A Preceptor’s Guide to Critical Thinking

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A Preceptor’s Guide to Critical Thinking

Suzanne Larson, PharmD, Director of Experiential Education, Midwestern University College of Pharmacy-Glendale

Janet Heather Cooley, PharmD, Director of Experiential Education, University of Arizona College of Pharmacy.

Acknowledgement None

Funding This research was not funded.

Conflict of Interest The authors declare that there are no conflicts of interest.

Over the last several decades of pharmacy practice, pharmacists have transitioned from being the stewards of drug knowledge and the dispensers of medication to professionals providing direct patient care in a variety of settings. To meet the demands of the rapidly evolving pharmacy practice landscape, it is essential that both didactic and experiential pharmacy educators help students develop the skills needed to think critically and to use clinical reasoning to work through the complex medication-related issues presented to pharmacists. With an increase in misinformation over the past several years, teaching students to think critically has never been more important. Ideally, skills and abilities in thinking should be taught during didactic education and reinforced through experiential learning. Reflect on your own education and experience in pharmacy school. Were you ever given a lecture or received a course that taught you how to think? Most of us would claim that the ability to think critically was infused as a “hidden” curriculum, something that is eventually learned but may not have been taught intentionally. Perhaps now is the time to coordinate efforts and devise an approach to teach thinking skills explicitly, not to simply model or imply these skills. The purpose of this article is to describe the importance of critical thinking for pharmacy learners and provide a framework for including critical thinking questions and concepts into Introductory (IPPE) and Advanced Pharmacy Practice Experiences (APPE). Due to their real world setting with clinical and logistical challenges, pharmacy preceptors are uniquely positioned to help pharmacy students grow in their ability to think critically and use sound clinical reasoning skills to provide patient care. But first, a disclaimer. Neither author is an expert in neuroscience or critical thinking. We are humble pharmacists who are also preceptors, academicians, and experiential education administrators. In these roles, we strive to improve and refine our own thinking, and to foster improved thinking for our students. We have personally sought to understand and apply the critical thinking model by Paul and Elder to pharmacy practice and pharmacy precepting.1 Much of our understanding of this topic is based on the works of Linda Elder and Richard Paul, the founders of the Foundation for Critical Thinking.1 An overview of their work can be found at www.criticalthinking.org.

2 For the purposes of this article, critical thinking can be defined as the art of analyzing and evaluating the process of thinking, with a goal of improving these processes.1 It is a way of thinking that is self-directed, self-disciplined, self-monitored, and self-corrective.1 Clinical reasoning can be defined as a mental process in which a health care provider engages in analytical and non-analytical reasoning and reflection to make clinical decisions.3 In other words, clinical reasoning is critical thinking applied to patient care. Why should pharmacy preceptors seek to improve the thinking of their students? Humans think. Essential elements of being human are thinking, making meaning, and finding connections. We think all the time. Yet, when left to itself, thinking is flawed, biased, and self-serving. Critical thinking is a way to take charge of our own cognitive processes with a view to limit unsound thinking and expand critical thought. The physician Ronald Epstein makes a profound statement in his book entitled Attending: Medicine, Mindfulness, and Humanity: “I’d need to be guardian of my patients’ health and also of my own ‘inner operating system’ in each moment. Awareness of my own mind might be one of the most important tools I could have in addressing patients’ needs.” (Epstein p.3).4 As pharmacists and pharmacy preceptors, we can work on our own thinking as we simultaneously promote and stimulate critical thought in our learners, thus improving what Epstein refers to as “awareness of our own mind.” From the perspective of Paul and Elder, the critical thinking model can help us analyze, evaluate, and improve our thinking processes, which can be impactful for both preceptors and students alike.1 The Paul and Elder model is based on a framework that uses three areas to improve thinking: standards, elements, and intellectual traits.1 The standards of critical thought must be applied to the elements of critical thought as we learn to develop intellectual traits. 1 The standards (Table 1), elements (Table 2), and intellectual traits (Table 3) are summarized below.

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Standards What this means Application questions for the learner

Clarity Understandable; the meaning can be grasped

Can you elaborate further? Can you please give me an example? Accuracy Free from errors or distortions How could we make sure this is true? Can you please provide me a reference? Precision Exact to the necessary level of detail Could you be more specific? Could you give me more details?

Relevance Relating to the matter at hand How is this related to what we are talking about? How will this help us solve this problem?

Depth Containing complexities and multiple interrelationships What makes this a difficult question? What are some of the complexities of this case?

Breadth Encompassing multiple viewpoints Do we need to look at this from another perspective?

Logic The parts make sense together; no contradictions

Significance Focusing on the important; not trivial

Fairness Justifiable; not self-serving or one-sided

How did you come to this conclusion? How does this all fit together? Is this the most important issue to consider? Which of the facts are most important? Are we being fair to everyone now? Are we considering the feelings of others in this situation?

Adopted from Paul and Elder1

Table 2 – The elements of critical thinking, definitions for each element and example questions that could be used to help a learner apply each element to their thinking.

Elements What this means Application questions for the learner

Purpose Goal, objective, functions What is our purpose in doing this?

Questions Problem or issue What questions are we trying to answer?

Information Data, facts, reasons, observations, experiences

What information do I need? To what extent is your reasoning supported by data? Interpretation and inference Conclusions, solutions What conclusions am I coming to? Are there other conclusions that I should consider?

Concepts Theories, definitions, laws, principles, models

Assumptions Presuppositions, axioms, taking for granted Implications and consequences

Point of view

That which follows logically, the effects Frames of reference perspective, orientations, world view

Adopted from Paul and Elder1 What are the main ideas I am relying on in my thinking? What am I taking for granted? Am I assuming something I shouldn’t?

If we do “X”, what will happen?

How am I looking at this situation? Is there another reasonable point of view?

Intellectual Traits What this means Application questions for the learner

Intellectual integrity

Hold yourself to the same standards to which you hold others

Intellectual autonomy Value independence of thought

Intellectual perseverance Refuse to give up easily; work your way through complexities and frustration

To what extent are there contradictions or inconsistencies in how I handle clinical issues?

Do I think through clinical issues on my own or just accept conclusions and judgments of others?

How can I keep working through complex clinical issues?

Intellectual empathy Learn to enter opposing views empathetically Can I listen to others with opposing viewpoints and accurately represent their side of the discussion? Can I actively seek to understand others’ reasoning?

Intellectual humility Strive to discover the extent of your ignorance

What do I really know about this issue? To what extent might my prejudices, attitude and experiences bias my judgement? Intellectual courage Develop the courage to change popular beliefs How can I speak up for what I believe is right?

Confidence in reason Respect evidence and reasoning and value them as tools for discovering truth Am I willing to change my position when evidence leads to a more reasonable position?

Adopted from Paul and Elder1

The standards, elements, and intellectual traits of critical thought listed above make sense and provide a map that can be used to evaluate one’s own thinking or the thinking of a learner. While this framework is logical and intuitive, it can also feel overwhelming to incorporate terminology and a framework that may be unfamiliar to a preceptor. A preceptor seeking to improve thinking using the Paul and Elder framework may wonder where to begin. One strategy that may be helpful is to print the tables used in this article and place them in a prominent setting, easily visible during precepting hours. Perhaps a bulletin board, a desktop screensaver, in a lab jacket pocket, or affixed to a clipboard could help keep the standards, elements, and intellectual traits front-of-mind and prompt questions that promote critical thought. More specifically, preceptors could also use the standards of critical thought to help a learner take a deeper dive into a patient case, or to explore a student’s depth of understanding during a formal or informal topic discussion. A preceptor could utilize the elements of critical thought for journal club presentations, patient chart review, or the interpretation and assessment of clinical or non-clinical data. Applying the intellectual traits of critical thought may be helpful to a preceptor as they help guide the student to develop affective abilities (such as a student’s feelings and attitudes), professional traits, the ability to evaluate social determinants of health, or assess a patient’s readiness to begin a behavior modification plan. In addition, when a preceptor is providing formative feedback to a student, instead of simply telling the student where and how they went wrong, consider instead using the questions in the tables above to help students self-assess and develop their critical thinking skills. Consider this example. You are precepting an APPE student and you note a problem with your patient’s antibiotic order. Recognizing a learning opportunity, you ask your student to review the patient’s record and identify the problem. The student responds with recommendations for renally adjusting the patient’s antibiotic dose. While the student correctly identified that the ordered dose was inappropriate for the patient’s renal function, you were hoping that the student would see that a more significant problem was that the patient is allergic to this antibiotic. You continued on next page 9

could correct the student and move on. However, time permitting, this could be an opportunity to make a lasting impression and help the student improve their thinking. You could help the student apply the standards of critical thinking to the patient’s case by asking some of the example questions. For example, to help the student consider the standard of assumptions, you could ask, “I appreciate that you noticed the patient’s impaired renal function, but it looks like you have missed something. Is this the most important problem to consider? Have we considered all of the patient’s specific factors?” Or you could help the student apply the elements of critical thinking, such as the element of assumptions, by posing questions like, “Are there other conclusions you should consider? Are you making any assumptions?” Finally, with this same example, the student could be guided to demonstrate the intellectual traits of autonomy by searching for the answer independently, or the intellectual trait of perseverance to keep working on the case until they see what they are missing. While on a rotation, our learners encounter a significant amount of information and it is hard to know how much will be retained long term, but helping a learner think critically can be a lasting gift that impacts every aspect of their life. The critical thinking guidelines presented here may seem esoteric, but pharmacists should be thinking critically in every professional decision. If the purpose of our rotation is to simply impart information, our students will be disadvantaged in a changing clinical landscape and new developments. But if we can help our students improve their thinking, their careers and lives will be impacted indefinitely. BF Skinner penned a similar sentiment with these words, “Education is what survives when what has been learned has been forgotten.”5 

REFERENCES

1. Paul R and Elder L. The Miniature Guide to Critical

Thinking: Concepts and Tools. London: Rowman and

Littlefield; 2020. 2. Criticalthinking.org [internet]. The Foundation for Critical

Thinking; [cited 2022 Feb 17]. Available from: http://www. criticalthinking.org/ 3. Newsom L, Augustine J, Funk K, Janke K. Enhancing the

“What” and “Why” of the PPCP with the “How” of Clinical

Reasoning. Am J Pharm Educ. Epub Aug 2021 4. Epstein R. Attending: Medicine, Mindfulness, and Humanity.

New York: Scribner; 2017. 5. Skinner BF. New Methods and New Aims in Teaching. New

Scientist. 1964; 122.

For adult patients with T2D, treated with diet and exercise For adult patients with T2D, treated with diet and exercise

When pills are no longer enough When pills are no longer enough

OZEMPIC ® IS INDICATED TO REDUCE THE RISK OF MACE OZEMPIC ® IS INDICATED TO REDUCE THE RISK OF MACE for adults with T2D and established CVD1,a

for adults with T2D and established CVD1,a

Ozempic®—The only type 2 diabetes treatment with

Ozempic®—The only type 2 diabetes treatment with greater results vs Trulicity®b and study-titrated Lantus® , greater results vs Trulicity®b and study-titrated Lantusand as add-on to basal insulin1,2 ® , and as add-on to basal insulin1,2

UNMATCHED GLYCEMIC CONTROL Superior results vs Trulicity® (in SUSTAIN 7) and as add-on to basal insulin, and statistically significant results vs study-titrated Lantus®1,2

aMajor adverse CV events (MACE) composed of CV death, nonfatal MI, or nonfatal stroke. bIn SUSTAIN 7. cWeight change was a secondary endpoint in clinical trials. dResults apply to Ozempic® plus standard of care vs standard of care alone in SUSTAIN 6. T2D=type 2 diabetes; CVD=cardiovascular disease; CVOT=cardiovascular outcomes trial; CV=cardiovascular; MI=myocardial infarction.

SIGNIFICANT WEIGHT REDUCTION1,2,c Ozempic® is not indicated for weight loss

UNMATCHED

GLYCEMIC CONTROL SIGNIFICANT REDUCTION

Superior results vs Trulicity® (in SUSTAIN 7) IN RISK OF MACE1,d

and as add-on to basal insulin, and as evaluated in a 2-year statistically significant results vs CVOT vs placebo

study-titrated Lantus®1,2 See results on page 3 See results on page 4 See results on page 2 aMajor adverse CV events (MACE) composed of CV death, nonfatal MI, or nonfatal stroke. bIn SUSTAIN 7. cWeight change was a secondary endpoint in clinical trials. dResults apply to Ozempic® plus standard of care vs standard of care alone in SUSTAIN 6. T2D=type 2 diabetes; CVD=cardiovascular disease; CVOT=cardiovascular outcomes trial; CV=cardiovascular; MI=myocardial infarction.

SIGNIFICANT WEIGHT REDUCTION1,2,c Ozempic® is not indicated for weight loss

SIGNIFICANT REDUCTION

IN RISK OF MACE1,d

as evaluated in a 2-year CVOT vs placebo

See results on page 3 See results on page 4 See results on page 2

Indications and Limitations of Use Indications and Limitations of Use

Ozempic® (semaglutide) injection 0.5 mg or 1 mg is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus and to reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, or nonfatal stroke) in adults with type 2 diabetes mellitus and established CV disease. • Ozempic® has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. • Ozempic® is not indicated for use in patients with type 1 diabetes mellitus.

Important Safety InformationOzempic® (semaglutide) injection 0.5 mg or 1 mg is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus and to reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, or nonfatal stroke) in adults with type 2 diabetes mellitus and established CV disease. WARNING: RISK OF THYROID C-CELL TUMORS • In rodents, semaglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures. It is unknown whether Ozempic® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in • Ozempic® has not been studied in patients with a history of pancreatitis. Consider other antidiabetic humans as human relevance of semaglutide-induced rodent thyroid C-cell tumors has not been determined.therapies in patients with a history of pancreatitis. • Ozempic® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine • Ozempic® is not indicated for use in patients with type 1 diabetes mellitus. Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk for MTC with the use of Ozempic® and inform

them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring

of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Ozempic® .

Important Safety Information

WARNING: RISK OF THYROID C-CELL TUMORS

• In rodents, semaglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures. It is unknown whether Ozempic® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in

humans as human relevance of semaglutide-induced rodent thyroid C-cell tumors has not been determined.

• Ozempic® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine

Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk for MTC with the use of Ozempic® and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Ozempic® .

Please see additional Important Safety Information throughout. Please see additional Important Safety Information throughout. Please see Prescribing Information, including Boxed Warning, at https://www.novo-pi.com/ozempic.pdf. Please see Prescribing Information, including Boxed Warning, at https://www.novo-pi.com/ozempic.pdf.

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