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Cultivating Critical Thinking in Healthcare

Published: 06 January 2019

Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).

Given this, it's necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught , assessed and integrated into the design and development of staff and nurse education and training programs (Papp et al. 2014).

So, what exactly is critical thinking and how can healthcare educators cultivate it amongst their staff?

What is Critical Thinking?

In general terms, ‘ critical thinking ’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills .

In practice, however, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions .

Several formal definitions of critical thinking can be found in literature, but in the view of Kahlke and Eva (2018), most of these definitions have limitations. That said, Papp et al. (2014) offer a useful starting point, suggesting that critical thinking is:

‘The ability to apply higher order cognitive skills and the disposition to be deliberate about thinking that leads to action that is logical and appropriate.’

The Foundation for Critical Thinking (2017) expands on this and suggests that:

‘Critical thinking is that mode of thinking, about any subject, content, or problem, in which the thinker improves the quality of his or her thinking by skillfully analysing, assessing, and reconstructing it.’

They go on to suggest that critical thinking is:

• Self-directed
• Self-disciplined
• Self-monitored
• Self-corrective.

Key Qualities and Characteristics of a Critical Thinker

Given that critical thinking is a process that encompasses conceptualisation , application , analysis , synthesis , evaluation and reflection , what qualities should be expected from a critical thinker?

In answering this question, Fortepiani (2018) suggests that critical thinkers should be able to:

• Formulate clear and precise questions
• Gather, assess and interpret relevant information
• Reach relevant well-reasoned conclusions and solutions
• Think open-mindedly, recognising their own assumptions
• Communicate effectively with others on solutions to complex problems.

All of these qualities are important, however, good communication skills are generally considered to be the bedrock of critical thinking. Why? Because they help to create a dialogue that invites questions, reflections and an open-minded approach, as well as generating a positive learning environment needed to support all forms of communication.

Lippincott Solutions (2018) outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:

• Inquisitiveness with regard to a wide range of issues
• A concern to become and remain well-informed
• Alertness to opportunities to use critical thinking
• Self-confidence in one’s own abilities to reason
• Open mindedness regarding divergent world views
• Flexibility in considering alternatives and opinions
• Understanding the opinions of other people
• Fair-mindedness in appraising reasoning
• Honesty in facing one’s own biases, prejudices, stereotypes or egocentric tendencies
• A willingness to reconsider and revise views where honest reflection suggests that change is warranted.

Papp et al. (2014) also helpfully suggest that the following five milestones can be used as a guide to help develop competency in critical thinking:

Stage 1: Unreflective Thinker

At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.

Stage 2: Beginning Critical Thinker

Here, the learner begins to think critically and starts to recognise cognitive differences in other people. However, external motivation  is needed to sustain reflection on the learners’ own thought processes.

Stage 3: Practicing Critical Thinker

By now, the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.

Stage 4: Advanced Critical Thinker

As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.

Stage 5: Accomplished Critical Thinker

At this stage, the skilled critical thinker can take charge of their thinking and habitually monitors, revises and rethinks approaches for continual improvement of their cognitive strategies.

Facilitating Critical Thinking in Healthcare

A common challenge for many educators and facilitators in healthcare is encouraging students to move away from passive learning towards active learning situations that require critical thinking skills.

Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are also several generally recognised hallmarks of teaching for critical thinking . These include:

• Promoting interaction among students as they learn
• Asking open ended questions that do not assume one right answer
• Allowing sufficient time to reflect on the questions asked or problems posed
• Teaching for transfer - helping learners to see how a newly acquired skill can apply to other situations and experiences.

(Lippincott Solutions 2018)

Snyder and Snyder (2008) also make the point that it’s helpful for educators and facilitators to be aware of any initial resistance that learners may have and try to guide them through the process. They should aim to create a learning environment where learners can feel comfortable thinking through an answer rather than simply having an answer given to them.

Examples include using peer coaching techniques , mentoring or preceptorship to engage students in active learning and critical thinking skills, or integrating project-based learning activities that require students to apply their knowledge in a realistic healthcare environment.

Carvalhoa et al. (2017) also advocate problem-based learning as a widely used and successful way of stimulating critical thinking skills in the learner. This view is echoed by Tsui-Mei (2015), who notes that critical thinking, systematic analysis and curiosity significantly improve after practice-based learning .

Integrating Critical Thinking Skills Into Curriculum Design

Most educators agree that critical thinking can’t easily be developed if the program curriculum is not designed to support it. This means that a deep understanding of the nature and value of critical thinking skills needs to be present from the outset of the curriculum design process , and not just bolted on as an afterthought.

In the view of Fortepiani (2018), critical thinking skills can be summarised by the statement that 'thinking is driven by questions', which means that teaching materials need to be designed in such a way as to encourage students to expand their learning by asking questions that generate further questions and stimulate the thinking process. Ideal questions are those that:

• Embrace complexity
• Challenge assumptions and points of view
• Question the source of information
• Explore variable interpretations and potential implications of information.

To put it another way, asking questions with limiting, thought-stopping answers inhibits the development of critical thinking. This means that educators must ideally be critical thinkers themselves .

Drawing these threads together, The Foundation for Critical Thinking (2017) offers us a simple reminder that even though it’s human nature to be ‘thinking’ most of the time, most thoughts, if not guided and structured, tend to be biased, distorted, partial, uninformed or even prejudiced.

They also note that the quality of work depends precisely on the quality of the practitioners’ thought processes. Given that practitioners are being asked to meet the challenge of ever more complex care, the importance of cultivating critical thinking skills, alongside advanced problem-solving skills , seems to be taking on new importance.

Additional Resources

• The Emotionally Intelligent Nurse | Ausmed Article
• Refining Competency-Based Assessment | Ausmed Article
• Socratic Questioning in Healthcare | Ausmed Article
• Carvalhoa, D P S R P et al. 2017, 'Strategies Used for the Promotion of Critical Thinking in Nursing Undergraduate Education: A Systematic Review', Nurse Education Today , vol. 57, pp. 103-10, viewed 7 December 2018, https://www.sciencedirect.com/science/article/abs/pii/S0260691717301715
• Fortepiani, L A 2017, 'Critical Thinking or Traditional Teaching For Health Professionals', PECOP Blog , 16 January, viewed 7 December 2018, https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/
• Jacob, E, Duffield, C & Jacob, D 2017, 'A Protocol For the Development of a Critical Thinking Assessment Tool for Nurses Using a Delphi Technique', Journal of Advanced Nursing, vol. 73, no. 8, pp. 1982-1988, viewed 7 December 2018, https://onlinelibrary.wiley.com/doi/10.1111/jan.13306
• Kahlke, R & Eva, K 2018, 'Constructing Critical Thinking in Health Professional Education', Perspectives on Medical Education , vol. 7, no. 3, pp. 156-165, viewed 7 December 2018, https://link.springer.com/article/10.1007/s40037-018-0415-z
• Lippincott Solutions 2018, 'Turning New Nurses Into Critical Thinkers', Lippincott Solutions , viewed 10 December 2018, https://www.wolterskluwer.com/en/expert-insights/turning-new-nurses-into-critical-thinkers
• Papp, K K 2014, 'Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing', Academic Medicine , vol. 89, no. 5, pp. 715-720, https://journals.lww.com/academicmedicine/Fulltext/2014/05000/Milestones_of_Critical_Thinking___A_Developmental.14.aspx
• Snyder, L G & Snyder, M J 2008, 'Teaching Critical Thinking and Problem Solving Skills', The Delta Pi Epsilon Journal , vol. L, no. 2, pp. 90-99, viewed 7 December 2018, https://dme.childrenshospital.org/wp-content/uploads/2019/02/Optional-_Teaching-Critical-Thinking-and-Problem-Solving-Skills.pdf
• The Foundation for Critical Thinking 2017, Defining Critical Thinking , The Foundation for Critical Thinking, viewed 7 December 2018, https://www.criticalthinking.org/pages/our-conception-of-critical-thinking/411
• Tsui-Mei, H, Lee-Chun, H & Chen-Ju MSN, K 2015, 'How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning', Journal for Nurses in Professional Development , vol. 31, no. 3, pp. 170-175, viewed 7 December 2018, https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx

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Clinical problem solving and diagnostic decision making: selective review of the cognitive literature

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This article has a correction. Please see:

• Clinical problem solving and diagnostic decision making: selective review of the cognitive literature - November 02, 2006
• Arthur S Elstein , professor ( aelstein{at}uic.edu ) ,
• Alan Schwarz , assistant professor of clinical decision making.
• Department of Medical Education, University of Illinois College of Medicine, Chicago, IL 60612-7309, USA
• Correspondence to: A S Elstein

This is the fourth in a series of five articles

This article reviews our current understanding of the cognitive processes involved in diagnostic reasoning in clinical medicine. It describes and analyses the psychological processes employed in identifying and solving diagnostic problems and reviews errors and pitfalls in diagnostic reasoning in the light of two particularly influential approaches: problem solving 1 , 2 , 3 and decision making. 4 , 5 , 6 , 7 , 8 Problem solving research was initially aimed at describing reasoning by expert physicians, to improve instruction of medical students and house officers. Psychological decision research has been influenced from the start by statistical models of reasoning under uncertainty, and has concentrated on identifying departures from these standards.

Summary points

Problem solving and decision making are two paradigms for psychological research on clinical reasoning, each with its own assumptions and methods

The choice of strategy for diagnostic problem solving depends on the perceived difficulty of the case and on knowledge of content as well as strategy

Final conclusions should depend both on prior belief and strength of the evidence

Conclusions reached by Bayes's theorem and clinical intuition may conflict

Because of cognitive limitations, systematic biases and errors result from employing simpler rather than more complex cognitive strategies

Evidence based medicine applies decision theory to clinical diagnosis

Problem solving

Diagnosis as selecting a hypothesis.

The earliest psychological formulation viewed diagnostic reasoning as a process of testing hypotheses. Solutions to difficult diagnostic problems were found by generating a limited number of hypotheses early in the diagnostic process and using them to guide subsequent collection of data. 1 Each hypothesis can be used to predict what additional findings ought to be present if it were true, and the diagnostic process is a guided search for these findings. Experienced physicians form hypotheses and their diagnostic plan rapidly, and the quality of their hypotheses is higher than that of novices. Novices struggle to develop a plan and some have difficulty moving beyond collection of data to considering possibilities.

It is possible to collect data thoroughly but nevertheless to ignore, to misunderstand, or to misinterpret some findings, but also possible for a clinician to be too economical in collecting data and yet to interpret accurately what is available. Accuracy and thoroughness are analytically separable.

Pattern recognition or categorisation

Expertise in problem solving varies greatly between individual clinicians and is highly dependent on the clinician's mastery of the particular domain. 9 This finding challenges the hypothetico-deductive model of clinical reasoning, since both successful and unsuccessful diagnosticians use hypothesis testing. It appears that diagnostic accuracy does not depend as much on strategy as on mastery of content. Further, the clinical reasoning of experts in familiar situations frequently does not involve explicit testing of hypotheses. 3 10 , 11 , 12 Their speed, efficiency, and accuracy suggest that they may not even use the same reasoning processes as novices. 11 It is likely that experienced physicians use a hypothetico-deductive strategy only with difficult cases and that clinical reasoning is more a matter of pattern recognition or direct automatic retrieval. What are the patterns? What is retrieved? These questions signal a shift from the study of judgment to the study of the organisation and retrieval of memories.

Problem solving strategies

Hypothesis testing

Pattern recognition (categorisation)

By specific instances

By general prototypes

Viewing the process of diagnosis assigning a case to a category brings some other issues into clearer view. How is a new case categorised? Two competing answers to this question have been put forward and research evidence supports both. Category assignment can be based on matching the case to a specific instance (“instance based” or “exemplar based” recognition) or to a more abstract prototype. In the former, a new case is categorised by its resemblance to memories of instances previously seen. 3 11 This model is supported by the fact that clinical diagnosis is strongly affected by context—for example, the location of a skin rash on the body—even when the context ought to be irrelevant. 12

The prototype model holds that clinical experience facilitates the construction of mental models, abstractions, or prototypes. 2 13 Several characteristics of experts support this view—for instance, they can better identify the additional findings needed to complete a clinical picture and relate the findings to an overall concept of the case. These features suggest that better diagnosticians have constructed more diversified and abstract sets of semantic relations, a network of links between clinical features and diagnostic categories. 14

The controversy about the methods used in diagnostic reasoning can be resolved by recognising that clinicians approach problems flexibly; the method they select depends upon the perceived characteristics of the problem. Easy cases can be solved by pattern recognition: difficult cases need systematic generation and testing of hypotheses. Whether a diagnostic problem is easy or difficult is a function of the knowledge and experience of the clinician.

The strategies reviewed are neither proof against error nor always consistent with statistical rules of inference. Errors that can occur in difficult cases in internal medicine include failure to generate the correct hypothesis; misperception or misreading the evidence, especially visual cues; and misinterpretations of the evidence. 15 16 Many diagnostic problems are so complex that the correct solution is not contained in the initial set of hypotheses. Restructuring and reformulating should occur as data are obtained and the clinical picture evolves. However, a clinician may quickly become psychologically committed to a particular hypothesis, making it more difficult to restructure the problem.

Decision making

Diagnosis as opinion revision.

From the point of view of decision theory, reaching a diagnosis means updating opinion with imperfect information (the clinical evidence). 8 17 The standard rule for this task is Bayes's theorem. The pretest probability is either the known prevalence of the disease or the clinician's subjective impression of the probability of disease before new information is acquired. The post-test probability, the probability of disease given new information, is a function of two variables, pretest probability and the strength of the evidence, measured by a “likelihood ratio.”

Bayes's theorem tells us how we should reason, but it does not claim to describe how opinions are revised. In our experience, clinicians trained in methods of evidence based medicine are more likely than untrained clinicians to use a Bayesian approach to interpreting findings. 18 Nevertheless, probably only a minority of clinicians use it in daily practice and informal methods of opinion revision still predominate. Bayes's theorem directs attention to two major classes of errors in clinical reasoning: in the assessment of either pretest probability or the strength of the evidence. The psychological study of diagnostic reasoning from this viewpoint has focused on errors in both components, and on the simplifying rules or heuristics that replace more complex procedures. Consequently, this approach has become widely known as “heuristics and biases.” 4 19

Errors in estimation of probability

Availability —People are apt to overestimate the frequency of vivid or easily recalled events and to underestimate the frequency of events that are either very ordinary or difficult to recall. Diseases or injuries that receive considerable media attention are often thought of as occurring more commonly than they actually do. This psychological principle is exemplified clinically in the overemphasis of rare conditions, because unusual cases are more memorable than routine problems.

Representativeness —Representativeness refers to estimating the probability of disease by judging how similar a case is to a diagnostic category or prototype. It can lead to overestimation of probability either by causing confusion of post-test probability with test sensitivity or by leading to neglect of base rates and implicitly considering all hypotheses equally likely. This is an error, because if a case resembles disease A and disease B equally, and A is much more common than B, then the case is more likely to be an instance of A. Representativeness is associated with the “conjunction fallacy”—incorrectly concluding that the probability of a joint event (such as the combination of findings to form a typical clinical picture) is greater than the probability of any one of these events alone.

Heuristics and biases

Availability

Representativeness

Probability transformations

Effect of description detail

Conservatism

Anchoring and adjustment

Order effects

Decision theory assumes that in psychological processing of probabilities, they are not transformed from the ordinary probability scale. Prospect theory was formulated as a descriptive account of choices involving gambling on two outcomes, 20 and cumulative prospect theory extends the theory to cases with multiple outcomes. 21 Both prospect theory and cumulative prospect theory propose that, in decision making, small probabilities are overweighted and large probabilities underweighted, contrary to the assumption of standard decision theory. This “compression” of the probability scale explains why the difference between 99% and 100% is psychologically much greater than the difference between, say, 60% and 61%. 22

Support theory

Support theory proposes that the subjective probability of an event is inappropriately influenced by how detailed the description is. More explicit descriptions yield higher probability estimates than compact, condensed descriptions, even when the two refer to exactly the same events. Clinically, support theory predicts that a longer, more detailed case description will be assigned a higher subjective probability of the index disease than a brief abstract of the same case, even if they contain the same information about that disease. Thus, subjective assessments of events, while often necessary in clinical practice, can be affected by factors unrelated to true prevalence. 23

Errors in revision of probability

In clinical case discussions, data are presented sequentially, and diagnostic probabilities are not revised as much as is implied by Bayes's theorem 8 ; this phenomenon is called conservatism. One explanation is that diagnostic opinions are revised up or down from an initial anchor, which is either given in the problem or subjectively formed. Final opinions are sensitive to the starting point (the “anchor”), and the shift (“adjustment”) from it is typically insufficient. 4 Both biases will lead to collecting more information than is necessary to reach a desired level of diagnostic certainty.

It is difficult for everyday judgment to keep separate accounts of the probability of a disease and the benefits that accrue from detecting it. Probability revision errors that are systematically linked to the perceived cost of mistakes show the difficulties experienced in separating assessments of probability from values, as required by standard decision theory. There is a tendency to overestimate the probability of more serious but treatable diseases, because a clinician would hate to miss one. 24

Bayes's theorem implies that clinicians given identical information should reach the same diagnostic opinion, regardless of the order in which information is presented. However, final opinions are also affected by the order of presentation of information. Information presented later in a case is given more weight than information presented earlier. 25

Other errors identified in data interpretation include simplifying a diagnostic problem by interpreting findings as consistent with a single hypothesis, forgetting facts inconsistent with a favoured hypothesis, overemphasising positive findings, and discounting negative findings. From a Bayesian standpoint, these are all errors in assessing the diagnostic value of clinical evidence—that is, errors in implicit likelihood ratios.

Educational implications

Two recent innovations in medical education, problem based learning and evidence based medicine, are consistent with the educational implications of this research. Problem based learning can be understood as an effort to introduce the formulation and testing of clinical hypotheses into the preclinical curriculum. 26 The theory of cognition and instruction underlying this reform is that since experienced physicians use this strategy with difficult problems, and since practically any clinical situation selected for instructional purposes will be difficult for students, it makes sense to provide opportunities for students to practise problem solving with cases graded in difficulty. The finding of case specificity showed the limits of teaching a general problem solving strategy. Expertise in problem solving can be separated from content analytically, but not in practice. This realisation shifted the emphasis towards helping students acquire a functional organisation of content with clinically usable schemas. This goal became the new rationale for problem based learning. 27

Evidence based medicine is the most recent, and by most standards the most successful, effort to date to apply statistical decision theory in clinical medicine. 18 It teaches Bayes's theorem, and residents and medical students quickly learn how to interpret diagnostic studies and how to use a computer based nomogram to compute post-test probabilities and to understand the output. 28

We have selectively reviewed 30 years of psychological research on clinical diagnostic reasoning. The problem solving approach has focused on diagnosis as hypothesis testing, pattern matching, or categorisation. The errors in reasoning identified from this perspective include failure to generate the correct hypothesis; misperceiving or misreading the evidence, especially visual cues; and misinterpreting the evidence. The decision making approach views diagnosis as opinion revision with imperfect information. Heuristics and biases in estimation and revision of probability have been the subject of intense scrutiny within this research tradition. Both research paradigms understand judgment errors as a natural consequence of limitations in our cognitive capacities and of the human tendency to adopt short cuts in reasoning.

Both approaches have focused more on the mistakes made by both experts and novices than on what they get right, possibly leading to overestimation of the frequency of the mistakes catalogued in this article. The reason for this focus seems clear enough: from the standpoint of basic research, errors tell us a great deal about fundamental cognitive processes, just as optical illusions teach us about the functioning of the visual system. From the educational standpoint, clinical instruction and training should focus more on what needs improvement than on what learners do correctly; to improve performance requires identifying errors. But, in conclusion, we emphasise, firstly, that the prevalence of these errors has not been established; secondly, we believe that expert clinical reasoning is very likely to be right in the majority of cases; and, thirdly, despite the expansion of statistically grounded decision supports, expert judgment will still be needed to apply general principles to specific cases.

Series editor J A Knottnerus

Preparation of this review was supported in part by grant RO1 LM5630 from the National Library of Medicine.

Competing interests None declared.

“The Evidence Base of Clinical Diagnosis,” edited by J A Knottnerus, can be purchased through the BMJ Bookshop ( http://www.bmjbookshop.com/ )

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Teaching Critical Thinking and Problem-Solving Skills to Healthcare Professionals

• Published: 27 October 2020
• Volume 31 , pages 235–239, ( 2021 )

Cite this article

• Jessica A. Chacon 1 &
• Herb Janssen   ORCID: orcid.org/0000-0001-8015-9369 1  

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Introduction

Determining approaches that improve student learning is far more beneficial than determining what can improve a professor’s teaching. As previously stated, “Lecturing is that mysterious process by which the contents of the note-book of the professor are transferred through the instrumentation of the fountain-pen to the note-book of the student without passing through the mind of either” [ 1 ]. This process continues today, except that the professor’s note-book has been replaced with a PowerPoint lecture and the student’s note-book is now a computer.

In 1910, the Flexner report noted that didactic lectures were antiquated and should be left to a time when “professors knew and students learned” [ 2 ]. Approximately 100 years later, the Liaison Committee on Medical Education (LCME) affirmed Flexner’s comment and suggested that student learning must involve active components [ 3 ]: It seems somewhat obscured that almost 100 years separated these two statements.

Our strategy requires the following: student engagement in the learning process; a curriculum that develops a foundation for each student’s knowledge acquisition; focusing primarily on student learning instead of professor teaching; helping enable students develop critical thinking skills; and encouraging students to develop “expertise” in their chosen discipline.

Six fundamental topics that play a role in the development of a health sciences student’s critical thinking ability will be described. In “Section I,” these topics will be discussed independently, highlighting the importance of each. In “Section II: Proposed Curriculum and Pedagogy to Improve Student Learning,” the topics will be united into a practical approach that can be used to improve student learning, curriculum, pedagogy, and assessment.

Foundation Knowledge

Students use mnemonics to provide a foundation for new information. Although mnemonics help students associate information that they want to remember with something they already know, students learn tads of information that is not placed into a practical, meaningful framework developed by the student [ 4 , 5 ]. This commentary highlights the problem of recalling facts when these facts are presented in isolation. The responsibility for this resides not with the student, but with a curriculum that teaches isolated facts, instead of integrated concepts.

A taxonomy for significant learning presented by Dr. Fink emphasizes the need to develop foundational knowledge before additional information can be learned in an effective manner [ 6 ]. He provides suggestions on developing specific learning goals in given courses. Two of his most important criteria are (1) the development of a foundation of knowledge and (2) helping students “learn how to learn” [ 6 ].

Learning Approaches and Abilities

Howard Gardner introduced the concept of multiple intelligences in the 1980s [ 7 ]. Gardner expanded this idea to include intelligence in the areas of (1) Verbal-linguistic, (2) Logical-mathematical, (3) Spatial-visual, (4) Bodily-kinesthetic, (5) Musical, (6) Interpersonal, (7) Intrapersonal personal, (8) Naturalist, and (9) Existential. He concluded that students gifted in certain areas will be drawn in that direction due to the ease with which they excel. While it is important to recognize these differences, it is crucial to not ignore the need for student development in areas where they are less gifted. For example, students gifted in mathematics who fail to develop intrapersonal and interpersonal skills will more likely become recluse, limiting their success in real-world situations [ 7 , 8 ]. Similar examples can also be found in the medical world [ 7 , 8 ].

Based on Gardner’s work, it seems evident that students admitted to our health sciences schools will arrive with different skills and abilities. Despite this, educators are required to produce graduates who have mastered the competencies required by the various accrediting agencies. Accomplishing this task demands sensitivity to the students’ different abilities. While the curriculum remains focused on the competencies students must demonstrate when training is complete. Creating this transition using a traditional lecture format is difficult, if not impossible.

Active Engagement

In 1910, Flexner suggested that didactic lecture is important; however, it should be limited only to the introduction or conclusion of a given topic [ 2 ]. Flexner stated that students should be given the opportunity to experience learning in a context that allowed them to use scientific principles rather than empirical observations [ 2 ]. Active engagement of the student in their learning process has been recently promoted by the LCME [ 3 ]. This reaffirmation of Flexner’s 1910 report highlights the incredibly slow pace at which education changes.

Critical Thinking

Critical thinking is an active process that, when applied appropriately, allows each of us to evaluate our own activities and achievements. Critical thinking also allows an individual to make minor, mid-course corrections in thinking, instead of waiting until disastrous outcomes are unavoidable.

Educators in Allied Health and Nursing have included critical thinking as part of their curriculum for many years [ 9 ]. Medical educators, on the other hand, have not fully integrated critical thinking as part of their curriculum [ 10 , 11 ].

Bloom’s taxonomy has often been used to define curriculum [ 12 ]. The usefulness and importance of Bloom’s taxonomy is not to be underestimated; however, its limitations must also be addressed. As Bloom and his colleagues clearly stated, their taxonomy describes behavioral outcomes and is incapable of determining the logical steps through which this behavior was developed [ 12 ]. Bloom highlights this shortcoming in his initial book on the cognitive domain. He described two students who solved the same algebra problem. One student does this by rote memory, having been exposed to the problem previously, while the other student accomplishes the task by applying mathematical principles. The observer has no way of knowing which approach was used unless they have prior knowledge of the students’ background [ 12 ]. The importance of this distinction becomes apparent in medical problem-solving.

Contextual Learning

Enabling students to learn in context is critical; however, trying to teach everything in context results in a double-edged sword [ 13 ]. On the one hand, learning material in context helps the student develop a solid foundation in which the new information can be built. On the other hand, the educator will find it impossible to duplicate all situations the student will encounter throughout his or her career as a healthcare provider. This dilemma again challenges the educator to develop a variety of learning situations that simulate real-world situations. It seems that “in context” can at best be developed by presenting a variety of patients in a variety of different situations.

In the clinical setting, the physician cannot use a strict hypothesis-driven study on each patient, but must treat patients using the best, most logical treatment selected based on his or her knowledge and the most reliable information.

Development of Expertise

Several researchers have studied the characteristics required of expert performance, the time required to obtain these traits, and the steps that are followed as an individual’s performance progresses from novice to expert.

Studies involving expert physicians have provided data that can be directly used in our attempt to improve curriculum and pedagogy in the healthcare profession. Patel demonstrated that medical students and entry-level residents can recall a considerable amount of non-relevant data while the expert cannot [ 14 ]. Conversely, the expert physician has a much higher level of relevant recall, suggesting they have omitted the non-relevant information and retained only relevant information that is useful in their practice. Using these methods, the expert physicians produce accurate diagnosis in almost 100% of cases, while the medical students can achieve only patricianly correct or component diagnosis only [ 14 ].

In the healthcare setting, both methods are used. The expert physicians will use forward reasoning when the accuracy of the data allows this rapid problem-solving method. When the patient’s conditions cannot be accurately described using known information, the expert diagnostician will resort to the slower hypothesis-driven, backward reasoning approach. In this manner, the highest probability of achieving an accurate diagnosis in the shortest time will be realized [ 14 ].

Section II: Proposed Curriculum and Pedagogy to Improve Student Learning

The following section will outline several distinct but interrelated approaches to accomplish the six educational principles discussed above. The topics will be highlighted as they apply to the specific topic and each section will be comprised of curriculum, pedagogy, and assessment.

Developing a Knowledge Base Using Active Learning Sensitive to Students’ Abilities

Students admitted into healthcare training programs come from various backgrounds. This is both a strength for the program and a challenge for the educator. The strength is recognized in the diversity the varied backgrounds bring to the class and ultimately the profession. The challenge for the educator is attempting to provide each student with the material and a learning approach that will fit their individual ability and knowledge level. The educator can provide prerequisite objectives that identify the basic knowledge required before the student attempts the more advanced curriculum. Scaffolding questions can also be provided that allow students to determine their mastery of these prerequisite objectives. Briefly, scaffolding questions are categorized based on complexity. Simple, factual questions are identified with a subscript “0” (i.e. 1. 0 , 2. 0 , etc.). Advanced questions have a subscript suggesting the estimated number of basic concepts that must be included/combined to derive the answer.

Using technology to provide these individual learning opportunities online allows each student to address his or her own potential deficits. Obviously, those who find their knowledge lacking will need to spend additional time learning this information; however, using technology, this can be accomplished without requiring additional class time. This approach will decrease learning gaps for students, while excluding unnecessarily repeating material known by others.

The curriculum is divided into two parts: (1) content and (2) critical thinking/problem-solving skills. The basic knowledge and factual content can be provided online. Students are expected to learn this by actively engaging the material during independent study. This saves classroom or small-group sessions for interaction where students can actively learn critical thinking/problem-solving skills.

The curriculum should be designed so that students can start at their own level of understanding. The more advanced students can identify the level appropriate for themselves and/or review the more rudimentary information as needed. As shown by previous investigators, experts omit non-relevant information so that they can focus on appropriate problem-solving. Requiring students to learn by solving problems or exploring case studies will be emphasized when possible.

Technology can be used to deliver the “content” portion of the curriculum. Voice-over PowerPoints and/or video clips made available online through WebCT or PodCast will allow each student to study separately or in groups at their own rate, starting at their own level of knowledge. The content delivered in this fashion will complement the handout and/or textbook information recommended to the students. This will provide the needed basic information that will be used as a foundation for the development of critical thinking and problem-solving. The flipped classroom and/or team-based learning can both be used to help facilitate this type of learning. [ 15 ]

Student Assessments

It is imperative for students to know whether they have mastered the material to the extent needed. This can be accomplished by providing online formative evaluations. These will not be used to determine student performance; however, the results will be provided to the educator to determine the class’s progress and evaluation of the curriculum.

Developing Critical Thinking Skills in the Classroom or Small-Group Setting

Critical thinking skills are essential to the development of well-trained healthcare professionals. These skills are not “taught” but must be “learned” by the student. The educator provides learning experiences through which the students can gain the needed skills and experience. Mastery of the content should be a responsibility placed on the student. Information and assistance are given to the students, but students are held accountable for learning the content. This does not indicate that the educator is freed from responsibility. In fact, the educator will most likely spend more time planning and preparing, compared to when didactic lectures were given; however, the spotlight will be placed on the student. Once the learning modules are developed, they can be readily updated, allowing the educators to improve their sessions with each evaluation.

Curriculum designed to help student students develop critical thinking/problem-solving skills should be learned in context. During the introductory portions of the training, this can be accomplished by providing problem-based scenarios similar to what will be expected in the later clinical setting. The transition to competency-based evaluation in many disciplines has made this a virtual necessity. Critical thinking/problem-solving skills should emphasize self-examination. It should teach an individual to accomplish this using a series of steps that progress in a logical fashion, stressing that critical thinking is a progression of logical thought, not an unguided process.

The methods of teaching critical thinking can be traced back to the dialectic methods used by Socrates. Helping the students learn by posing questions remains an effective tool. Accomplishing this in a group setting also provides each student with the opportunity to learn, not only from their mistakes and accomplishments, but from the mistakes and accomplishments of others. Scenario questions can be presented in a manner similar to those found in many board and licensure exams. This exposes students to material in a format relevant to the clinical setting and to future exams. In larger groups, PowerPoint presentation of scenario questions can be used. Team-based learning (TBL) is useful in encouraging individual self-assessment and peer-peer instruction, while also providing an opportunity for the development of critical thinking and problem-solving skills. After the Individual Readiness Assurance Test (iRAT) exam, students work together to answer the Group Readiness Assurance Test (gRAT). Following this, relevant material is covered by clinicians and basic scientists working together and questions asked using an audience response system. This has been useful in encouraging individual self-assessment and peer-peer instruction while also providing an opportunity for the development of critical thinking and problem-solving skills.

Formative assessment of the students will be given in the class session. This can be accomplished using an audience response system. This gives each individual a chance to determine their own critical thinking skill level. It will prevent the “Oh, I knew that” response from students who are in denial of their own inabilities. Summative assessment in the class will be based on the critical thinking skills presented in the classroom or small-group setting. As mentioned earlier, the students will be evaluated on their ability to think critically and to problem-solve. This will by necessity include evaluation of content knowledge—but only as it pertains to the critical thinking and problem-solving skills. This will be made clear through the use of objectives that describe both content and critical thinking.

Enhancing Critical Thinking Skills in Simulation Centers and Clinics

The development of critical thinking skills in healthcare is somewhat unique. In chess, students can start playing using the same tools employed by the experts (the chess board); however, in healthcare, allowing students to make medical decisions is ethically inappropriate and irresponsible. Simulations centers allow students to gain needed experience and confidence without placing patients at risk. Once the students have mastered simulation center experiences and acquired the needed confidence, they can participate in patient diagnosis under the watchful eye of the expert healthcare professional.

The student’s curriculum now becomes the entire knowledge base of each healthcare discipline. This includes textbooks and journal articles. Students are required to come well prepared to the clinics and/or hospital having developed and in-depth understanding of each patient in their care.

Each day, the expert healthcare provider, serving as a mentor, will provide formative evaluation of the student and his/her performance. Mentors will guide the student, suggesting changes in the skills needed to evaluate the patients properly. In addition, standardized patients provide an excellent method of student/resident evaluation.

Summative evaluation is in the form of subject/board exams. These test the student’s or resident’s ability to accurately describe and evaluate the patient. The objective structured clinical examination (OSCE) is used to evaluate the student’s ability to correctly assess the patient’s condition. Thinking aloud had been previously shown as an effective tool for evaluating expert performance in such settings [ 16 ]. Briefly, think aloud strategies require the student to explain verbally the logic they are using to combine facts to arrive at correct answers. This approach helps the evaluator to determine both the accuracy of the answer and if the correct thought process was followed by the student.

If the time required to develop an expert is a minimum of ten years, what influence can education have on the process?

Education can:

Provide the student with a foundation of knowledge required for the development of future knowledge and skills.

Introduce the student to critical thinking and problem-solving techniques.

Require the student to actively engage the material instead of attempting to learn using rote memory only.

Assess the performance of the student in a formative manner, allowing the lack of information of skills to be identified early, thus reducing the risk of failure when changes in study skills are more difficult and/or occur too late to help.

Provide learning in a contextual format that makes the information meaningful and easier to remember.

Provide training in forward reasoning and backward reasoning skills. It can relate these skills to the problem-solving techniques in healthcare.

Help students develop the qualities of an expert healthcare provider.

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Chacon, J.A., Janssen, H. Teaching Critical Thinking and Problem-Solving Skills to Healthcare Professionals. Med.Sci.Educ. 31 , 235–239 (2021). https://doi.org/10.1007/s40670-020-01128-3

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Medical problem solving.

Medical problem-solving skills are essential to learning how to develop an effective differential diagnosis in an efficient manner, as well as how to engage in the reflective practice of medicine. 
 Students' experience in CBI complements the clinical reasoning skills they learn through the UA COM Doctor and Patient course and through their Societies mentors.

The UA COM medical problem-solving structure applies the B-D-A ( Before-During-After)  framework as an educational strategy. Thus, CBI requires students to engage in reflection before, during and following facilitated sessions. Reflection contributes to improvement in problem-solving skills and helps medical students cultivate a habit of reflection that will serve them well as they become lifelong professional learners.

As with medical-problem solving, practice-based learning (learning through experience) requires students to engage in reflection before, during and following each learning experiences. Reflection contributes to improvement in problem-solving skills and cultivating a habit of reflection will serve medical students well as they become lifelong professional learners. 

Related Resources

B-D-A Framework   Reflective Learning Guide   Cognitive Error   Quick Guide

The medical problem solving process

• PMID: 7429488
• DOI: 10.1016/s0046-8177(80)80048-7

Understanding the medical problem solving process has implications for medical education and the effectiveness of medical services. Through adaptation to the task at hand the human problem solver is able to ameliorate the effects of inherent limitations. In adapting to the medical problem solving task demands related to diagnosis and therapy, the physician uses the hypotheticodeductive process. The process draws upon the problem solver's disease centered and data centered knowledge and can be made more effective through the use of various heuristic rules and strategies that the physician develops with increasing expertise. Additional and more refined modes of laboratory support for the medical problem solver can evolve through further understanding of the problem solving process.

• Clinical Laboratory Techniques
• Decision Making
• Diagnostic Techniques and Procedures
• Education, Medical
• Information Services
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• Problem Solving*
• Therapeutics

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Problem Solving

Problem Solving in the Medical Practice Using the Five Whys

Ron Harman King, MS | Neil Baum, MD

December 8, 2018

There is no doctor or medical practice that hasn’t experienced a problem or a crisis in either the care of patients or the business aspect of the practice. Unfortunately, most doctors have few or no skills in crisis management or nonclinical problem solving. This task often is left to the office manager or the practice’s medical director. This article discusses the use of the root cause analysis and how it can be applied to nearly every medical practice. The “five whys” concept is a way to try to find the causes of potentially complex problems. When done properly, this strategy will help you to get to the root cause of many issues so that it can be addressed, rather than just focusing on symptoms of that problem.

When done properly, the “five whys” strategy has been shown not only to be effective, but also to be easy to use on a wide range of issues throughout many medical practices. It also can be combined and used with a variety of other techniques used to identify and solve workplace problems.

The five whys technique, which began in Japan at the Toyota Motor Company, is based on a scientific approach to problem solving. It has been applied through just about every type of industry around the world and could easily be used in the healthcare profession as well.

In the five whys process, you ask “why?” at least five times to get to the root cause of a problem. The process starts out with a problem that is affecting the practice, and then keeps asking why things happened until the root cause of the issue has been identified.

One of the best ways to get a good understanding of the five whys is to look at examples of how it has been explained with an example from the automotive industry. The following example is commonly used—how to discover the root cause of a car that will not start. The initial problem is “The car will not start.” From there, the five whys are asked:

Why won’t the car start? Answer: The battery is dead.

Why is the battery dead? Answer: The alternator is not working properly.

Why isn’t the alternator working? Answer: The serpentine belt has broken.

Why did the serpentine belt break? Answer: It was not replaced when worn.

Why wasn’t it replaced? Answer: The owner did not follow the recommended service schedule.

The last why is considered the root cause of the problem. If the owner of the vehicle had followed the recommended service schedule, this issue would not have happened. Not only that, but following the recommended service schedule will help to prevent a wide range of other problems including a decrease in radiator, brake, and oil fluids.

Applying the Five Whys Process to the Healthcare Practice

The problem to be solved is the practice is running behind schedule:

Why is the practice already one hour behind schedule in seeing patients by mid-morning when the doctor is supposed to start seeing patients at 9:00 AM? Answer: Patients are arriving 30 to 60 minutes late for their appointments.

Why are patients showing up late for their appointments? Answer: The doctor is usually 30 to 60 minutes late, and patients don’t want to wait to be seen so they arrive and check in 30 to 60 minutes after their designated appointment times.

Why is the doctor 30 to 60 minutes late by mid-morning? Answer: The doctor arrives for his office clinic 30 minutes late because patients usually are not taken to the exam rooms until 9:30. Instead the doctor goes to the computer to check e-mails.

Why are patients put in the rooms 30 minutes after their appointment times? Answer: The staff doesn’t arrive until 8:30 and is not ready to place patients in the rooms until 9:30.

Why is the lab data previously ordered not placed in the chart or recorded on the electronic medical record causing delays making decisions regarding patient care? Answer: The results have been sent to the office via fax but not recorded in the patient’s cart.

Solution: Start the day at 8:00 A.M. and start putting patients in the room at 8:45. Inform the doctor that he or she should arrive in the office by at least 8:45, allowing a few minutes to look at the computer, and that patients are to be seen starting promptly at 9:00.

Finding the Root Cause

The primary goal of the five whys is to take a problem and find the root cause so a solution can be identified and put in place. When done properly, a practice can find the root cause of most problems so that they can take actions to prevent it from happening in the future.

One of the best things about the five whys is that it is inexpensive to implement. A medical practice or a hospital can begin using it without added expense. The only cost is the time required to go through the process.

Why Look for the Root Cause

Most medical practices solve problems by identifying a problem and then using a quick fix for prompt resolution. In the long run, it is much better to identify the root cause of the issue and fix it—that will prevent the problem from occurring again. Seeking a root cause solution rather than just addressing the symptoms allows the practice to reduce recurrence (by dealing with the root cause, the symptoms are less likely to happen again in the future); prevent problems before they occur; gather information that identifies other issues that are impacting the practice; and place an emphasis on quality and safety over speed by avoiding a quick fix that temporarily solves the problem.

Every practice is unique, and all workplaces have their own set of problems that need to be dealt with. Implementing the use of the five whys can help medical practices to better understand their issues, and give them a clear roadmap on how those issues can be addressed permanently.

Getting Started with the Five Whys

The five whys system can be customized based on the specific needs of a given practice. Most practices or hospitals that are implementing this type of strategy will use some general rules or guidelines that can help keep the strategy focused on finding the root cause of the problem. Here are a few rules of performing the five whys:

Form the questions from the patient’s point of view. For example, when the practice runs behind schedule, patients are not happy that they are being seen 60 or even 90 minutes after their designated appointment. Another example would be that patients complain that they don’t receive results of lab tests or imaging studies until two or three weeks after the test or the procedure.

Keep asking or drilling until the root cause is discovered (even if more than five whys are required). This strategy is looking to find the root cause of the problem, not to place blame on any person(s) in the practice.

Base all statements on facts, not assumptions or hearsay.

Make sure to clearly distinguish the causes of problems from the symptoms of the problem (example: Doctor doesn’t start on time is a problem; Patients are upset is a symptom).

Involve physicians, nurses, administration, and ancillary personal as needed.

Focus on long-term success rather than short-term or quick-fix solutions.

Write down the problem at the top of a white board or flip chart and make sure that everyone understands the problem.

Try to make your answers concise and precise.

Be patient and don’t jump to conclusions.

Focus on the process, not on finding someone to blame.

Perform a root cause analysis as soon as possible after the error or variance occurs; otherwise, important details may be missed.

Explain that the purpose of the root cause analysis process is to focus on fixing or correcting the error and the systems involved. Make a point of stressing that the purpose of the analysis is not to assign blame but to solve problems.

Ask the question “Why?” until the root cause is determined. It is important to understand that in healthcare there may be more than one root cause for an event or a problem. The difficult part of identifying the root cause often requires persistence.

Finally, after the root cause is identified, conclude with the solution that will prevent the error from occurring again

It is this last step—identifying corrective action(s)—that will prevent recurrence of the problem that initially started the analysis. It is necessary to check that each corrective action, if it were to be implemented, is likely to reduce or prevent the specific problem from occurring.

The purpose of identifying solutions to a problem is to prevent recurrence. If there are alternative solutions that are equally effective, then the simplest or lowest-cost approach is preferred.

It is important that the group that identifies the solutions that will be implemented agrees on those solutions. Obtaining a consensus of the group that all are in agreement before solutions are implemented is important. You want to make every effort not to introduce or create a new problem that is worse than the original issue that you were attempting to solve.

The primary aims of root cause analysis are:

To identify the factors that caused the problem that may even result in harmful outcomes;

To determine what behaviors, actions, inactions, or conditions need to be changed;

To prevent recurrence of similar and perhaps harmful outcomes; and

To identify solutions that will promote the achievement of better outcomes and improved patient satisfaction.

To be effective, root cause analysis must be performed systematically using the five whys to drill down to the seminal event that initiates or produces the problem. The best result occurs when the root cause is identified and then backed up by documented evidence. For this systematic process to succeed, a team effort is typically required.

Bottom Line: Root cause analysis can help transform a reactive culture or one that moves from one crisis to the next into a forward-looking culture or a practice that solves problems before they occur or escalate into a full-blown crisis. More importantly, a practice that uses the five whys/root cause analysis reduces the frequency of problems occurring over time.

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Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott & White Health. January 6, 2016

Second Victim: Error, Guilt, Trauma, and Resilience. May 22, 2013

Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care. September 26, 2012

Patient Safety: An Engineering Approach. November 23, 2011

The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. October 19, 2011

Rethinking Patient Safety. May 24, 2017

Surgeon, Heal Thyself: Optimising Surgical Performance by Managing Stress. May 31, 2017

Healthcare Safety for Nursing Personnel: An Organizational Guide to Achieving Results. February 4, 2015

Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition. April 13, 2019

The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals. March 27, 2005

Patient Safety Culture: Theory, Methods and Application. January 21, 2015

The Public's Views on Medical Error in Massachusetts. December 17, 2014

Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm. July 7, 2021

Soaring to Success: Taking Crew Resource Management from the Cockpit to the Nursing Unit. October 26, 2011

The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making. January 27, 2021

After the Error: Speaking Out About Patient Safety to Save Lives. May 1, 2013

Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. August 2, 2017

Impact of Medical Errors and Malpractice on Health Economics, Quality, and Patient Safety. April 26, 2017

Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer. June 4, 2014

Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. June 25, 2008

Clinical Risk Management. Enhancing Patient Safety. 2nd ed. March 27, 2005

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. March 10, 2010

Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, Second edition. June 1, 2011

Practicing Medicine in Difficult Times: Protecting Physicians from Malpractice Litigation. August 13, 2008

Meltdown: Why Our Systems Fail and What We Can Do About It. February 6, 2019

Charting the Course: Launching Patient-Centric Healthcare. January 30, 2013

When Doctors Don't Listen. January 23, 2013

Building the Case for Health Literacy: Proceedings of a Workshop. August 8, 2018

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. April 20, 2022

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. November 15, 2023

All in Her Head. The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today. March 20, 2024

The good, the bad, and the ugly: operative staff perspectives of surgeon coping with intraoperative errors. June 14, 2023

Annual Perspective

Formalizing the hidden curriculum of performance enhancing errors. March 22, 2023

Impact of medical education on patient safety: finding the signal through the noise. February 8, 2023

Improved Diagnostic Accuracy Through Probability-Based Diagnosis. September 28, 2022

Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA. September 21, 2022

Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study. April 27, 2022

NCICLE Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, 2021. November 24, 2021

Developing critical thinking skills for delivering optimal care July 28, 2021

Resident-faculty overnight discrepancy rates as a function of number of consecutive nights during a week of night float. January 13, 2021

ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. November 18, 2020

Misdiagnosis, mistreatment, and harm - when medical care ignores social forces. April 8, 2020

Professionalism lapses and adverse childhood experiences: reflections from the island of last resort. August 14, 2019

Association of residency work hour reform with long term quality and costs of care of US physicians: observational study. July 24, 2019

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). June 26, 2019

Pediatric faculty knowledge and comfort discussing diagnostic errors: a pilot survey to understand barriers to an educational program. June 12, 2019

Health Professions Education. June 12, 2019

Associations between in-hospital mortality, health care utilization, and inpatient costs with the 2011 resident duty hour revision. May 15, 2019

Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors in clinical setting. April 10, 2019

Sleep and alertness in a duty-hour flexibility trial in internal medicine. March 13, 2019

Patient safety outcomes under flexible and standard resident duty-hour rules. March 13, 2019

"Does your knee make more of a click or a clack?"; teaching "Car Talk" to new docs. March 13, 2019

Teaching about diagnostic errors through virtual patient cases: a pilot exploration. February 27, 2019

Adjusting to duty hour reforms: residents' perception of the safety climate in interdisciplinary night-float rotations. February 20, 2019

Data omission by physician trainees on ICU rounds. February 6, 2019

Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care. January 16, 2019

Medical overuse as a physician cognitive error: looking under the hood. December 12, 2018

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How Critical Thinking Skills Apply to Healthcare

Critical Thinking Includes

• The skill to draw conclusions.
• The skill to troubleshoot and problem-solve.
• The capability to use skills or knowledge in a variety of situations.

Examples of Everyday Critical Thinking

• Thinking about what steps should to be taken to avoid an accident.
•  Creating a list that gives ability to accomplish every task efficiently and effectively.
• Thinking through the process and dealing with issues that might arise. (missing an ingredient needed for a dish or finding out that the vacuum cleaner is broken)

Examples of Work-Related Critical Thinking

• Deciding how to deal with a customer who is upset over service or bill to ensure a happy customer.
• Handling a disagreement with another coworker.
• Presenting an issue or proposal to the supervisor.

Examples of Work-Related Critical Thinking Situations

• If you have worked in customer service then the same critical thinking skills that are used to deal with customers will be used to deal with patients in the medical field .
• If you have worked in a fast-paced environment requiring prioritizing then you will carry that skill over to the medical field.

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Essential Soft Skills for Medical Assistants: Mastering the Art of Patient-Centered Care

In the role of a Medical Assistant, a blend of clinical skills and patient care expertise is essential for success. While technical competencies such as administering injections and performing laboratory tests are crucial, mastering essential soft skills allows Medical Assistants to provide compassionate, patient-centered care that significantly impacts the patient experience and overall health outcomes.

In this article, we will explore key soft skills every Medical Assistant should develop and refine throughout their careers. These skills include effective communication, active listening, empathy, teamwork, adaptability, and problem-solving. Additionally, we will discuss how Northwest Suburban College emphasizes the development of these critical soft skills and prepares students to become well-rounded healthcare professionals who excel in the dynamic and demanding medical field.

Join us as we delve into the qualities that set exceptional Medical Assistants apart from the rest, highlighting the importance of soft skills in facilitating positive patient interactions and creating a supportive healthcare environment. Discover valuable tips and strategies for refining these vital skills and learn how the Northwest Suburban College equips aspiring professionals with the tools necessary for a successful and rewarding career in patient-centered care.

1. Effective Communication and Active Listening

Effective communication is the cornerstone of quality patient care, allowing Medical Assistants to convey critical information, respond to patient concerns, and collaborate with colleagues efficiently. Active listening involves paying close attention to the speaker, showing empathy and understanding through nonverbal cues, and asking relevant follow-up questions. To improve these vital skills, consider these strategies:

– Be aware of nonverbal cues, such as facial expressions, body language, and tone of voice, to ensure messages are clear and compassionate.

– Paraphrase information and reflect it back to the speaker to demonstrate understanding and clarify inconsistencies.

– Utilize open-ended questions to encourage elaboration and gain a complete understanding of the patient’s concerns or needs.

By committing to honing communication and active listening skills, Medical Assistants can foster trust, rapport, and cooperation with both patients and healthcare team members.

2. Empathy and Compassion

Empathy and compassion are essential for providing patient-centered care and demonstrating genuine concern for each patient’s well-being. Tips for cultivating empathy and compassion as a Medical Assistant include:

– Practice putting yourself in the patient’s shoes, considering their feelings, fears, and frustrations when addressing their concerns.

– Remain nonjudgmental, as patients may be experiencing challenging situations or diverse backgrounds that may impact their healthcare needs and perspectives.

– Offer emotional support and encouragement during difficult medical circumstances, reinforcing the patient’s resilience and fostering a sense of comfort and trust.

By developing and maintaining empathy and compassion, Medical Assistants can offer genuine, heartfelt care that directly impacts patient outcomes and satisfaction.

3. Teamwork and Collaboration

Medical Assistants play an essential role in the healthcare team, working alongside physicians, nurses, and other medical professionals to ensure outstanding patient care. Effective teamwork and collaboration skills include:

– Clear and concise communication with colleagues, ensuring vital patient information is shared promptly and accurately.

– The ability to work harmoniously within diverse teams, understanding various roles, and respecting different viewpoints and approaches.

– Prioritizing collaboration and cooperation by offering assistance, listening to feedback, and being open to learning from colleagues with diverse expertise.

By investing in teamwork and collaboration, Medical Assistants can contribute to a harmonious, efficient healthcare team that delivers exceptional care to patients.

4. Adaptability and Problem-Solving

The dynamic nature of medical settings requires Medical Assistants to adapt to changing schedules, patient needs, and unexpected circumstances quickly. Being flexible and resourceful in the face of challenges is crucial to maintaining a high level of patient care and ensuring a successful career. Consider the following tips for enhancing adaptability and problem-solving skills:

– Embrace change with a positive attitude, acknowledging that growth and personal development often occur in response to challenging situations.

– Approach obstacles with patience, creativity, and a willingness to search for alternative solutions or perspectives.

– Develop the ability to prioritize and reorganize tasks efficiently, recognizing that prioritization is essential for maintaining quality care in the face of unforeseen circumstances.

By strengthening adaptability and problem-solving skills, Medical Assistants can remain composed and resourceful in fast-paced, ever-changing healthcare environments.

Cultivating Soft Skills for a Rewarding Medical Assistant Career

Mastering essential soft skills is crucial for Medical Assistants who aim to provide the highest quality of patient-centered care. By refining and honing skills such as effective communication, active listening, empathy, teamwork, adaptability, and problem-solving, Medical Assistants can significantly impact patient experiences and outcomes and succeed in their demanding, diverse roles.

The Northwest Suburban College is committed to preparing well-rounded healthcare professionals who excel in both technical and soft skills. Our comprehensive curriculum covers essential competencies while emphasizing the critical soft skills needed to thrive in the medical field. Learn more about our Medical Assistant program today and start developing the skills necessary for a successful, fulfilling career in compassionate, patient-centered care.

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• v.31(2); 2021 Apr

The Application of Engineering Principles and Practices to Medical Education: Preparing the Next Generation of Physicians

Mishan rambukwella.

Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111 USA

Aniksha Balamurugan

Henry klapholz, paul beninger, introduction.

Modern medicine is a dynamic, complex field that continually introduces new technology, seeks greater interconnectedness among disciplines, and faces increasing unpredictability about healthcare’s future landscape. It is surprising, then, that the current scope of typical allopathic medical education continues to focus largely on inpatient clinical experience and thus is inadequate to the task of training future physicians to cope with dynamic, systemic changes in areas such as digital health, quality improvement, personalized medicine, regulations, and reimbursement models [ 1 – 4 ]. Historically, academic medical education sought to address these gaps in education through the creation of combined degree programs, such as the MD/PhD, MD/MPH, and MD/MBA; these programs allow medical students to pursue training in the non-clinical, yet crucial, aspects of medicine including research methods, population health, healthcare delivery, and healthcare management science [ 5 – 7 ]. Given the increasingly technological nature of healthcare changes, MD/MEng [ 8 ] programs are now beginning to gain traction because they help students acquire technical interdisciplinary skills that bridge the gap between clinical medicine and the increasingly demanding technological dimensions of the healthcare environment. The growing popularity of these engineering-focused combined degree programs indicates a pressing need for future clinical professionals to acquire skills and expertise beyond the traditional medical curriculum. We propose ways in which to incorporate fundamental aspects of engineering education to help medical students acquire these skills.

The decades-long expansion of biomedical device innovation and the dramatic recent growth of digital health have expanded the opportunities for the fields of engineering and medicine to find common ground over the past several decades. The traditional medical school curriculum has a primary focus on training physicians to diagnose medical conditions and manage treatment courses; however, it offers little to equip future physicians with the skills needed to assess the clinical relevance of novel medical devices, operational changes, or new approaches to providing treatments for patients with unmet medical needs [ 9 ]. As of 2017, there are approximately 190,000 engineering degrees awarded annually, with a yearly growth rate of nearly 6% [ 10 ]. Nevertheless, only approximately 1–2% of graduating engineers apply to medical school [ 11 ]. Data collected from the Association of American Medical Colleges (AAMC) shows that engineering majors comprise only 3–5% of applicants and matriculants alike (Tables  1 and ​ and2) 2 ) [ 12 ]. In contrast, applicants with majors such as Biological Sciences make up an overwhelming majority of medical school applicants and matriculants [ 11 ]. Thus, while engineers are well-prepared to offer effective solutions to medical problems, only a small percentage of engineering graduates matriculate to medical school.

Raw data obtained from the AAMC showing the number of applicants to medical school with an engineering degree compared to the total number of applicants from the application cycles of years 2010–2011 to 2018–2019

Raw data obtained from the AAMC displaying the number of matriculants to medical school with an engineering degree compared to the total number of applicants from the application cycles of years 2010–2011 to 2018–2019

Why Engineering?

Engineering education is an interdisciplinary practice that emphasizes the application of scientific principles to find creative solutions to everyday problems that may have limited information available. Engineering requires both technical and inter-professional skills that blend creativity, collaboration, and experience with business acumen and entrepreneurship. An engineering education teaches students how to apply their knowledge and skills in a variety of occupations across many industry sectors [ 12 ]. Thus, the field of medicine stands to gain significant benefits from the contributions of students with engineering backgrounds.

Engineers have well-honed quantitative and analytical skills to solve problems, understanding that solutions often require an iterative approach. Thus, engineers have the perspective, expertise, creativity, and pragmatism needed to successfully craft new systems, methods, and processes to adapt to medicine’s highly dynamic environment. For example, three of the fourteen Grand Challenges for Engineering in the twenty-first century put forth by the National Academy of Engineering (NAE) involve healthcare [ 13 ]. These Grand Challenges were developed under the guidance of international technological experts to improve society through engineering. By including the theme of healthcare, the Grand Challenges exemplify the synergy that is needed between both fields. Specifically, these challenges are as follows: (1) to reverse engineer the brain, (2) to engineer better medicines, and (3) to advance health informatics.

In The Engineer of 2020: Visions of Engineering in the New Century , the NAE highlights key attributes of an engineer that are gained through appropriate education [ 14 ]. As shown in Table ​ Table3, 3 , these closely parallel the 15 core competencies for entering medical students set forth by the American Association of Medical Colleges (AAMC) [ 15 ]. The virtually complete overlap of these competencies points to the marked similarity of the fundamental skill sets that are needed in both the engineering sciences and medicine, which suggests that having a background in engineering could be helpful preparation for medical education. We highlight examples of how engineering training in problem-solving, innovation, systems-based thinking, collaboration, and interdisciplinary education can be translated to, and thus benefit, the field of medicine. We choose to highlight this subset of skills because they serve as a proxy for most of the core competencies listed in Table ​ Table3 3 and they provide the clearest examples of those aspects of engineering that are most applicable to medical education.

Comparison of the National Academy of Engineering key attributes with the 15 core competencies for entering medical students set forth by the AAMC

Problem-Solving

Physicians require strong problem-solving skills. Engineering is one of the few undergraduate disciplines that explicitly focus on application-based, analytical problem-solving that offers important clinical reasoning skills for future physicians.

Problem-solving in the engineering realm is grounded in the “engineering design process.” Though analogous to the hypothesis-driven experimental process, a key differentiating feature of the design process in engineering is the use of failures and unforeseen circumstances to adapt [ 16 ]. Although welcoming failure may seem counterintuitive to medicine, it, in fact, parallels medical practice. Medical students, residents, and practicing physicians alike are regularly faced with complex problems heavily weighted with either the potential for failure or the inability to solve a problem on the first try. For example, when the decision is made to treat a patient with depression with an antidepressant medication, treatment is usually initiated on a “trial and error” basis: a physician puts a patient on a “trial” of a certain antidepressant medication and adjusts dosing based on a patient’s response to treatment; there is no “one size fits all” approach for treating all patients, even for those who present with similar symptoms [ 17 ]. Thus, clinicians must optimize solutions for their patients through a range of strategies: dose titration, addition of another drug, or transition to another treatment modality altogether. Closely linked, iterative thinking processes, another engineering trait, are therefore essential to medical practice, which become second nature through years of training.

Engineering training is likely to improve a physician’s ability to understand the strengths and limitations of technologies that play an increasingly broader role in modern medicine. Likewise, a fundamental understanding of medical technology enables physicians to streamline patient care by redirecting their mental energies to patients themselves.

One approach to understanding technology and innovation is through design thinking and project-based learning, which are distinguishing features of an engineering education [ 18 ]. Design thinking is a method used to drive innovation and improve services in sectors such as healthcare [ 19 ]. Design thinking is often included as a capstone course in engineering education in which students translate an idea into a prototype. One of the initial steps of design thinking focuses on teaching students how to ask appropriate questions to define a problem that meets user criteria, given available resources. Other aspects of design thinking include considering system dynamics, reasoning about uncertainty, preparing estimates, and conducting experiments [ 18 ]. These aspects are directly transferable to the practice of clinical medicine when troubleshooting a broad range of issues, such as improving health outcomes, standardizing clinical processes, and reducing costs [ 20 ]. For example, during the early days of the COVID-19 pandemic, physicians were forced to create innovative solutions to help develop respirators and required personal protective equipment when faced with acute shortages of these items in the USA [ 21 ].

In another example, Dr. Herman Morchel, an emergency room physician at Hackensack Meridian Health, directly harnessed his engineering background to spearhead development of high-technology mobile emergency medical units, essentially intensive care units on wheels, as a way to extend critical care to where it was most needed while limiting spread of SARS-CoV-2 [ 22 ]. Such efforts, in addition to fostering an innovation-inclined mindset, greatly benefit from the design thinking process ingrained in engineering education.

Physicians with engineering backgrounds possess both clinical and technical skills that enable them to bridge the divide between engineering and medical disciplines to improve healthcare through technology. With the increasing popularity of technologies, including 3D printing, machine learning, and artificial intelligence, physicians with engineering backgrounds are uniquely positioned to contribute to medical education and biomedical research involving medicine, engineering, and technology. Additionally, since the implementation of new technologies in a medical setting is often quite challenging, physicians with engineering backgrounds are in the strategic position of being able to translate medical terminology into engineering jargon and vice versa, lessening the risk that valuable information will be lost in translation [ 9 ]. Furthermore, physicians with technical understanding are also able to facilitate physician buy-in regarding the integration of such new technology [ 23 ].

One clear example that shows how technology and innovation can come together in the healthcare setting is quality improvement (QI) initiatives. The expansion of these initiatives is due largely to the relatively recent requirements imposed by the US Accreditation Council for Graduate Medical Education (ACGME) that asks residency programs to provide QI education for medical trainees [ 24 ]. Individuals with backgrounds in design thinking, innovation, and technology are in an ideal position to identify and drive QI initiatives that occur at the rarefied intersections of technology with medicine, policy, and business.

Systems-Based Thinking

The human body can be viewed as a complex physiological system. An engineering perspective facilitates understanding of systems-based thinking of the human body’s physiological processes (e.g., modeling the cardiovascular system as an electrical circuit). Viewing these basic pre-clinical concepts through the lens of engineering can power the development of novel medicines and technologies.

Medical students are clearly expected to graduate with a competency in systems-level problem-solving abilities, according to the AAMC and the American Medical Association (AMA), but the means of attaining this competency and the degree to which it is integrated into students’ medical education are less clear. One proven method of teaching this skill is inclusion of design thinking and innovation-related collaborative activities into medical education, as described above [ 1 ]. However, documentation of competence in the application to systems-level problem-solving will require further research.

Collaboration

The importance of collaboration in medicine is well-established: it is widely accepted and appreciated that healthcare is a multidisciplinary field that requires close collaboration and communication among all of the different healthcare specialties and professions to deliver high-quality patient care. Additionally, medicine is a rapidly changing field that demands timely adaptability on the part of both the individual and the team. Thus, cross-functional communication is critical as patient cases are infrequently simple and uncommonly isolated to one profession or even one specialty. Finally, collaborative learning goes beyond simple crosstalk and seeks to instill values of shared goals, teamwork, trust, continual learning, individual responsibility, and self-discipline [ 25 ].

While most medical schools recognize the need for students to develop collaborative skills, attempts at teaching best practices are often overshadowed by the rigor and competitiveness of other required course material. Notably, for undergraduate students in the USA, pre-medical education encompasses the “formal curriculum as well as informal and hidden curricula”; collaborative learning remains largely a part of the hidden curriculum [ 26 ]. While certain pre-medical courses, such as biology and chemistry, may involve collaboration, such as having a partner for laboratory exercises, the emphasis is still placed on the individual and not on collaboration or teamwork. In fact, pre-medical curricular requirements generally include “weeder” courses that, to the contrary, emphasize competition among students based on exams, individual assignments, and letter grades [ 26 ]. Even those who seek additional opportunities, such as research or volunteer work, have no assurance that they will be exposed to team-based learning or collaboration, since these endeavors may be pursued in isolation, for example, under a fume hood or behind a desk. Once these students reach medical school, they may find it challenging or even uncomfortable to develop adequate flexibility in assuming roles and responsibilities in different team environments while they ascend the generally lock-stepped medical hierarchy as medical students, residents, fellows, and attending physicians.

Weak collaboration skills can also have detrimental effects on the students themselves: by choosing individual approaches to work habits over collaborative approaches for the sake of comfort, they could isolate themselves from potential peer support systems that are crucial to the development of resilience and success in medical school. It could be argued that, given the lack of insight needed to seek support from classmates, the under-emphasis of collaborative skills during pre-medical education may actually accelerate early withdrawal of students from the pre-medical track [ 26 ]. Furthermore, collaboration may be key to combating physician burnout and the resulting shortage of healthcare professionals in the USA.

In contrast, the cornerstone of the engineering field is an emphasis on collaboration: Engineers recognize that a complex problem is rarely solved by an individual. Instead, a team effort is required to produce a solution to a complex problem. While all engineering students must participate in a core curriculum of lower division courses that may be individually focused and initially exam-based, most upper division courses require extensive amounts of group work and collaboration [ 27 ]. This requirement leads to a learning environment that encourages students to efficiently resolve challenges arising from interpersonal conflict and to quickly adapt to changing roles throughout their educational journey.

While efforts at the medical school level to increase collaboration through small group sessions and problem-based learning are laudable, looking to the model of engineering education may help to solidify such skills earlier in the overall educational process and accomplish the task in more robust way.

Interdisciplinary Education

There is indirect evidence for medical school recognition of the importance of an engineering background. AAMC data from the application cycles of 2010–2011 to 2018–2019 show the matriculation rate for engineering majors is consistently greater (6.44–9.50%) than the average overall matriculation rate for applicants (Table ​ (Table4) 4 ) [ 11 ]. This finding suggests that students who complete engineering curricula are better positioned for admission to medical school than the general, non-engineering trained applicant, based on the attributes highlighted above.

Raw data from AAMC comparing the overall (general) matriculation rate of medical school applicants compared to the matriculation rate of those applying with engineering degrees from the application cycles of years 2010–2011 to 2018–2019

In a similar manner, there is an evident trend in interdisciplinary medical curricula related to engineering. The Carle Illinois School of Medicine, discussed below, is the first engineering-based medical school to focus on furthering improvement and innovation of patient care in this manner [ 28 ]. This trend is not a novel concept. For example, Dr. René Favaloro (July 12, 1923–July 29, 2000), a cardiovascular surgeon well-known for his contributions to the standardization of coronary artery bypass surgery, felt strongly that “individualism had to be replaced by collective interests… through daily preventive education” and that “projects are more important than disciplines” [ 29 ]. Thus, a new, interdisciplinary curriculum is proposed that integrates engineering with biological sciences to inform functional interoperability, exchanges rote memorization for applied knowledge, and sparks creativity [ 29 ]. This type of integrated curriculum could alter the relationship between medical education and biomedical research by encouraging physician-scientists to couple biomedical research with engineering and technology. As another example, select MD/PhD programs have established partnerships with engineering schools to take advantage of the intersection of their highly specialized knowledge and skills with rapidly advancing fields of medical technology [ 30 ].

The combination of engineering and medicine holds the potential to empower future clinicians to make an impact not only in medicine but also in the larger healthcare sector by leveraging the expertise needed to be at the forefront of healthcare innovation, entrepreneurship, and research [ 8 ]. Thus, the integration of engineering-related concepts into medical education should become more widespread.

Schools and Programs That Combine Engineering and Medicine

The Carle Illinois College of Medicine, created in partnership by the University of Illinois at Urbana-Champaign and the Carle Health System, is the first medical school in the world to incorporate engineering principles into the traditional medical school curriculum. Instead of compartmentalizing medicine and engineering, Carle synthesizes the fields of biological science, clinical applications, and engineering by course [ 28 ].

While not as integrated as Carle, other academic institutions also see the benefits of combining engineering training and medical education to tackle the complexity of modern medicine. By offering courses such as “Matlab for Medicine,” Harvard’s Health Sciences and Technology program, a collaboration with the Massachusetts Institute of Technology, encourages medical students to engage in interdisciplinary research, “bring clinical insights from the bedside to the bench,” and vice versa [ 31 ]. This program also requires student applicants to “be comfortable with mathematics and computational methods,” skills also required of engineering students [ 32 ]. The Health, Technology, and Engineering program at the University of Southern California (HTE@USC) brings together medical and engineering students through case-based instruction and project-based collaboration to identify and solve real-world healthcare problems [ 33 ]. As evidenced by these examples, there is growing appreciation of the fact that bench-to-bedside research is rarely a straightforward collaborative enterprise and that there may be a misalignment among the participants. For example, academia is often satisfied with publications and grants, but healthcare entrepreneurship requires further demonstration of proof of concept and implementation [ 34 ].

How Can We Implement These Ideas?

In our present and increasingly competitive drive for talent, medical schools and graduate medical education programs could benefit from updated programmatic approaches that specifically bridge the fields of engineering and medicine. The following recommendations discuss focused diversification of the student body through inclusion of engineering majors [ 1 , 2 ]; improvements in the medical curriculum through addition of engineering principles and collaborative work styles [ 3 – 5 ]; and structural measures to sustain programmatic changes through the establishment of new interdisciplinary societies and cross-disciplinary journals [ 6 ]. While the focus of these recommendations is best considered at the institutional level, that is, the Liaison Committee on Medical Education (LCME) and the ACGME, other stakeholders in medical education are welcomed to assist with their implementation:

• That medical schools develop policies and procedures that have greater flexibility with admissions requirements for non-traditional applicants. Barriers such as admissions committees’ negative perceptions of lower GPAs in engineering majors due to increased course units and academic rigor can prevent acceptance of engineering students into medical school programs. Flexibility with such requirements may increase applicant number and diversity and encourage prospective pre-medical students to pursue engineering majors. Additionally, an emphasis on the demonstration of collaborative activities through coursework or extra-curricular activities may facilitate earlier development of relevant skills that can then be honed in a healthcare context.
• That medical schools actively seek students with diverse educational backgrounds with experiences in an interdisciplinary field, such as engineering, the humanities, or social sciences. Such experiences are likely to enhance skills needed in medicine, such as adaptability and tolerance of ambiguity, and contribute to the diversity of medical professionals.
• That medical schools seek opportunities to integrate engineering principles and practices into the medical education curriculum. For example, a brief electrophysiology course in basic circuitry may better equip students to understand conductance and resistance related to the nervous and cardiovascular systems. Additionally, incorporation of a course in design thinking would increase capabilities in problem-solving, resilience, collaboration, innovation, and creativity. Inviting guest speakers such as engineers working on medically relevant projects may further contribute to and reinforce integration of engineering and medicine.
• That medical schools augment their curricula with early collaborative experiences to teach students how to seek support, thus inculcating habits that can foster lifelong resilience and success. Though exams are necessary preparation for standardized tests and individual responsibility, a greater proportion of team projects may overcome the hallmark rigors of medical school stemming from isolation and individual work.
• That graduate medical education programs incorporate engineering principles during training for residencies and fellowships in technologically heavy specialties such as radiology [ 35 ]. Emphasis on working with other medical professionals and offering master’s degrees in engineering disciplines may facilitate the development of innovative approaches to medical problems.
• That the medical profession establishes interdisciplinary societies and cross-disciplinary journals that emphasize careers in physician entrepreneurship and innovation. By harnessing problem-solving, systems-based thinking, collaboration, and interdisciplinary attitudes, these programs would encourage physicians to be at the forefront of medical innovation and technological implementation in the healthcare field.

It is imperative to track the effects of the aforementioned recommendations to understand their impact on medical students and medical education. Continuing to track the proportions of engineers in the applicant, matriculant, and graduate pools across medical schools will help us understand whether these changes have attracted more engineers to the field of medicine. Regarding academic and curriculum changes, serial assessments and surveys of students can provide further insight into ways that will continue to enhance medical education. For example, student grades and board scores can be tracked for performance outcomes as engineering principles are implemented in curricula. Additionally, students could be asked explicitly through surveys whether the incorporation of engineering principles facilitated better conceptual understanding and retention of key concepts after taking relevant board or certification exams. Similarly, after group projects, students may be surveyed about their experience and how they felt about working in a team. As students progress into clinical rotations and residencies, longitudinal surveys and evaluations incorporating clerkship directors and program directors can be used to track trainees’ willingness and adaptability to collaborate. These surveys could also be done within or across specialties. Innovation metrics can be tracked at different programs and institutions through numbers of intellectual property filings, joint ventures, publications, and general garnered interest in clubs and activities focused on technological advances. Finally, these changes, such as replacing individual exams with more group evaluations, may improve student well-being and mental health, and may ultimately be a factor in addressing physician burnout. Since we believe these recommendations will have a long-term impact on an individual student’s medical career, all outcomes can be tracked longitudinally to verify these hypotheses and help inform medical education practices.

Solving the challenges of a rapidly changing healthcare system requires training and expertise beyond the basic and clinical sciences of traditional medical education. We propose that greater inclusion of engineers into the ranks of healthcare providers, introduction of engineering principles and practices to medical education, and incorporation of the social skills crucial to both engineering and medicine are all necessary to drive the evolution of medical education.

Compliance with Ethical Standards

MR, AB, and HK report no conflicts of interest. PB was employed by Sanofi until his retirement in April, 2017. He has been a guest speaker at commercial venues, Proventa in 2018 and Veeva in 2019, that provided transportation and hotel accommodations, and he has been a consultant to pharmaceutical companies for less than 5% of his professional time.

Reported as not applicable

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Consortium identifies 5 grand challenges in biomedical engineering

A consortium of 50 renowned researchers from universities around the world, including Cornell Engineering, has published a paper establishing five grand challenges in biomedical engineering, which it said will lay the foundation for a concerted worldwide effort to achieve technological and medical breakthroughs.

The paper titled, “ Grand Challenges at the Interface of Engineering and Medicine ” published Feb. 21 in the IEEE Open Journal of Engineering in Medicine and Biology, and was the result of a two-day workshop organized by the IEEE Engineering in Medicine and Biology Society, the Department of Biomedical Engineering at Johns Hopkins University and the Department of Bioengineering at the University of California San Diego. Among the co-authors is Marjolein van der Meulen, the James M. and Marsha McCormick Director of the Meinig School of Biomedical Engineering at Cornell.

“The interface of engineering and medicine is important and growing, extending beyond biomedical engineering,” said van der Meulen, who is also a senior scientist in the Research Division of the Hospital for Special Surgery. “This workshop brought together leaders in the field to focus on critical areas for future progress, leading to the identification of five grand challenges. These challenges are an opportunity for engineering approaches and interdisciplinary teams to transform human health and disease.”

"What we’ve accomplished here will serve as a roadmap for groundbreaking research to transform the landscape of medicine in the coming decade,” said Dr. Michael Miller, senior author of the paper and professor and director of the Department of Biomedical Engineering at Johns Hopkins University. “The outcomes of the task force, featuring significant research and training opportunities, are poised to resonate in engineering and medicine for decades to come.”

Through the course of the workshop, the researchers identified five primary medical challenges that have yet to be addressed, but, by solving them with advanced biomedical engineering approaches, can greatly improve human health. By focusing on these five areas, the consortium has laid out a roadmap for future research and funding.

The five grand challenges facing biomedical engineering:

1. Bridging precision engineering and precision medicine for personalized physiology avatars In an increasingly digital age, we have technologies that gather immense amounts of data on patients, which clinicians can add to or pull from. Making use of this data to develop accurate models of physiology, called “avatars” – which take into account multimodal measurements and comorbidities, concomitant medications, potential risks and costs – can bridge individual patient data to hyper-personalized care, diagnosis, risk prediction, and treatment. Advanced technologies, such as wearable sensors and digital twins, can provide the basis of a solution to this challenge.

2. The pursuit of on-demand tissue and organ engineering for human health Tissue engineering is entering a pivotal period in which developing tissues and organs on demand, either as permanent or temporary implants, is becoming a reality. To shepherd the growth of this modality, key advancements in stem cell engineering and manufacturing – along with ancillary technologies such as gene editing – are required. Other forms of stem cell tools, such as organ-on-a-chip technology, can soon be built using a patient’s own cells and can make personalized predictions and serve as “avatars.”

3. Revolutionizing neuroscience using artificial intelligence (AI) to engineer advanced brain-interface systems Using AI, we have the opportunity to analyze the various states of the brain through everyday situations and real-world functioning to noninvasively pinpoint pathological brain function. Creating technology that does this is a monumental task, but one that is increasingly possible. Brain prosthetics, which supplement, replace or augment functions, can relieve the disease burden caused neurological conditions. Additionally, AI modeling of brain anatomy, physiology, and behavior, along with the synthesis of neural organoids, can unravel the complexities of the brain and bring us closer to understanding and treating these diseases.

4. Engineering the immune system for health and wellness With a heightened understanding of the fundamental science governing the immune system, we can strategically make use of the immune system to redesign human cells as therapeutic and medically invaluable technologies. The application of immunotherapy in cancer treatment provides evidence of the integration of engineering principles with innovations in vaccines, genome, epigenome and protein engineering, along with advancements in nanomedicine technology, functional genomics and synthetic transcriptional control.

5. Designing and engineering genomes for organism repurposing and genomic perturbations Despite the rapid advances in genomics in the past few decades, there are obstacles remaining in our ability to engineer genomic DNA. Understanding the design principles of the human genome and its activity can help us create solutions to many different diseases that involve engineering new functionality into human cells, effectively leveraging the epigenome and transcriptome, and building new cell-based therapeutics. Beyond that, there are still major hurdles in gene delivery methods for in vivo gene engineering, in which we see biomedical engineering being a component to the solution to this problem.

“These grand challenges offer unique opportunities that can transform the practice of engineering and medicine,” remarked Dr. Shankar Subramaniam, lead author of the taskforce, distinguished professor, Shu Chien-Gene Lay Department of Bioengineering at the University of California San Diego and past President of IEEE EMBS. “Innovations in the form of multi-scale sensors and devices, creation of humanoid avatars and the development of exceptionally realistic predictive models driven by AI can radically change our lifestyles and response to pathologies. Institutions can revolutionize education in biomedical and engineering, training the greatest minds to engage in the most important problem of all times – human health.”

This article was adapted with permission from an original version published by the IEEE Engineering in Medicine and Biology Society.

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Four of the biggest problems facing education—and four trends that could make a difference

Eduardo velez bustillo, harry a. patrinos.

In 2022, we published, Lessons for the education sector from the COVID-19 pandemic , which was a follow up to,  Four Education Trends that Countries Everywhere Should Know About , which summarized views of education experts around the world on how to handle the most pressing issues facing the education sector then. We focused on neuroscience, the role of the private sector, education technology, inequality, and pedagogy.

Unfortunately, we think the four biggest problems facing education today in developing countries are the same ones we have identified in the last decades .

1. The learning crisis was made worse by COVID-19 school closures

Low quality instruction is a major constraint and prior to COVID-19, the learning poverty rate in low- and middle-income countries was 57% (6 out of 10 children could not read and understand basic texts by age 10). More dramatic is the case of Sub-Saharan Africa with a rate even higher at 86%. Several analyses show that the impact of the pandemic on student learning was significant, leaving students in low- and middle-income countries way behind in mathematics, reading and other subjects.  Some argue that learning poverty may be close to 70% after the pandemic , with a substantial long-term negative effect in future earnings. This generation could lose around $21 trillion in future salaries, with the vulnerable students affected the most.

2. Countries are not paying enough attention to early childhood care and education (ECCE)

At the pre-school level about two-thirds of countries do not have a proper legal framework to provide free and compulsory pre-primary education. According to UNESCO, only a minority of countries, mostly high-income, were making timely progress towards SDG4 benchmarks on early childhood indicators prior to the onset of COVID-19. And remember that ECCE is not only preparation for primary school. It can be the foundation for emotional wellbeing and learning throughout life; one of the best investments a country can make.

3. There is an inadequate supply of high-quality teachers

Low quality teaching is a huge problem and getting worse in many low- and middle-income countries.  In Sub-Saharan Africa, for example, the percentage of trained teachers fell from 84% in 2000 to 69% in 2019 . In addition, in many countries teachers are formally trained and as such qualified, but do not have the minimum pedagogical training. Globally, teachers for science, technology, engineering, and mathematics (STEM) subjects are the biggest shortfalls.

4. Decision-makers are not implementing evidence-based or pro-equity policies that guarantee solid foundations

It is difficult to understand the continued focus on non-evidence-based policies when there is so much that we know now about what works. Two factors contribute to this problem. One is the short tenure that top officials have when leading education systems. Examples of countries where ministers last less than one year on average are plentiful. The second and more worrisome deals with the fact that there is little attention given to empirical evidence when designing education policies.

To help improve on these four fronts, we see four supporting trends:

1. Neuroscience should be integrated into education policies

Policies considering neuroscience can help ensure that students get proper attention early to support brain development in the first 2-3 years of life. It can also help ensure that children learn to read at the proper age so that they will be able to acquire foundational skills to learn during the primary education cycle and from there on. Inputs like micronutrients, early child stimulation for gross and fine motor skills, speech and language and playing with other children before the age of three are cost-effective ways to get proper development. Early grade reading, using the pedagogical suggestion by the Early Grade Reading Assessment model, has improved learning outcomes in many low- and middle-income countries. We now have the tools to incorporate these advances into the teaching and learning system with AI , ChatGPT , MOOCs and online tutoring.

2. Reversing learning losses at home and at school

There is a real need to address the remaining and lingering losses due to school closures because of COVID-19.  Most students living in households with incomes under the poverty line in the developing world, roughly the bottom 80% in low-income countries and the bottom 50% in middle-income countries, do not have the minimum conditions to learn at home . These students do not have access to the internet, and, often, their parents or guardians do not have the necessary schooling level or the time to help them in their learning process. Connectivity for poor households is a priority. But learning continuity also requires the presence of an adult as a facilitator—a parent, guardian, instructor, or community worker assisting the student during the learning process while schools are closed or e-learning is used.

To recover from the negative impact of the pandemic, the school system will need to develop at the student level: (i) active and reflective learning; (ii) analytical and applied skills; (iii) strong self-esteem; (iv) attitudes supportive of cooperation and solidarity; and (v) a good knowledge of the curriculum areas. At the teacher (instructor, facilitator, parent) level, the system should aim to develop a new disposition toward the role of teacher as a guide and facilitator. And finally, the system also needs to increase parental involvement in the education of their children and be active part in the solution of the children’s problems. The Escuela Nueva Learning Circles or the Pratham Teaching at the Right Level (TaRL) are models that can be used.

3. Use of evidence to improve teaching and learning

We now know more about what works at scale to address the learning crisis. To help countries improve teaching and learning and make teaching an attractive profession, based on available empirical world-wide evidence , we need to improve its status, compensation policies and career progression structures; ensure pre-service education includes a strong practicum component so teachers are well equipped to transition and perform effectively in the classroom; and provide high-quality in-service professional development to ensure they keep teaching in an effective way. We also have the tools to address learning issues cost-effectively. The returns to schooling are high and increasing post-pandemic. But we also have the cost-benefit tools to make good decisions, and these suggest that structured pedagogy, teaching according to learning levels (with and without technology use) are proven effective and cost-effective .

4. The role of the private sector

When properly regulated the private sector can be an effective education provider, and it can help address the specific needs of countries. Most of the pedagogical models that have received international recognition come from the private sector. For example, the recipients of the Yidan Prize on education development are from the non-state sector experiences (Escuela Nueva, BRAC, edX, Pratham, CAMFED and New Education Initiative). In the context of the Artificial Intelligence movement, most of the tools that will revolutionize teaching and learning come from the private sector (i.e., big data, machine learning, electronic pedagogies like OER-Open Educational Resources, MOOCs, etc.). Around the world education technology start-ups are developing AI tools that may have a good potential to help improve quality of education .

After decades asking the same questions on how to improve the education systems of countries, we, finally, are finding answers that are very promising.  Governments need to be aware of this fact.

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Consultant, Education Sector, World Bank

Senior Adviser, Education

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