Using the same word to mean different things (e.g., using "man" to mean humankind and later to mean man as opposed to "woman")
Allowing Time for Reflection
Teaching students how to use critical thinking skills shifts teaching from a model that largely ignores thinking to an approach that renders it pervasive 43 When content is didactically taught, it is treated as static and students are unlikely to question or think it through. They tend to rely on rote memorization without grasping the logic, supporting evidence and application of what they are trying to memorize. Students who learn through a critical thinking process truly learn content. At every level, students need to learn how to:
Ask questions precisely, define contexts and purposes, pursue relevant information, analyze key concepts, derive sound inferences, generate good reasons, recognize questionable assumptions, trace important implications, and think empathetically within different points of view (p. 20). 44
Critical thinking is difficult and requires overt practice using a variety of learning activities across the dental curriculum. It is also important to recognize the role that reflection plays in its development. Students need time to think about what they are learning and reflect upon that information. However, what they are learning must have an impact on their feelings in order for critical thinking to occur.
Emotions and Critical Thinking
The role of emotion in learning to use critical thinking skills is yet another area that necessitates research inquiry. As Zull suggests, if we want students to retain concepts we must allow them to put things into their own words, verbally and in writing. 45 Give students time to think before speaking and better construct ideas in their own words. Processing information takes time; stating one's thinking correctly also takes time. If a student cannot do this alone, we can give him or her the opportunity to discuss questions with others. Giving students time to reflect is giving them time to make connections.
Zull explains the process that takes place within the brain. First, the sensory cortex receives sensory input or concrete experiences. Next, the back integrative cortex tries to create meaning and images during the human process of reflection. The frontal integrative cortex is responsible for short-term memory and problem solving, making decisions and language, and making judgments and evaluations. This activity is akin to how learners handle abstractions-manipulating images and language to create new mental arrangements. The motor cortex triggers all coordinated and voluntary muscle contractions. This matches with the action that completes the learning cycle-actively testing abstractions and converting ideas into physical actions. The brain visualizes items in small amounts and all information arrives at the same time, producing an outline of objects and features in the visual field. 46 Thus, the brain can fully see great detail and nuance. Converting ideas into images helps students learn. Images enhance recall and aid in discovery. Sometimes the best teaching is just showing the student how.
To ensure that students learn, educators need to limit the amount of information they give. Instructors should limit or condense to three or four pieces the amount of information they want students to process.
The amygdala is responsible for screening experiences. 47 If something is recognized as dangerous, the amygdale will instinctively cause the body to "freeze." When a student first encounters something new, he or she may have a somewhat negative reaction. The instructor needs to find a way for the student to move into a more positive emotional territory. 48 Making suggestions or showing examples can remind the student what he or she already knows, and then the student can hang newly acquired knowledge on that "scaffolding." The support given by the instructor allows the student some level of success. Recognizing his or her success helps the student feel more hope, interest, and curiosity. At this point, the student is able to assume more control of the learning process. Boyd (2002) concurs and states, "emotions ... constantly regulate what we experience as reality." She also points out, "The limbic system plays an important role in processing emotion and memory and therefore appears to be important in the transfer of short-term memory into long-term memory." 49 Engaging students emotionally and actively strengthens memory.
Teaching students to use CTS during instruction
There is some empirical evidence that a four-year undergraduate experience contributes to modest gains in overall CT. However, there is little scientific evidence that a single course, other than a critical thinking skills course makes a positive measurable difference. 50 Even in the case of a specific CTS course, the evidence is mixed. 51
Recent studies show that limited efforts to infuse critical thinking in instruction can lead to improved scores on the Cornell Critical Thinking Test Level Z, a test that is aimed at a sophisticated audience and measures six common critical thinking skills. 52 Allegrettti and Frederick (1995) reported pre- to post-test gains on the Cornell Z for a group of college seniors (n = 24) who took a capstone integrated psychology and philosophy course. 53 Solon (2001) found that a partial treatment group of psychology students (n = 26) improved their scores on the Cornell Z compared to a group of untreated humanities students (n = 26). The results were statistically significant (beyond .001). In 2003, Solon studied three groups to compare coursework effects and reported that the full treatment group (n = 25) significantly outscored both the partial (n = 25) and non-treatment (n = 25) groups on the Cornell Z test. 54 Solon (2007) reported that a group of introductory psychology students (n = 25) received a moderate infusion of critical thinking skills (10 hours instruction and 20 hours homework). Compared to the non-treatment group (n= 26), the experimental group significantly improved their scores on the Cornell Z test. 55 These findings suggest that even a moderate infusion of critical thinking skills instruction can result in enhanced reasoning skills without requiring a significant investment from the instructor. 56
Collins and Onwuegbuzie reported significant relationships between overall CTS and achievement in a graduate level research methodology course at the midterm (r = .34, p < .01) and final (r = .26, p < .01) stages. 57 Onwuegbuzie compared the CTS of master's and doctoral level students. He reported that doctoral level students (n = 19) obtained statistically higher overall CTS using the California Critical Thinking Skills Test than the masters' degree students (n = 101, t = -3.54, p < .01). The effect size (d = 0.92) associated with this difference was extremely large. 58
Teaching CTS requires instruction that uses higher order taxonomic skills. These skills require student demonstration or teacher usage of behaviors classified as analysis, evaluation, and creation (levels 4, 5, and 6 on Bloom's revised taxonomy). When teaching takes place at higher levels of learning, lower order behaviors such as remembering, understanding, and applying are subsumed within instruction. The following table lists behaviors common at each level of learning and examples of related dental education activities.
Table 6. Revised Bloom's Taxonomy, Sample Verbs, and Related Learning Activities 59
Taxonomic Levels from Highest to Lowest | Sample Verbs | Dental Learning Activity |
Level 6-Creating | Synthesize, organize, deduce, plan, present, arrange, blend, create, devise, rearrange, rewrite | A prosthodontics patient, age 62, has two fixed mandible bridges that have deteriorated over the last two years due to poor hygiene. These bridges now need replacement. You are a recent dental graduate in practice with two senior partners. The senior partners suggest taking impressions and replacing the fixed bridges. You have read the recent literature on dental implants and would offer the patient this option. You also recognize that implants are more appropriate to the patient's needs and that over time they represent a cost savings. However, the senior partners are not really familiar with state of the art information about implants. Develop a plan for responding to the senior partners inwhich you provide an evidence-based rationale for suggesting the use of dental implants. |
Level 5-Evaluating | Critique, defend, interpret, judge, measure, test, select, argue, award, verify | Two patients, aged 18 months and 10 years, have cleft palate. Neither patient has been seen by health professionals or treated for this condition until now. Based on a complete summary of the dental, medical, social, and psychological health of each child, develop a treatment plan using authoritative and credible sources. |
Level 4-Analyzing | Determine, discriminate, form, generalize, categorize, illustrate, select, survey, take apart, transform, classify | A 32-year-old white male arrives at your office and presents with pain and swelling over the "upper right canine tooth" for the past three days. His medical history is remarkable for GERD, for which he takes Prilosec daily, and a penicillin allergy (rash over his torso and fever after taking Keflex). Your exam reveals intraoral and extra oral swelling over tooth #6. A radiograph reveals radiolucency with caries under the crestal bone (nonrestorable). What are your concerns? How would you treat and prescribe? |
Level 3-Applying | Convert, demonstrate, differentiate between, examine, experiment, prepare, produce, record, discover, discuss, explain | After completing textbook readings about the basics of periodontology, explain with images the progression of periodontal disease from the perspective of pathogenesis. Choose lay terms appropriate for use with a patient. |
Level 2-Understanding | Differentiate, fill in, find, group, outline, predict, represent, trace, compare, demonstrate, describe | State four or five reasons that rubber dam isolation is essential during endodontic procedures. |
Level 1-Remembering | Define, distinguish, draw, find, match, read, record, acquire, label, list | From a list of 10 options, choose the five items associated with a periodontic pocket. |
Making Critical Thinking Explicit
Teaching for critical thinking is a rational and intentional act. Typically, instructors cannot suddenly decide to teach CTS and develop an appropriate learning activity. An instructor must have a clear understanding of what CTS is, how it is implemented during instruction, and what strategies should be used during particular classroom and predoctoral clinical learning activities. Developing a repertoire of well-honed CTS activities appropriate to your specific discipline is advisable.
Also crucial to the teaching of CTS is an educator announcing to students he or she will teach CTS, how he or she intends to do so, and what will be required of the students as learners. It is important to have an explicit conversation with students about what CTS is, what it looks like, and how educators will model it so students can differentiate the teaching of CTS from lower level learning. Effective teaching of university-age students is characterized by collegial and collaborative processes, not instruction that is ambiguous. In ambiguous instruction, the learner does not know what to expect next or have a clear understanding of what behavioral or skill changes he or she should demonstrate as a result of teacher-student interaction. Teaching explicitly helps ensure that less re-teaching will be necessary. Both teachers and students know their responsibilities as instructors and learners.
Stages of Critical Thinking
Paul and Elder claim that individuals progress through predictable stages of unreflective, challenged, beginning, practicing, advanced, and master thinking. 60 They state that unless educators help students develop an intellectual vocabulary for discussing their thought processes and challenge them to identify the problems in their thinking, the students' cognitive processes will remain invisible to them. The implication for curriculum development: If instructors want students to develop critical thinking skills, then critical thinking must be integrated into the foundations of instruction.
It is also important to recognize that when patient care is task focused, it can obscure the bigger picture and become a barrier to the development of critical thinking skills. Individual personality, background, and position might also limit one's ability to think critically. Additionally, gender, age, religion, and socioeconomic status might influence the development of critical thinking skills. One of the biggest barriers to the development of CTS is our educational system. Although it is important to recognize these attributes as potential barriers, it is more important that dental educators establish the kind of learning environments that will foster the development of CTS.
Case #2-Why Are Mrs. Connor's Teeth Yellow?
Mrs. Connor, a 74-year-old white female, comes to your office as a new patient. She presents you with a complaint that her teeth have become yellowed and unattractive. Her husband died one year prior, and since then she has been drinking 8-10 cups of coffee daily. Her internist diagnosed anemia and high blood cholesterol. She is taking iron and Lipitor. She feels better since she began taking Lipitor, but feels her teeth are too yellow. She recently met a widower who invited her to dinner next week. She is worried about the appearance of her teeth.
Teachers must recognize that not all students will apply critical thinking skills at the same rate they learn these skills. Thus, instructional methods and objectives need to match students' cognitive and experiential abilities while trying to stretch students to their growing edge. 61 Students' capacity for self-directed learning (SDL), which is required to implement reflective judgment, underlies many of the critical thinking skill dispositions. 62 There is evidence that the students who routinely use the "learn by doing" approach to explore problems develop more sophisticated SDL than students in lecture-based curricula. 63 The reflection element of critical thinking is considered essential to clinical judgment. 64 Tanner asserts that using the skills associated with reflective thinking prepares students for ill-structured or ambiguous problems that they are likely to encounter in clinical practice. 65
Problem-based learning (PBL) is a popular instructional strategy for promoting collaboration and reflection and negotiating different and individual constructions of knowledge. Some researchers assert that PBL is best used when problems are unsolvable or when they generate many individual constructions of knowledge that appear valid. 66 However, using only problem-based learning to teach critical thinking skills may not be enough. This instructional strategy does not necessarily equip students with the ability to analyze or critique a given situation or the information with which they are been provided. A variety of instructional strategies that give students the opportunity to think aloud, role play, prioritize alternatives, communicate conclusions effectively, simulate, or defend the logical basis of their thinking is recommended to foster students' ability to use critical thinking.
Asking students to apply their understanding of dental and medical knowledge to treatment planning and diagnosis is not an example of CTS. However, asking students to determine differential diagnoses of caries and periodontal disease among patients at various stages of lung cancer requires the ability to reason and justify particular treatment plans or demonstrate critical thinking skills. Habits of the students who demonstrate critical thinking are:
(a) | Making logical inferences | |
(b) | Offering opinions with reasons | |
(c) | Evaluating | |
(d) | Grasping principles | |
(e) | Classifying | |
(f) | Making criteria-based judgments | |
(g) | Making evidence-based decisions | |
(h) | Reflexivity |
Case #3-Female with Erythroplakia
Mrs. Jacklin, a 40-year-old female, presents you with a history of SLE and erythroplakia on the left lateral border of the tongue. She states she is experiencing a burning sensation on her tongue. She asks why she is having this discomfort and what she can do to make the sore on her tongue go away. The oral exam shows that Mrs. Jacklin has poor oral hygiene and mild dry mouth (xerostomia) but is otherwise not in danger for oral health concerns.
Critical thinking is not :
(a) | Applying what you have learned in decisionmaking and treatment planning | |
(b) | Keeping students awake, interested, and motivated | |
(c) | Linear or step-by-step thinking |
Critical thinking cannot be taught in a learning environment where the dental educator always lectures, tells students what ought to be undertaken during patient treatment, or shows students how to do a procedure correctly. Some habits of students who do not use critical thinking skills are:
(a) | Disorganization (in thought processing, preparation, and behaviors) | |
(b) | Overly simplistic thinking ("I had enough information. There was no need to ask for additional information.") | |
(c) | Use of unreasonable criteria ("If my belief is sincere, evidence to the contrary is irrelevant.") | |
(d) | Erratic use of facts (Looking only at the area of interest, he offered biased interpretations of the radiographs.) |
Critical thinking skills can be developed with frequent practice and the use of ill-structured problems and situations that require the ability to recall useful knowledge quickly, use pattern recognition, discern pertinent information, think ahead, and anticipate outcomes and problems while remaining composed so that emotions do not hinder decisionmaking skills. However, it is important to recognize CTS do not develop spontaneously or with maturation. Since strong personality components underlie CT dispositions, what happens if students admitted to colleges of dentistry do not already possess these traits?
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