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Teaching Clinical Reasoning and Critical Thinking: From Cognitive Theory to Practical
Application

Jeremy B. Richards, MD, MA, Margaret M. Hayes, MD, Richard M. Schwartzstein,

MD

PII: S0012-3692(20)31449-5
DOI: https://doi.org/10.1016/j.chest.2020.05.525
Reference: CHEST 3197

To appear in: CHEST

Received Date: 31 January 2020

Revised Date: 4 May 2020
Accepted Date: 8 May 2020

Please cite this article as: Richards JB, Hayes MM, Schwartzstein RM, Teaching Clinical Reasoning
and Critical Thinking: From Cognitive Theory to Practical Application, CHEST (2020), doi: https://
doi.org/10.1016/j.chest.2020.05.525.

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 1 Abstract word count: 237

2 Manuscript word count: 3999

4 Title: Teaching Clinical Reasoning and Critical Thinking: From Cognitive Theory to Practical

5 Application

6 Short title / running head: Teaching clinical reasoning and critical thinking

8 Author list: Jeremy B. Richards, MD, MA, Margaret M. Hayes, MD, Richard M. Schwartzstein,

9 MD

10 Affiliations: Center for Education, Shapiro Institute for Education and Research, Department of

11 Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School

12

13 Corresponding author: Richard M. Schwartzstein, MD

14 Address: 330 Brookline Avenue, KS-B32, Boston, MA 02215

15 Email: rschwart@bidmc.harvard.edu

16

17 Summary conflict of interest statements: The authors, Jeremy B. Richards, Margaret M.

18 Hayes, and Richard M. Schwartzstein, have no relevant conflicts of interest to report.

19

20 Funding: No external funding applies to this manuscript.

21

22 Notation of prior abstract publication / presentation: Not applicable.

23
 1 Abstract

2 Teaching clinical reasoning is challenging, particularly in the time-pressured and complicated

3 environment of the Intensive Care Unit. Clinical reasoning is a complex process in which one

4 identifies and prioritizes pertinent clinical data to develop a hypothesis and a plan to confirm or

5 refute that hypothesis. Clinical reasoning is related to and dependent on critical thinking skills,

6 which are defined as one’s capacity to engage in higher cognitive skills such as analysis,

7 synthesis, and self-reflection. The authors review how an understanding of the cognitive

8 psychological principles that contribute to effective clinical reasoning have led to strategies for

9 teaching clinical reasoning in the ICU. With familiarity with System 1 and System 2 thinking,

10 which represent intuitive versus analytical cognitive processing pathways, respectively, the

11 clinical teacher can use this framework to identify cognitive patterns in clinical reasoning. In

12 addition, the authors describe how internal and external factors in the clinical environment can

13 affect students’ and trainees’ clinical reasoning abilities, as well as their capacity to understand

14 and incorporate strategies for effective critical thinking into their practice. Utilizing applicable

15 cognitive psychological theory, the relevant literature on teaching clinical reasoning is reviewed

16 and specific strategies to effectively teach clinical reasoning and critical thinking in the ICU and

17 other clinical settings are provided. Definitions, operational descriptions, and justifications for a

18 variety of teaching interventions are discussed, including the ‘one minute preceptor’ model, the

19 use of concept or mechanism maps, and cognitive de-biasing strategies.

20

21
 1 Introduction
2

3 Clinical reasoning is a complex process that involves identifying pertinent clinical data,

4 prioritizing these data to develop a hypothesis or conclusion, and developing a plan to confirm or

5 refute the clinical hypothesis.1,2 The ability to engage in effective clinical reasoning is influenced

6 by internal factors such as curiosity, motivation, fatigue, and burnout, as well as external factors

7 such as time constraints, environment, distractions, and team dynamics. Clinical reasoning is

8 both related to and informed by critical thinking skills, which describe one’s ability to employ

9 higher cognitive processes such as analysis, synthesis, and self-reflection – skills necessary to

10 demonstrate effective clinical reasoning.3

11

12 In this review, we describe the foundational cognitive principles underlying critical thinking, the

13 context in which clinical reasoning occurs, and educational interventions designed to develop

14 learners’ clinical reasoning skills. Finally, we identify areas for further research into teaching

15 and assessing clinical reasoning. Although the focus is on clinical reasoning in the intensive care

16 unit (ICU), which offers a particularly rich environment to teach and practice inductive

17 reasoning, the educational interventions and skills described herein are applicable to all medical

18 environments and all medial learners.

19

20 Overview - Definitions

21 The terms “critical thinking” and “clinical reasoning” are used frequently in medical education,

22 often synonymously, but they are rarely explicitly defined. At a national conference in 2011,

23 teams from 9 medical schools defined critical thinking as “the ability to apply higher cognitive

24 skills (e.g., analysis, synthesis, self-reflection, perspective taking) and/or the disposition to be
 1 deliberative about thinking (being open-minded or intellectually honest) that leads to action that

2 is logical and appropriate”.3 The elements of clinical reasoning, a less clearly defined construct,

3 include both the biomedical knowledge that is the foundation of clinical medicine, and a range of

4 thinking skills.4 While medical schools, particularly in the pre-clerkship curriculum, and

5 residency programs have historically focused largely on content transfer (knowledge) as the core

6 of their educational mission, thinking skills have not typically been explicitly addressed.

7 Memorization and recall of material have been highly prioritized, but not clinical reasoning. In

8 contrast, clinical reasoning was assumed to be acquired as part of the apprenticeship phase of

9 training; one learned clinical reasoning by taking care of patients and observing how mentors did

10 it.

11

12 The hypothetico-deductive approach to thinking has been the basis of medical school training for

13 decades. It emphasizes a quick determination of differential diagnoses (the hypotheses), from

14 which one deduces what one knows about each disease; aligning the patient’s symptoms,

15 physical findings, and laboratory data with diagnostic hypotheses. The best match is the answer.5

16 But what if the match isn’t that perfect? What if you only can think of two possible diagnoses?

17 What if something doesn’t fit? And what is the impact of the patient the trainee saw yesterday or

18 last week on the diagnostic hypotheses (i.e., is the trainee being influenced by cognitive biases or

19 a predisposition to respond in a particular way)?6

20

21 In contrast, other professionals, such as engineers, who face daunting “diagnostic” problems, use

22 an inductive approach.7 Using inductive reasoning, one works with data (facts) to create

23 intermediate hypotheses that explain mechanisms of function, not immediately worrying about
 1 the final answer. These hypotheses can be tested, and new hypotheses created, until a final

2 solution to the problem is determined.

4 Probabilistic thinking also plays a role in medical decision-making. Bayesian analysis, making

5 use of data from clinical epidemiology, can be a useful instrument in one’s thinking toolkit in

6 many situations.8,9

8 We believe that effective clinical reasoning is best represented as a combination of hypothetico-

9 deductive, inductive, and probabilistic approaches (Figure 1). Of these, medical educators have

10 taught both evidence-based medicine and Bayesian analysis most explicitly, but this approach is

11 limited in solving the most difficult or atypical cases, particularly when learners are struggling to

12 even understand the patient’s problem. Thus, the focus of this review will be on the cognitive

13 science underlying clinical reasoning and the approaches to teaching hypothetico-deductive and

14 inductive thinking, and the benefits and pitfalls of these strategies.

15

16 Thinking Fast/Thinking Slow

17 Confronted with a new problem, the brain quickly scans the situation to see if it recognizes a

18 previously encountered pattern. This process is extremely fast (typically occurring within a

19 second or two), often unconscious, and frequently accurate. We get through our days, recognize

20 friends and family, and manage many tasks this way, using what is called System 1, or

21 ‘intuitive’, thinking.10 This system, along with the use of heuristics, or cognitive ‘rules of

22 thumb’, helps us navigate complex problems with uncertain probabilities, but can lead to

23 systematic errors.10 Neuroimaging studies suggest that when making decisions using System 1
 1 thinking, such as quickly diagnosing chest radiographs, we utilize deeper portions of the brain

2 not associated with higher-order cognitive processing.11 There is minimal research about the role

3 of System 1 versus System 2 thinking in the ICU setting, and no studies of which we are aware

4 that relate the different types of thinking with clinical outcomes.

7 System 1 thinking does not have to be taught, per se; it evolves as the brain learns more patterns.

8 Its use is often facilitated in medical education by teaching “illness scripts,” which are

9 prototypical clinical patterns of particular diseases.12 ‘Routine expertise’ is defined as having

10 built knowledge through experience, and trusting that one’s knowledge is entirely sufficient to

11 address all future problems.13 In clinical medicine, “routine experts” have large stores of

12 knowledge in the form of illness scripts and can access these scripts quickly when presented with

13 a patient or problem.13 System 2 thinking, in contrast, must be developed by the learner, either

14 implicitly (e.g., when behavior is modeled but not described), or explicitly in sessions designed

15 to support specific thinking skills. Individuals who are able to apply System 2 reasoning can

16 solve problems and explain cases characterized by issues they have never encountered before.

17 This type of thinking is described as “adaptive expertise” and is characterized as flexible and

18 innovative.13

19

20 As System 2 thinking is analytical, deliberative, and conscious, the neurological loci for these

21 processes are believed to exist in the frontal cortex.10 Rather than being based primarily on

22 pattern recognition, System 2 thinking is, at its best, represented by inductive reasoning and the

23 creation of hypotheses rooted in understanding of foundational principles or concepts. This type

 1 of reasoning, when used to evaluate medical problems, often focuses on intermediate hypotheses

2 rather than jumping immediately to a diagnosis. For example, a hypotensive patient with warm

3 extremities and normal capillary refill suggests high cardiac output and normal to low systemic

4 vascular resistance. Having made that formulation, one can consider diagnoses consistent with

5 that physiology, such as sepsis or neurogenic shock, and exclude other processes such as

6 hypovolemic or cardiogenic shock. While this thinking is “slow” compared to the intuitive,

7 almost immediate response provided by System 1 thinking, it can often be done in seconds to

8 minutes.

10 Simpler forms of System 2 thinking include a forced pause when evaluating a patient, sometimes

11 referred to as a “cognitive time out,”14,15 to ask, “what else could this be?” Such a forced pause

12 is intended to invoke System 2 thinking. Practicing physicians skilled in both types of thinking

13 will often move quickly back and forth between System 1 and 2. A qualitative and observational

14 study of 28 surgeons described how they transitioned from System 1 to System 2 behaviors in

15 the operating room.16 Surgeons described or were observed “stopping” or “fine-tuning” (e.g.,

16 slowing down both physically and cognitively) during challenging or effortful portions of the

17 operation.

18

19 Cognitive Bias and De-biasing Strategies

20 Cognitive biases, are subconscious reflexes that influence conclusions, especially those reached

21 using System 1 thinking.16 Although first recognized in Medicine in the 1970s,17 cognitive biases

22 were well-described in psychology, economics, and marketing years earlier.18 Heuristics

23 contribute to many of the errors associated with System 1 thinking and errors associated with
 1 common teaching strategies used for clinical reasoning that rely on hypothetico-deductive

2 reasoning and illness scripts.

4 Cognitive biases have been shown to contribute to diagnostic errors in over 70% of cases, based

5 on studies assessing the role of cognitive errors and biases in malpractice claims.19–21 While over

6 100 biases have been described,22 the ones that are particularly prevalent in the ICU are

7 described in Table 1.23 These cognitive biases lead to thinking errors, which are translated to

8 diagnostic errors, such as delays in diagnosis and mis-diagnosis.24–26

10 Unaware of their influence on cognitive processing, many physicians do not appreciate the

11 impact of bias on their clinical decision making,27. Most people are not aware they are engaging

12 in heuristics or cognitive biases most of the time.28 These mental short cuts and superficial

13 assumptions may be adequate for making clinical decisions when one is confronted with

14 “typical” cases for which System 1 thinking is sufficient.24 However, when a clinician is faced

15 with an atypical case, which can be among the most challenging and high stakes clinical

16 scenarios, cognitive biases may be exposed. Therefore, it is important for physicians to have

17 strategies to mitigate the false reassurances provided by cognitive biases. Learning to

18 consistently and effectively pursue inductive reasoning, even when a case may seem to be

19 “straightforward”, is critical to overcoming the effects of cognitive biases on clinical reasoning.

20

21 De-biasing or cognitive forcing strategies are critical tools for eliminating the most common

22 thinking mistakes. Although these strategies require effort27, physicians can and should be taught

23 to monitor their thought processes for biases so that they can self-regulate.24 One of the most
 1 useful de-biasing strategies is metacognition, which is defined as thinking about one’s thought

2 processes, e.g., “I might be considering diagnosis X is correct because I missed a case of this

3 last week.”27,29,30 Other de-biasing strategies include explicit efforts to acknowledge one’s

4 uncertainty about a given clinical scenario and to consider alternative diagnoses.27,29,31,39

5 Effectively communicating diagnostic uncertainty when providing sign-outs or hand-offs is a

6 specific opportunity to clearly describe uncertainty to other providers, and can contribute to

7 creating a more accurate shared mental model of a patient’s clinical circumstances. In addition,

8 we encourage our trainees to use the word “hypothesis” instead of “diagnosis” since

9 “hypothesis” implies uncertainty about the proposed solution, which needs to be scrutinized and

10 tested; in contrast, the term “diagnosis” is often associated with a sense of finality. This semantic

11 substitution may lead to a reduction in anchoring; the more physicians can tolerate uncertainty,

12 the more comfortable they feel not having “one” right answer or “one” explanation.

13

14 Other strategies include a focus on accountability32 and feedback.22,23,33 In the face of duty hours,

15 shift work and frequent handoffs, outcomes of diagnostic and therapeutic hypotheses are not

16 always available to the clinician who formulated them. Furthermore, the time-pressured

17 environment in which handoffs frequently occur may increase the risk of diagnostic momentum

18 contributing to faulty reasoning. One strategy to decrease the risk of duty hours and handoffs

19 affecting clinical reasoning is for all physicians to ascertain the progress of patients for whom

20 they have provided care and seek feedback on whether or not one’s thought processes were

21 correct. In addition, quality improvement and assurance processes can influence and support

22 effective decision-making in the clinical setting. These components of systems-based practice

23 can complement the individual’s efforts to avoid cognitive biases and faulty clinical reasoning.
 1

2 Strategies for teaching clinical reasoning and critical thinking skills

3 Clinical Teaching Techniques

4 To foster clinical reasoning and critical thinking skills, faculty must help learners develop

5 analytic reasoning skills and habits of life-long self-directed learning. These skills are necessary

6 to identify, prioritize, and justify pertinent positive and negative data from a patient’s

7 presentation. While some authors have argued that critical thinking and clinical reasoning cannot

8 be taught,34 there is no definitive evidence supporting this claim, and others have demonstrated

9 the limitations of the studies on which these claims have been made.21 We contend that the

10 knowledge, skills, and attitudes necessary to learn and effectively engage in effective clinical

11 reasoning are transferrable. These skills will motivate the trainee to engage in effortful clinical

12 reasoning and critical thinking, as well as to independently formulate and answer key questions

13 necessary to manage patients.

14

15 Posing questions to learners is a general strategy for assessing and teaching critical thinking in

16 clinical settings. However, questions that begin with ‘what,’ (e.g., “what is the most common

17 cause of X?”), are generally perceived as threatening by learners, closed-ended in nature, and

18 frequently result in brief answers that do not explain the learner’s deeper understanding. In

19 contrast, prioritizing questions that begin with ‘why’ or ‘how’ will encourage learners to explain

20 their reasoning and provide justification for their answers.23

21

22 A common strategy medical educators employ to encourage learners’ to engage in clinical

23 reasoning is the ‘one minute preceptor’ technique (also referred to as the ‘microskills’ model of
 1 clinical teaching).34,35 The ‘one minute preceptor’ has been well-described, and has been studied

2 in a variety of clinical settings (Table 2).34,35 In the ‘one minute preceptor’ model, the learner

3 must commit to a prioritized differential diagnosis for a patient’s clinical problem, allowing

4 educators to probe and analyze the learners’ clinical reasoning. This technique prioritizes

5 exploration of a learner’s clinical assessment of a patient’s problems or complaints. It has been

6 demonstrated to improve faculty’s ability to evaluate students’ reasoning abilities and to improve

7 the effectiveness of clinical teaching encounters.36 In addition, when done well, with probing

8 questions aimed at evaluating the learner’s understanding of underlying mechanisms of disease,

9 the ‘one minute preceptor’ technique teaches higher level concepts and prompts provision of

10 feedback from faculty to learners.37

11

12 A modification of the ‘one minute preceptor’ is the SNAPPS model.38 SNAPPS is an acronym

13 for ‘Summarize, Narrow, Analyze, Probe, Plan, and Self-study’. Unlike the classic ‘one minute

14 preceptor’ model, SNAPPS is a largely learner-driven methodology, as the learner is primarily

15 responsible for each step in the SNAPPS protocol (Table 3). In this manner, the learner assumes

16 responsibility for the patient-centered discussion, developing autonomy, responsibility, and self-

17 directed learning skills. As with the one-minute preceptor, however, the student’s initial

18 diagnosis may be informed primarily by pattern recognition, and the self-initiated analysis and

19 probing elements of SNAPPS may become superficial and pro forma for many students over

20 time.

21

22 In a randomized trial conducted over an eight month period at a single academic medical center,

23 64 medical students on a compulsory, Family Medicine clerkship were assigned to either use
 1 SNAPPS, a general feedback training approach, or “usual-and-customary instruction”. Students

2 who employed SNAPPS had more concise presentations, a greater number of diagnoses in the

3 differential and number of justifications, higher frequency of seeking information, and greater

4 self-directed learning behaviors.38

6 For both the ‘one minute preceptor’ and SNAPPS, if not done properly, these techniques may

7 reinforce reliance on illness scripts, which may predispose individuals toward System 1 thinking,

8 which may be susceptible to cognitive biases. Furthermore, studies of the long-term impact of

9 these strategies are not available.

10

11

12 Reflection and Reflective Writing

13 Reflective exercises, and reflective writing in particular, are powerful educational tools for

14 developing medical learners’ metacognitive and clinical reasoning skills.39 Reflective writing is a

15 method for helping learners engage in meaningful consideration of their actions and thinking,

16 and leverages the innately human orientation towards storytelling as a means of sharing

17 information and learning from experiences.41 The act of writing requires one to process events

18 and experiences with the intent of relating them to others.42 Reflective writing is not intuitive; so

19 support and training is initially required for learners to be able to effectively engage in and get

20 the most of out of the exercise.39 We have used brief reflective writing exercises in the ICU,

21 including providing learners with time to reflect on and write down their personal learning

22 objectives for the rotation as well as using ‘one minute papers’ at the end of select teaching

23 sessions. We also use systematic team reflection to determine errors in clinical evaluation or
 1 judgment we may have made when patients self-extubate and remain off mechanical ventilation

2 thereafter, i.e., why did we not determine the patient could have been extubated sooner? Was our

3 thinking flawed?

5 Reflective writing has been demonstrated to be well-received by medical students and residents,

6 and has been shown to improve students’ empathy,43 professionalism,44 and narrative reasoning

7 abilities.45 In addition, one study of 41 Internal Medicine residents who participated in reflective

8 writing exercises and small group discussions demonstrated that the residents were able to use

9 reflective writing to identify personal experiences with diagnostic errors and cognitive biases that

10 may have contributed to the errors.46 These effects of reflective writing on learners’ perspectives,

11 characteristics, and clinical reasoning performance underscore the potential role for reflective

12 writing in teaching clinical reasoning and critical thinking skills. For reflection to lead to

13 modifications in future behavior, however, instructors should guide students to develop explicit

14 changes in how they will approach clinical problems in the future.47

15

16 Concept or Mechanism Maps

17 Concept maps are visual representations of relationships between knowledge and principles. In

18 their classical form (Figure 2), they have a hierarchical structure with the largest or most general

19 form of the topic at the top of the map, and progressive levels of subtopics or component parts

20 are outlined below.48 This type of map assists learners as they organize new information. A

21 different form of concept map used in medical education (Figure 3), termed a mechanism map,

22 links information or concepts based on biological, physiological and pathological

23 mechanisms.49,50
 1

2 Mechanism maps help students develop inductive reasoning skills, by explicitly linking elements

3 of the history, physical exam, and laboratory data in an active and graphic manner.50–52 Rather

4 than ask the learner for a diagnosis, instructors push students to explain how pieces of the case fit

5 together pathophysiologically to account ultimately for all that is being observed. Intermediate

6 hypotheses can be created; anecdotally, we believe this leads to broader thinking and generation

7 of more potential diagnoses. When an element does not seem to fit, the learner is compelled to

8 create additional or new hypotheses to account for the data rather than ignore or jettison the

9 information. In this manner, various thinking errors and cognitive biases, such as premature

10 closure and confirmation bias, can be avoided in the initial analysis of a clinical problem.

11

12 Collaborative work among learners to create concept/mechanism maps mimics the way a clinical

13 team solves problems.51,53,54 Students are fully engaged and the creation of the map becomes a

14 focal point for group interactions. When students or residents struggle to “put a case together”,

15 creating a mechanism map gives them a place to start. By placing the “data” from the case on

16 paper or a screen and then creating links between data elements, foundational biomedical

17 knowledge is retrieved and reinforced, and an explanatory solution can be created, even one not

18 seen before, a characteristic of the adaptive expert.13 One is not attempting to discern a pattern or

19 recall an illness script; rather, the learner is truly “working the problem”, using conceptual

20 knowledge to truly explore the case. Constructing the map is a concrete strategy to explicitly

21 teach diagnostic reasoning. In the context of time-pressured work rounds, one may focus on a

22 portion of a map, such as one component of the patient’s problem, to reinforce analytical skills.

23 We use mechanism maps on rounds in a very targeted manner, both as a means of slowing down
 1 (modeling to learners that we are prioritizing teaching and learning in the moment) and to

2 graphically demonstrate a concept or topic that is difficult for the learners. In the context of

3 rounds, emphasizing key mechanistic relationships (e.g., how a pulmonary embolism can cause

4 shock) with mechanism or concept maps can be done while ensuring that teaching is focused and

5 time-limited.

7 Role-modeling

8 Cognitive biases can impact students, trainees, and attending physicians. Attending physicians

9 can acknowledge the impact of cognitive biases and errors in reasoning, which can be a powerful

10 tool for demonstrating the need for a role of metacognition to students and trainees. “Thinking

11 out loud”, and articulating one’s own uncertainties and thought process, attending physicians can

12 demonstrate how to actively use System 2 reasoning to trainees.

13

14 Context and the Environment

15 Internal Context

16 The personal attributes, characteristics, perspectives, and behaviors of learners are critical

17 components of their readiness and motivation to engage in deeper learning and to participate in

18 effortful clinical reasoning. Specifically, curiosity and motivation are considered to positively

19 influence clinical reasoning and critical thinking skills,55–57 while burnout and fatigue negatively

20 impact the ability to effectively engage in effortful cognitive activities.58,59

21

22 Intellectual curiosity, measured by different questionnaire-based tools, has been demonstrated to

23 decrease during undergraduate medical education,63,64 potentially negatively affecting learners’

 1 clinical reasoning abilities. Burnout and fatigue have been negatively associated with students’

2 and residents’ clinical reasoning abilities,58,59 as the effortful nature of engaging in critical

3 thinking is adversely affected by burnout, fatigue, and lack of motivation. Strategies to assess

4 and minimize burnout in medical students and residents may result in improved clinical

5 reasoning skills, although literature demonstrating such outcomes is lacking.

7 External Context

8 The environment in which learners operate influences critical thinking and clinical reasoning

9 skills. Factors ranging from distractions and interruptions to interpersonal and team-based issues

10 affect learners’ abilities to engage in clinical reasoning and the effectiveness of critical thinking

11 skills. The relationship between the external environment and cognitive capacity is described in

12 cognitive load theory, and specifically the concept of working memory.65 Working memory is

13 one’s capacity to process information, and it can be affected by internal factors, such as the

14 cognitive work of performing a task, and external factors, such as distractions, interruptions, and

15 system-based issues.

16

17 External distractions are particularly influential in predisposing learners to engage in cognitive

18 shortcuts and System 1 thinking.65 One study of Emergency Medicine physicians demonstrated

19 that these providers were interrupted every 3 to 6 minutes during clinical work.66 Interruptions

20 or distractions in the clinical setting result in increased multitasking and decreased focus and

21 attention on important clinical tasks or problems.67 Best practices for addressing workplace

22 interruptions and distractions are not well-described in the literature, although one single center

23 study demonstrated that an interprofessional, workplace-based intervention designed to increase

 1 awareness of and decrease the frequency of interruptions resulted in improved perceptions of job

2 satisfaction and patients’ perceptions of the care they received.68 Clinical reasoning skills and

3 patient-level outcomes, however, were not assessed.

5 Teaching in the ICU

6 The cognitive theoretical topics and educational strategies we describe are particularly pertinent

7 to teaching medical learners in the ICU. The ICU is a complex clinical environment, and learners

8 are challenged to gather and process large amounts of complex information, including

9 physiological data that can support the use of inductive reasoning. Critical thinking skills are

10 necessary to engage in effective patient care in the ICU, and clinicians and educators can help

11 learners develop their reasoning skills by emphasizing the role of inductive reasoning in clinical

12 practice, asking effective questions (using ‘how’ and ‘why’), acknowledging the impact of

13 cognitive biases in clinical reasoning, and using concept or mechanism maps when teaching.

14 These and other strategies can leverage best practices in teaching critical thinking to help

15 learners develop clinical reasoning and decision-making skills in the ICU.

16

17 Future Research

18 The literature describing effective educational interventions for addressing and improving

19 medical learners’ critical thinking and clinical reasoning skills is heterogeneous. Furthermore,

20 many studies describing or assessing educational interventions of clinical reasoning involve a

21 single cohort of learners at a single center. Some have argued that critical thinking and clinical

22 reasoning cannot be taught.69 The studies on which this conclusion is based, however, are fraught

23 with methodological challenges and can be countered by practical experiences.24 Multi-

 1 institutional research describing the effects of educational interventions on learners’ clinical

2 reasoning and critical thinking skills are needed, as are confirmatory studies re-assessing the

3 impacts of previously studied educational interventions.

5 Conclusion

6 Clinical reasoning is a complex cognitive process involving multiple steps, from gathering and

7 prioritizing data, to synthesizing and analyzing disparate information to reach a cogent clinical

8 hypothesis or conclusion. Clinical reasoning abilities are directly informed by and dependent on

9 critical thinking skills, and the cognitive processes of clinical reasoning and critical thinking are

10 inexorably linked. Understanding foundational considerations in cognitive processing, from the

11 role of System 1 and System 2 thinking to the impact of cognitive biases on critical thinking, can

12 allow medical educators to effectively teach clinical reasoning skills.

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19

20

21
1 Figure legends:

2 Figure 1: Overlapping components of clinical reasoning and critical thinking.

3 Figure 2: An example of a classic concept, in which clinical findings and pathophysiologic

4 concepts are linked with connecting words in a hierarchical manner.

5 Figure 3: An example of a mechanism map, in which clinical findings and pathophysiologic

6 mechanisms are linked in an interconnected, multilayered manner.

Table 1. Some of the common biases encountered in clinical medicine and their associated debiasing strategies.
Of note, metacognition is an important strategy to ward off all the listed biases, and as such is not listed in the
Table. In addition to the strategies listed, one should always look for red flags such as data that doesn’t fit, only
one diagnosis coming to mind etc., in those cases one should be stimulated to use inductive reason as explained
in the text. Table adapted from Hayes, et al.20
Cognitive Bias Description/Definition
Overconfidence Tendency to be confident in
Bias one’s diagnosis/hypothesis
Anchoring on a certain
Anchoring Bias aspect of case early in the
work- up
Judging a diagnosis or
Availability hypothesis more likely if it
Bias quickly and easily comes to
mind
Organizing a case in a
Framing Effect particular way to influence
the leading diagnosis
Finalizing a diagnosis
Premature before one has all the data;
Closure closing one’s mind to other
possible diagnoses
Failure to revisit diagnostic
Diagnostic
labels once they are
Momentum
attached to a patient
Suggested
Clinical examples De-biasing
Strategies
A patient presents with headache, neck
stiffness, and fever. The physician begins Explicitly
treatment for meningitis, and decides not to acknowledge
perform a lumbar puncture because the uncertainty
diagnosis is “classic”
A physician diagnoses a patient with
Consider alternative
pneumonia, and continues to treat the patient
diagnoses; explicitly
for pneumonia despite accumulating evidence
acknowledge
that the patient has acute pulmonary edema
uncertainty
from congestive heart failure.
A physician admitted three patients with acute
pancreatitis last week. Today, a patient is
being admitted with abdominal pain, nausea, Taking
and vomiting, and the physician immediately accountability for
begins to treat the patient for acute diagnoses
pancreatitis while diagnostic studies are
pending.
A physician calls a surgery consult, stating “I
have a homeless patient here who comes in all
the time. This time, he says he has abdominal
pain and tenderness. He might be a little
tender on exam, but it’s not impressive. If you
Consider alternative
could come see him and confirm it’s OK to
diagnoses
discharge him, that would be great.” The
surgeon sees the patient quickly and does not
perform her usual thorough evaluation,
because the consult was framed in a manner
that was dismissive of the patient’s symptoms.
A patient presents with wheezing and
shortness of breath, and the physician
diagnoses and starts treating the patient for an Consider alternative
acute COPD exacerbation. When the patient diagnoses; seek
subsequently develops a fever, the physician feedback on
does not pursue further work-up because the diagnoses
physician has settled on the diagnosis of
COPD.
A patient is evaluated in clinic for shortness
of breath. She is diagnosed with pneumonia,
and sent to the ED. In the ED, the patient is Consider alternative
treated for pneumonia, and no further diagnoses
diagnostic evaluations are pursued. The
patient is admitted to the hospital, and

Selectively searching for
Confirmation evidence to confirm a
Bias diagnosis rather than refute
it
treatment for pneumonia is continued. After
three days of treatment without improvement,
a chest CTA is ordered and the patient is
found to have a large pulmonary embolism.
A patient presents with chest pain, and the
physician diagnoses him with GERD. The
patient subsequently undergoes an ECG,
demonstrating inferior ST depressions which Acknowledging
the physician discounts as artifact. The patient uncertainty
subsequently develops nausea and abdominal
discomfort, which the physician interprets as
confirmation of the diagnosis of GERD.
Table 2. One minute preceptor (adopted from Neher, et al).35
Microskills of clinical Example of learner
teaching performance
Early in the discussion with the
attending, the learner should
commit to a diagnosis, work-up, or
Get a commitment therapeutic plan. The commitment
can even be a hunch or a guess
about they think is going or what
should be done next for the patient.
After committing to a diagnosis or a
plan of action, the learner should
reflect on how they arrived at that
decision. The goal of this step is to
Probe for supporting evidence help both the learner and attending
identify what the learner knows and
doesn’t know about the clinical
topic, diagnostic, and/or
management plan.
From what the attending has
learned from ‘getting a
commitment’ and having the
Teach general rules learner ‘prove for supportive
evidence’, gaps in knowledge or
understanding can be addressed at
this stage.
The learner should be asked about
what went well during the
encounter and/or their evaluation of
Reinforce was done right the patient. Specific behaviors that
were done well should be identified
and reinforced at this stage of the
‘one minute preceptor’.
The learner should be asked about
what could have gone better during
Correct mistakes the encounter and/or their
evaluation of the patient.
Example of attending action
The attending can ask the learner:
“What do you think is going on?”
“What diagnostic studies do you
think are indicated?”
“What would you like to
accomplish with this patient?”
The attending can ask the learner:
“Where are the pertinent positives
that led to your diagnosis?”
“Why did you choose that
diagnostic study?”
“What else did you consider in
evaluating this patient?”
The attending should teach to
specifically identified deficits in the
learner’s knowledge,
understanding, or reasoning, ideally
providing ‘general rules’ rather than
anecdotes or idiosyncratic
preferences.
The attending should comment on
specific behaviors that the learner
should be able to repeat consciously
and intentionally. In addition,
informing the learner about the
positive impact of their action(s) on
others is appropriate at this stage.
Constructive feedback, focused on
specific behaviors, should be
provided to learners, particularly if
they are unable to independently
identify errors or issues with their
reasoning.
Table 3. SNAPPS components with examples of learner performance and attending responses.
Example of learner
SNAPPS component
performance
The learner summarizes the case of
a patient admitted to the ICU with
hypotension and acute respiratory
failure. He incorporates relevant
information from the history,
Summarize physical exam, and available
diagnostic studies, and concludes
with an ordered differential
diagnosis for the patient’s primary
clinical issues.
The learner narrows his differential
diagnosis for both hypotension and
Narrow acute respiratory failure to the two
or three most likely processes that
could be causing each issue.
The learner identifies specific
pertinent positives and negatives for
hypotension and acute respiratory
failure, to explicitly justify his
Analyze narrowed differential diagnosis as
well as to demonstrate his clinical
reasoning in selecting those
diagnoses.
The learner identifies areas of
uncertainty, and is expected to state
what he doesn’t know about the
clinical and/or pathophysiologic
aspects of the patient’s presentation
Probe and/or the entities in the differential
diagnosis. In this instance, the
learner notes that he does not
exactly understand how PE causes
hypoxemia.
The learner offers his plan for
diagnostic evaluations and
therapeutic interventions to
Plan evaluate and address the most likely
processes delineated in the
differential diagnosis.
The learner identifies a specific
question for self-study for him to
independently address after the
Self-study clinical encounter. In this case, the
learner’s question is “By what
pathophysiologic mechanisms does
PE cause hypoxemia?”
Example of attending
response or action
The attending comments on the
content, order, and organization of
the learner’s summary and
differential diagnosis. She provides
specific, focused guidance about
what the learner did well in
synthesizing and organizing the
summary and differential, as well as
what could be improved for future
presentations.
The attending comments on the
learner’s selection of most likely
diagnoses, providing guidance and
modification as indicated.
Using ‘why’ and ‘how’ questions,
the attending prompts the learner to
expand upon his reasoning in
identifying and selecting specific
pertinent positives and negatives.
At the end of this component of
SNAPPS, the primary, unifying
diagnosis for the patient’s
presentation is submassive
pulmonary embolism (PE).
Ensuring that the learner does not
offer superficial or ego-protective
examples of what he doesn’t
understand is critical for this
component of SNAPPS. Helping
the learner to honestly reflect on his
understanding, and to identify
relevant and meaningful areas of
uncertainty is the key role of the
attending during the “probe”
portion of SNAPPS.
In addition to encouraging the
learner to explain his reasoning
with regard to the diagnostic
evaluations and therapeutic
interventions he suggests, the
attending offers guidance,
modifications, and revisions to the
learner’s plan.
The attending may offer
suggestions about or modifications
to the learner’s question. In
addition, the attending and learner
need to identify a specific date and
time when the learner will present
what he found in researching his
self-study question.