Evidence and its uses in health care and

research: The role of critical thinking

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We propose critical thinking and decision-making as the tools for making better decisions in
clinical care.

Critical thinking is involved in medical research, medical writing, and communication with
patients and lay stakeholders.

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Sackett et al. defined evidence based medicine as the use of current best evidence in
making decisions about the care of individual patients, and its integration with individual
clinical expertise. They also stated that physicians need to develop their critical thinking skills.

This case had a good outcome, although the patient might have suffered permanent
neurological injury requiring lifelong catheterisation for urination. The physician faced a
variety of obstacles to ensure optimal patient care, which had little to do with EBM.

Our scenario illustrates some key points about critical thinking. It is important to keep in mind
that a patient's symptoms may have more than one cause, and that a physician's diagnostic
task is to gather data that will determine which cause is responsible for the patient's problem.

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Medical practice involves critical thinking, which involves deciding what to believe and/or
what to do. Various lists of abilities and criteria are available to measure critical thinking skills
and dispositions.

The editors of leading medical journals have called for critical thinking in medical research
and medical writing, and have proposed a contemporary approach to argument along the
lines used by the philosopher Toulmin.

A theory of dual process thinking states that we have two general modes of thinking, one
fast, reflexive, autonomous, and the other slow, deliberate, rule-based. The mechanisms that
underlie System 1 thinking are based on associative learning and innate dispositions.

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Contemplative, fully reflective thinking is appropriate in internal medicine, psychiatry, public
health, and other specialties, in etiological research and clinical trials, and in writing up the
results of such research. A shortcut or heuristic approach is appropriate in emergency
medicine, surgery, and obstetrics.

No responsible physician would engage in reflective thinking on every occasion when a

decision had to be made. In extreme situations, a shortcut may be used, involving pattern
recognition, steepest ascent reasoning, or algorithmic paths.

To train future generations of health professionals as critical thinkers, clinical teachers

should know how to run a Socratic discourse, and should be aware of contemporary models
of argument. They should also engage with their interns and residents in meaningful
discourse.

The best available evidence should be used to guide care decisions, but we should also
consider the patient's biology, values and preferences, the clinical or community setting, and
other circumstances.

Medical students should be taught how to think critically, and should be exposed to
contemporary approaches to 'rational' medical decision making. This can be done by offering
separate courses on critical thinking and decision making, or by spreading learning, practice
and experience in critical thinking and decision making across various specialties.

Similar education is required for framing grant applications and research reports as
reasoned arguments, especially in the discussion section. We may see a day when most
medical journals are reflective journals.

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Almost four decades ago, Feinstein asked what kind of basic science clinical medicine
needs. Recently, Redelmeier et al. proposed cognitive psychology.