Clinicians today need strong critical thinking skills in order to properly diagnose and treat patients. That’s one reason why it is critical for educators to help medical students cultivate these skills early in their training.

“Teaching critical thinking and clinical reasoning is the most transformational part of medical education. It’s a fundamental shift in how our students and how our learners think,” explains Jeremy Richards, MD, MA, FACP, ATSF, an assistant professor of medicine at Harvard Medical School. 

The Power of Critical Thinking

“It’s fascinating to see how, by the end of medical school, students exposed to critical thinking look at information differently and process it differently, which enables them to come up with conclusions in a different way,” Richards says. “Critical thinking helps clinicians think like a detective, so they can start to see information and put it into categories that help them to make a diagnosis,” he adds. 

“Let’s say a patient has a collection of symptoms. You can rule out certain causes to help narrow down the right diagnosis. You start to sort things in different ways, and then group them to make a case for an explanation or a diagnosis for a patient’s symptoms,” he says. To accomplish this, clinicians need to have the vocabulary, the concepts, and the experience to rule out—or keep in—a diagnosis.

“This requires the skills to analytically assess the patient without letting emotion, context, fatigue, or burnout come into the equation,” Richards says. “You need to say: ‘These are the facts, and here is how I’m going to interpret them.’ That’s the critical reasoning, or the systematic, analytic, logical approach to all of this data, to be able to analyze it in a way to come up with a conclusion that’s sound.”

Critical Thinking in Action

Richards offers this example: A patient comes in with very common symptoms, such as a cough, shortness of breath, and chest pain. Without learning more about the circumstances, a clinician may initially think that the person has pneumonia. But as the clinician gathers more information, this assumption could change. Perhaps they learn that the patient has had these symptoms for three months, and that the symptoms have been getting progressively worse, especially when they lie down at night or climb the stairs during the day. With these additional facts, the clinician shifts away from pneumonia as a diagnosis and moves toward heart failure. “As this example illustrates, clinicians are constantly gathering data, reassessing it, and dynamically reanalyzing in the moment. This is critical thinking,” Richards stresses. 

How to Incorporate Analytical Skills

To prepare the next generations of clinicians to objectively think in this way, the training needs to begin at the earliest stages of medical school, he says. “The question becomes: How do you start building skills in the classroom setting that will ultimately be applied in taking care of a patient?” He says it all comes down to finding new ways to connect the lessons to the actual experiences of real patients.

“Medical students have always had to learn these basic foundational things about cells and bones and genes,” he adds. But in the past, the focus was on these basic science principles and there wasn’t much teaching about how to apply these concepts in the clinical setting. Yet it’s the connections to real people that are at the heart of medicine—and, in fact, these connections are why most learners want to become clinicians in the first place, Richards points out.

Three Key Pillars of Critical Thinking

Richards stresses that it is essential for medical educators to make a concerted effort to build critical thinking skills into their curriculums. To do so, they must consider three key pillars:

1. Using case-based learning: “The first pillar is to really contextualize everything in cases, in patients, and in the care of other human beings,” he says. This means that rather than just teaching straight anatomy without any context, educators need to teach anatomy (or genetics or histology or any basic science) with a direct, explicit, meaningful link to the patient. Such case-based learning helps learners to start to use that information and understand how they can apply it in the care of patients.
2. Talking about thinking: “The second critical pillar is to be explicit about clinical reasoning and critical thinking,” Richards says. “You need to talk about how we reason and talk about strategies, or how we use our brains to process information effectively or ineffectively.” In the past, medical educators haven’t talked about how clinicians think and how their brains work from a cognitive psychological perspective. “That’s a missed opportunity to help actively form and optimize the process of how learners think—including our errors in thinking, or cognitive biases, which is where we let our emotions or preconceptions negatively affect our rational thinking,” he says.
3. Applying key principles: “The third pillar is applying those principles you’ve learned,” Richards says. “We’ve used simulation a lot to help our learners practice thinking and clinical scenarios to work through patient cases in a safe, nonjudgmental, active environment.” This means that instead of just talking about practices in the classroom, learners, even early in medical school, are applying their reasoning to patient care in a semi-clinical setting. In addition to helping to reinforce what they learn, medical students also get a chance to feel what it’s like to care for patients. “They are hands on and have a chance to realize if medicine is for them, and to become hooked early on,” he says.

Assessing Critical Thinking Skills

While building critical thinking and reasoning skills will continue to be a key focus for medical educators moving forward, Richards points out that finding effective ways to assess students’ abilities in this area poses a challenge for most programs.

“How do educators really know when their student is able to think critically or not? This has been a subject of research and medical education interest for decades,” he notes.

“It’s not sufficient in 2024 to just have knowledge and know a lot of facts. Learners need to be able to process those facts, synthesize them in the context of a patient’s symptoms or problems, and then apply those facts in a way that results in a meaningful, logical, patient-centered plan of care,” Richards says.

While a number of very broad tools attempt to assess critical thinking skills, he says that they are not particularly accurate; so new ways of evaluating these skills need to be developed. 

“Therefore, thinking about holistic assessments of clinical learners and how we see them and evaluate them in applying their critical thinking skills is something we need to be concerned about as a medical education community,” he adds. 

Richards serves as program director of Harvard Medical School’s Training to Teach in Medicine, an intensive six-month online certificate program that prepares clinical educators from around the world to instruct the next generation of medical professionals.