't make them too hard." Next, he describes standard of care and explains that there are things customary in patient dental care. Following this, he discusses the definition of malpractice and continues to provide an overview of legal terminology and legal procedure. He points out to students that when they are reviewing a plaintiff’s petition, it is important to not write anything down, and that they should first discuss the information with the attorney. "If you write anything down at this point, it will be introduced as evidence." The professor continues this overview with a discussion about statutes of limitation. "Well, you say, ‘Ya know, I don't want to know all this stuff.’ However, when you get that diploma you're supposed to know all of this stuff. Lawsuits are expensive. It is hard to practice when you have a lawsuit hanging over your head, and they will charge you for every single minute they are working on your case. It is a very involved process." He describes advantages of a settlement. "Litigation is civilized warfare, because you can't go out and shoot each other at noon anymore." He explains that the revenge factor is prominent in most lawsuits. He concludes the presentation with a George Bernard Shaw quote, “the greatest problem of communication is the illusion that it has been accomplished.” The last slide reads: Questions? Sub group assignment. “Does anyone have any questions about your assignment? You won't need any library stuff. I hope you think that this is kind of interesting. See you Thursday.” 1. Describe the way in which the teacher provides instruction. 2. What are some strategies that the instructor could have used to promote critical thinking skills? After you answer these questions, you may wish to review Appendix A. Vignette #3
Looking in: Oral Medicine
The professor greets his students. "OK, good morning, everybody.” Without pausing, he asks for two volunteers. Two students volunteer and walk up to the front of the room. One student reads a patient case aloud, while the other student writes on the board the relevant details. The student writes “inflammation” on the board. “When we see inflammation, what do we think of?" the professor asks. One student replies, “Abscess.” The professor repeats her reply and adds "cellulitis." Symptoms
Dental concerns
increased swelling upper right eye tooth Medical history
Clinical exam
The professor asks, "Why did the patient have the pain before the swelling? This is very important information, because the patient may call you in the middle of the night before pain occurs." The professor tells students that the patient has swelling contained in intraoral space. "When you see radiolucenox, what does this mean? The tooth is necrotic; it is an abscess. If the tooth is nonrestorable, what's the treatment?” “Extraction,” the students reply. “Right,” the professor says. “The patient has a 101.5 degree temperature. Guys, does he have a fever?” Students reply, “Yes.” “Is it a high fever?” the professor asks. "We aren't going to discuss the case right now. Look up Dialenese and Prilosec in the oral pharmacotherapeutics book. You can get it from your book or computer. Think about drug interaction, antibiotics, and analgesics. What about anti-hypertension drugs? Then think about the effect of infection on diabetes and diabetes on infection. Remember the meaning of two-way interaction. I expect you to be ready on Friday. If you have any questions, raise your hand." The class is silent. "OK, great." 1. Describe how the teacher provides instruction. 2. What are some strategies that the instructor used to promote critical thinking skills? After you answer these questions, you may wish to review Appendix A. Vignette #4
Looking in: Endodontics
Another professor presents the following case to the students. She states that a patient presents and complains of sensitivity to hot and cold in the maxillary right quadrant. The patient asks the dentist for a pain prescription. The professor asks the students, “What is the next step? Write on a sheet of paper what questions you have before proceeding with this case.” After giving them two minutes to write their questions, she asks students to share what they have written. After five seconds, nobody has volunteered to share. She continues to wait and probes the students by asking other questions. “What are you thinking? What other information do you need?” Twenty hands are immediately raised. One student shares, “I would want to do a percussion test.” The professor states, “Good. Now, what else?” Another student replies, “Does the patient have sinus problems?” Another student volunteers, “I would want a radiograph.” The professor asks, “Why?” Another student suggests that the area be palpated. Next a student asks if this patient has had previous endodontic treatment. Another student asks if the patient has any deep cavities. One student asks if the patient has a drug abuse history. The professor asks the students to form groups of four, rank the suggestions that have been provided from most important to least important, and come up with a differential diagnosis. The professor moves from small group discussions back to the large group. She puts a radiograph on the board. The radiograph shows radiolucency on tooth #4 at the apex and that the tooth has had previous endodontic treatment. The professor then asks each student to write down how he or she would communicate diagnosis, treatment plan, and cost to the patient. 1. Describe how the teacher provides instruction. 2. What are some strategies that the instructor used to promote critical thinking skills? After you answer these questions, you may wish to review Appendix A. Avenues for Research
While experts continue to debate whether CT is a learned skill or developmentally hard-wired, perhaps dental educators could test the notion. The following experiment is suggested for discovering whether dental curriculum helps students without CT dispositions become more proficient in critical thinking skills. • All incoming dental students take the CCDTI and the CCTST or the HSRT during the first weeks of school. • Double-blind matched-pair samples of students with and without CT training could be evaluated periodically (perhaps twice yearly in years one and two and twice each year in years three and four) to determine if their ability to reason has improved. • An expert panel could rate the reasoning skills of students solving practice-based problems commensurate with their year of training. • Mean changes between the two groups could be compared from year to year. An experiment of this sort would address the lack of research on students’ development of CTS and concerns about the validity of CTS assessment instruments. (Inter-rater reliability would need to be established among the expert panel prior to the experiment.) Before the end of the fourth year, students with and without CTS could take CCDTI and CCTST or HSRT tests again. Mean changes between the initial and final tests, as well as expert panel ratings, could be compared. Of course, dental educators should design and conduct their own studies. Critical Thinking and Assessment
As faculty seek to make CTS the gold standard and the aim of dental education, it is important to consider how much time and effort they will invest. It is also important to consider the purpose of formal assessment. The purposes of assessment can range from diagnosis to research and accountability. For example, asking students to take critical thinking skills test inventories allows researchers to diagnose students’ critical thinking skills. This information could be used to make decisions about where to focus instruction. Also, test scores could be shared with students so that they become aware of their CT strengths and weaknesses. The scores resulting from administration of a critical thinking skills inventory midway through students’ program, or at the end, can inform teachers about the effectiveness of their efforts to teach students CTS. When critical thinking scores become available, researchers can explore how instructional practices or the design of the curriculum influenced outcomes. For example, qualitative inquiry could be used to examine the amount of time used (e.g., by documenting the frequency of critical thinking strategies) to develop students’ CTS in didactic or clinical learning environments and compared to empirical changes in students’ CTS. Qualitative inquiry could also be used to interview faculty and students about the quantity or quality of instruction aimed at developing students’ CTS. Providing information about students’ CTS might also result in holding dental schools accountable for the students’ critical thinking skills prowess 83. Currently some dental schools are participating in a study that will correlate third and fourth year dental students’ critical thinking skills as measured by the CCTST with their GPAs and National Board scores for Part I and Part II. As more dental schools participate in studies like this one, information about the usefulness of the CCTST measure may become better known. However, because data have not yet been collected, publications may not be available until 2012. In a study about the predictive validity of the CCDTI and CCTST on dental hygiene students’ performance on the National Board Dental Hygiene Exam (NBDHE), William et al. reported that CCTST explained a statistically significant (p < .05) amount of the variance (exceeding GPA, number of college hours, and student’s age) in students’ (n = 76) multiple-choice and case-based NBDHE scores 84. The CCDTI scores were not a significant predictor of either outcome. The CCTST and HRST are measures of general CTS not specific to dental skills. Other researchers may develop a measure of critical thinking that specifically measures dental skills. Such an endeavor is likely to take several years. More studies in dental schools are needed to explore how instruction leads to changes in students’ dental critical thinking and whether variables like GPA, demographics, or board scores predict pre-test to post-test changes in mean scores. Dental schools might also consider qualitative studies of instruction in conjunction with using the CCTDI and CCTST; the HRST, the CCTDI, and CCTST; and the PJRF or the HRST and CCTST. It is important to point out that the use of pre-test and post-test comparisons are also fraught with problems. For example, if a control group is not used, then the findings are dubious. Also, as Ennis points out, “The use of the same test for pretest and posttest may alert students to the test questions" 85. Conclusions
Depending upon point of view, critical thinking has different meanings. From a philosophical perspective, critical thinking is the norm of good thinking. From a psychological perspective, critical thinking is higher order thinking skills, and from a sociocultural perspective, critical thinking skills are the “capacity to recognize and overcome social injustice” 86. Paul claims that critical thinking is not an aim of education, but the aim 87. In this toolkit, CT has been described predominately as a set of skills and dispositions. However, it is important to point out that, while CTS can be taught, whether CTS are learned is dependent upon a host of factors, such as students’ predispositions and developmental readiness, the nature of the learning environment and learning activities, and whether instruction is tailored to students’ developmental levels, among others. Another concern related to this discussion is the transferability of CTS. Some scholars assert that CT is the same across disciplines 88, 89. Others argue that there is no set of generalized thinking skills and that CT cannot be taught in isolation from subject matter 90. Brown posits that students cannot progress in the development of their thinking unless they are given something to think about 91. Giving students something to think about is central to the development of CTS. Instructional strategies that can promote the development of CTS are paying attention to students’ epistemological beliefs, promoting active learning, using a problem-based curriculum, and stimulating interactions among students in the study of real-life problems. Allowing students to contribute their insights to discussion with other students and the instructor is likely to have a significant influence on the development of CTS. Asking students to share their thinking verbally aids in understanding their frames of reference and selecting appropriate strategies to expand their capacity for critical thinking. Also, having students formulate their ideas in essay exams rather than identify known information in multiple choice exams will stimulate public thinking. This can also produce an influential effect. It is necessary for organizations to commit to teaching in ways that support CTS. Some instructors will buy in to this transformation, but others will need professional development, consultation on rewriting learning experiences and expanding teaching repertoires, administrative support, and revised expectations among supervisors that teaching supporting CTS is a requirement in the academy. ADEA can maintain a database of evidence-based best practices and serve as a resource for faculty across the United States and Canada. ADEA can also be a source for web-based cases, tutorials, and teaching technique videotapes to support professional development. To create a database of evidence-based practices, dental school faculty may need to think differently about conducting research and collaborating with scholars in colleges of education, health, and human performance to study teaching and instructional practices. From a programmatic perspective, dental education programs need to become learner-centered. The curriculum will need to engender actively engaging students and helping them assume greater ownership of their learning 92. Professors need to use strategies that build self-regulated learners and move away from teacher-centered and discipline-focused instruction. They need to encourage student dialogue, discovery, and curiosity. Curricula need to be designed so that students have ample opportunities to analyze tasks, set appropriate goals, monitor and control their behavior during performance, make judgments about their progress, and alter their behavior based on these judgments. Professors need to develop curricula that move toward integrated, contextualized delivery of content that embeds basic science as well as treatment planning and patient care. With enough problem-solving activities and opportunities to reason aloud, students can learn to emulate professors, strengthen poor problem-solving skills, learn appropriate problem-solving skills, self-monitor, and diagnose and treat patients’ oral health problems 93. To assist student development of CTS, need to model the value of scientific discovery and lifelong learning in their interactions with students, patients, and colleagues 94. Teaching students to use critical thinking skills will also require dental educators to reflect upon their beliefs about how they teach. It is crucial to recognize that both students and faculty make decisions based upon their current frames of reference. Understanding an individual’s attitude and willingness to consider and weigh alternative points of view is an essential component of teaching students how to develop and use critical thinking skills. Some faculty may fear their own imperfections. For some, making the changes to teaching described in this toolkit may create discomfort. Others may show an aversion to making any type of change 95. However, it must be stressed that teaching that fosters critical thinking skills has implications for the quality of not only education, but also patient care, education of patients in self-care, and overall systemic health in our society. Teaching students to use critical thinking requires careful planning prior to instruction, selection of instructional strategies matched to desired learning outcomes, provision of opportunities for students to think aloud or in writing among others to show how and what they know, and challenges for students who demonstrate simplistic or unreasonable thinking. When faculty model the process of thinking out loud, students learn how to use similar thinking processes on their own. Showing students how to use critical thinking skills aids in development of self-regulated learning. The combined number of empirical studies on critical thinking and coursework remains small. There is a need for better quality and more studies in this area to create a sufficient bank of evidence that even a moderate investment in teaching critical thinking can lead to enhanced reasoning skills 96. Once again, dental education has an opportunity to change the course of its history. Helpful Links
A Super-Streamlined Conception of Critical Thinking Academic Success Center, Oregon State University American Educational Research Association Critical Thinking Skills Definitions and Assessment Educational Resources Information Center International Center for Assessment of Higher Order Thinking National Council for Excellence in Critical Thinking Office of Faculty Development and Organization, Michigan State University Revised Bloom’s Taxonomy of Cognitive Levels The National Center for Teaching Thinking The Power of Critical Thinking Appendix A. Author's Impressions of
Vignettes

Vignette #1
The professor provides a continuous stream of information. He does not elicit or ask students questions throughout. He presents material in almost a run-on fashion, without pausing, and does not take time to assess student comprehension. He does not provide examples that illustrate the connections among oral health, patient care, and the information he is disseminating. Vignette #2
During instruction the professor controls the pace and flow of information that is disseminated. The entire period is spent discussing legal definitions and concepts. The professor does not assess student comprehension, nor does he give students experiences directed at promoting critical thinking skills or opportunities to be active in learning. The professor does not pose low- or high-level questions. Vignette #3
The professor begins class by soliciting volunteers, who read and write a description of
the case study on the board. The professor gives students some prompts to use while
analyzing the case, and he provides them with some questions to guide their inquiry.
Instruction is interactive. The professor prompts students to reason about the appropriate
care for the medically compromised patient as well as the impact and contraindications of
drugs on the care of that patient. However, rather than expect students to process the case
in class, he has provided them with an exercise outside of class to: (1) think through this
case, (2) make treatment decisions that consider the patient’s symptoms, dental and
medical conditions, and oral exam, and (3) formulate an appropriate and justifiable
treatment plan to present during the next class session. This professor combines a case-
based scenario with content while promoting the acquisition or use of critical thinking
skills and creates a classroom atmosphere that encourages student ownership of learning.
Vignette #4
The professor provides a case to the students and then asks them to write down their next
steps. She asks students to volunteer their thinking and when nobody does, she provides
wait time. When students do not respond, the professor prompts them by asking what
other information is needed. Students begin to volunteer and share their thinking aloud.
After receiving a number of suggestions, she asks students to form groups and rank their
suggestions. When the professor reconvenes the whole group, she provides additional
information about the case using a radiograph. She asks more questions and then asks
students to write how and what they will communicate the diagnosis, treatment, and cost
to the patient. The professor creates a climate of inquiry and uses “think aloud” and
written assignments that require students to analyze the problem, provide rationales for
diagnosis and treatment, and compare alternatives.

Source: http://dental.rcm.upr.edu/adeacci/The%20Critical%20Thinking%20Skills%20Toolkit%20was%20developed%20and%20written%20by%20Linda%20S.pdf

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