JDE
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

J Dent Educ. 73(1): 65-82 2009
© 2009 American Dental Education Association
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Chambers, D. W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chambers, D. W.

Educational Methodologies

Lessons from Students in a Critical Thinking Course: A Case for the Third Pedagogy

David W. Chambers, Ed.M., M.B.A., Ph.D.

Key words: critical thinking, reflective practice, research methods, situated learning, aptitude, learning organizations, pedagogies

Submitted for publication 06/06/08; accepted 09/28/08


   Abstract
Top
 Abstract
Teaching and Learning about...
 Materials and Methods
 Results
 Discussion
 References
 
There have been many calls for strengthening the level of critical thinking among dental students and faculty members, but few analyses of how such curricular experiences actually affect them. This report provides a rich, multifaceted description of eight years’ experience teaching a course in critical thinking. Among the data analyzed were a) course materials and learning experiences, b) student products demonstrating critical thinking, c) tests of subject matter knowledge, d) content analysis of what students and faculty members find problematic, e) a test of critical thinking aptitude, f) two personality inventories, g) measures of didactic and clinical performance, and h) student comments and evaluation of instruction. These data support the view that critical thinking involves more than knowledge and application of skills relative to science and research that can be taught using traditional didactic methods. Personality factors emerged as predictive of both critical thinking and clinical performance, and students’ approaches to learning appeared to be influenced by their practical considerations of what is needed to practice, rather than by the logic of good science. This analysis argues for designing curricula on the full concept of competency (knowledge, skills, and values needed to function as a dental practitioner) and for exploring a third pedagogy of reflective practice to supplement the traditional ones of didactic and skill teaching in dental education.

Critical thinking is increasingly recognized as important in dental education, but there is some lumpiness in the way the concept is understood and used. I have heard it used as a synonym for the scientific method, as a description for clinical problem-solving, as the attitude that makes evidence-based dentistry (EBD) go, as the goal of new educational approaches such as case- or patient-based teaching or problem-based learning (PBL). I have seen curricula and read grant applications that propose to teach critical thinking as a set of didactic procedures and others that imply or even state that seminar or clinical teaching automatically produces students who are critical thinkers. Educators have told me that critical thinking is problem-solving ability in specific contexts, innate logical or deductive reasoning, mastery of the rules of research design and statistical analysis, curiosity and other personal orientations, or just plain clinical wisdom. Very likely, critical thinking is some combination of most of these elements and more than any of them. The article that follows is frankly large and ranges over many perspectives. That is appropriate to our current nascent understanding of critical thinking in dental education. Multiple methods are used—from grounded observation to surveys to analysis of work samples of critical thinking. Multiple hypotheses are tested, but the question "what is critical thinking?" is left open for as long as possible before attempting a synthesis. The conclusion that is offered is that critical thinking extends beyond the traditional cognitive and psychomotor skills taught in dental schools and thus requires a new, additional educational approach called tentatively the "third pedagogy."

As a starting point, I have used an almost primitive definition of critical thinking in order to avoid prejudicing what is on the table for consideration. Critical thinking means being able to give reasons for what one says and does.1,2 These reasons should be acceptable to one’s peers, and the skill of grounding practice in reason should be general, extending to almost all of one’s activities and to the evaluation of novel practices.3,4 Sharing an expectation of reason giving marks one as a member of a community of reflective practitioners and advances a profession generally.5 The public and self-correcting nature of reasons works to ensure continuously more accurate and useful knowledge.

At the University of the Pacific dental school, critical thinking in this general sense is among the competencies expected of both students and faculty. The school’s competency statements #58 and #59 speak of critical thinking as a blend of understanding, skills, and values sufficient to "Evaluate scientific, lay, and trade information and claims about new products and procedures" and "think critically, solve problems, and base dental decisions on evidence and theory." In a values clarification exercise completed by students, faculty members, alumni, and staff at the school, improving critical thinking received the highest ranking among thirty-three alternatives as a goal for the school. The Commission on Dental Accreditation also addresses this competency in standard 2–23: "Graduates must be competent in the use of critical thinking and problem-solving related to the comprehensive care of patients." The dental educational literature contains many articles noting the need for students to think critically.6–26

This article describes evidence and reflections on eight years of working with dental students and faculty members on critical thinking competencies. It is also suggested that critical thinking is learned and used in a different fashion than are subject matter knowledge and psychomotor skills.


   Teaching and Learning About Critical Thinking
Top
 Abstract
 Teaching and Learning about...
Materials and Methods
 Results
 Discussion
 References
 
My experience at Pacific and from visiting other academic dental institutions suggests that the prevailing approach for improving critical thinking among dental schools is didactic, meaning that students learn from being told and shown by expert faculty members how to use the best science and how to think about the role of science in practice. Readings, web resources, seminars, and other projects often supplement, but do not fundamentally alter, the basic approach. It is natural to use this traditional dental school pedagogy when critical thinking is presumed to be essentially a cognitive skill that is to some extent free of application context. This model for teaching science to dental students is built on a "transfer of information metaphor"—a linear flow from researchers to practitioners, with a didactic "pump." In this approach, faculty members who are knowledgeable and use these methods as researchers or as practitioners instruct students about the value and methods of research.8,11,13,15,18,21,27–33 If these clinical or research experiences are sufficiently numerous and interwoven with feedback, a case could also be made that dental education’s second pedagogy, skill learning, is being used in some situations to teach critical thinking.

From the students’ and the practitioners’ perspectives, critical thinking and the scientific foundations of dentistry may not be as rational and skill-based as they appear to be to scientists who are interested in dental topics. Novices do not understand the relationships between scientific concepts and their clinical applications the same way research or clinical experts do—even when they can perform relevant tasks under controlled circumstances.34–36 Knowing the rules of science and even having the skill to apply them in controlled circumstances may not be a strong indicator of critical thinking performance.37

It is possible for students to be critical of the science supporting dentistry without being critical thinkers. Consider these illustrations noted in seminars. A student criticized a study comparing electric and manual toothbrushes because it was not double-blinded. Another student challenged a large-sample, randomized controlled trial comparing two pain medications because "any patient may have different psychological interpretations of pain." It was commonly heard that studies with designs open to bias could be repaired with larger sample sizes. Larger sample sizes were also thought to be an effective means for reducing standard deviation or increasing correlation coefficients. A student appealed to "lack of long-term trials" and "no meta-analyses" to justify his continued routine extraction of asymptomatic third molars and to reject minimally invasive procedures for caries management. The same student saw no relevance in the absence of long-term trials to the use of bleaching or flowable composites. To be fair, journal reviewers occasionally make the same kinds of mistakes.

In these examples, students have confused "being critical" with "critical thinking." They have tools, but are not yet skilled in using them. The critical frame of science and the critical frame of practice are not identical. Critical thinking goes beyond understanding the canons of scientific reasoning to entail their appropriate incorporation into clinical decision making, which might be characterized as "applied critical thinking," i.e., applying some fundamental rules of rational analysis to the intertwined tasks of patient assessment, diagnosis, and treatment planning.3,38–42 Thus, the presentation and evaluation of critical thinking must also extend beyond the traditional didactic and skill approaches. Literature review seminars in residencies and some courses for predoctoral students occasionally are designed to teach "gotcha" techniques, as though the goal of reading the literature were to find flaws that had slipped past reviewers. In the course to be described below, the goal was to teach students to identify and express the most useful clinical applications that could be validly defended based on the literature under consideration.

Applied critical thinking is likely to be a complex and uneven performance. At one level, the project of teaching critical thinking is to present information that will bring all students to a uniform level of knowledge. At a deeper level, we must explore the full range of factors that account for students’ habits of reflection on practice and which among them can realistically improve the use of these skills in dental practice. Consideration of some of these factors leads to the hypotheses that follow.

Faculty Members as Expert Critical Thinkers
Faculty members who stress critical thinking tend to be seen by students as part of the conduit through which critical thinking and the scientific foundations for practice are transferred to students. Using a knowledge-transfer metaphor, teaching critical thinking can be conceptualized as informing, modeling, and providing opportunity for practice with feedback, so students come up to the level of critical thinking knowledge and skill of some faculty members.8,11,13,15,18,21,27–33 The universal practice of characterizing dental curricula in terms of clock hours and even in terms of faculty presentation behavior supports the view that the faculty possesses or can tap into a standard body of scientific foundations for dental practice and critical thinking skills.

Hypothesis #1: A combination of lectures and seminars taught by qualified faculty members will bring dental students to a uniform acceptable level of critical thinking ability.

Scientific Reasoning as Foundation Knowledge
It is customary to use tests of knowledge or performance in simulations as measures of dental learning. Multiple-choice tests are almost exclusively used in this fashion to gauge the proportion of material presented by faculty members that is retained and demonstrated by students at the end of a course. In some schools, tests measuring knowledge of research design, inference from the literature, drawing conclusions from graphs, counterhypotheses, statistical probability, etc. are employed to assess the outcomes of teaching critical thinking. It is assumed that students who demonstrate comprehension of research methodology or problem-solving ability will be able to apply this knowledge in practice settings.

Hypothesis #2: Students with greater knowledge of the conventions of research will perform better in situations requiring critical thinking.

Logical Reasoning as a Basis for Critical Thinking
There appears to be a component of logical reasoning in critical thinking. Students who are not comfortable with deep distinctions or chains of logical inference might be prone to overlook important differences or accept stated conclusions uncritically, even when they know the rules of scientific logic. Viewing critical thinking as a logical aptitude analogous to "hand skills" could provide a rationale for skills-based pedagogies. Williams et al. recently reported an association between the California Critical Thinking Skills Test and performance of dental hygiene students on the National Board Dental Hygiene Examination43 and early clinical reasoning skills.44

Hypothesis #3: Students who score higher on a standardized test of logic will perform better in situations requiring critical thinking.

Personal Orientation Toward Critical Practice
Psychologist Carol Dweck45,46 has studied the relationship between motives and outcomes of learning. Some students take an instrumental approach to learning: they get the projects done because of a sense of obligation to the process and to get grades for graduation, graduate school, or honors. For students of this type, learning is a means to an end, and abilities have a fixed nature. Other students learn for intrinsic reasons: they are interested in the material and value personal growth. It is not possible to distinguish between these two types of students based on structured outcome measures—they both get results under controlled circumstances. However, it is possible to predict certain differences in patterns used in learning, such as time spent on task, persistence in the face of obstacles, transfer of learning to new applications, and even propensity to engage in academic dishonesty.46

Some of the research Dweck draws on includes the constructs of "achievement motivation" and "fear of failure." Studies performed in the 1960s through 1980s47 established that orientation toward success entails setting realistic goals, persistence in the face of disappointment, and acceptance of personal responsibility for outcomes. Research also demonstrates that those who are oriented toward avoiding failure set unrealistically high or low goals, give up more quickly following failure, and are apt to blame circumstances for undesirable outcomes. The constructs of achieving success or avoiding failure are weakly correlated with each other: an individual may score moderately high (or low) on both.

A psychologist at Columbia University, E. Troy Higgins,48 has advanced a more contemporary version of this dichotomy. He divides the world into those who are oriented toward promotion and those who are oriented toward risk prevention. Promotion-oriented individuals are concerned with ideals, advancement, aspiration, and accomplishment (including removal of unwanted or damaging conditions). They are easy to spot because they are eager and positive. Prevention-oriented individuals are concerned with security, conformance with rules (even when they bitterly complain about them), safety, responsibility, protection, and the prevention of unwanted outcomes. They are cautious. The distinction Higgins is making is not exactly the same as striving for success versus avoiding failure, and although similar, it also differs slightly from the distinction between beneficence and non-malfeasance. It is an orientation toward positive outcomes (getting the good ones and getting rid of the bad ones) versus preoccupation with negative outcomes (minimizing mistakes and errors). Higgins’s proposed distinction in personal orientation closely resembles the distinction between sensitivity and specificity of tests.

Developing critical thinking skills is a process involving multiple interactions with opportunities to evaluate potential courses of action and the evidence that supports them. Hence, orientations that predispose students and faculty members toward reacting to evidence and the outcomes of using it could result in strong or weak acquisition of these skills.

Hypothesis #4: Students who have personalities characterized by seeking success will perform better in situations requiring critical thinking because of more realistic goal setting, persistence in the face of ambiguity, and personal responsibility for outcomes.

Hypothesis #5: Students with an orientation toward prevention will perform better in situations requiring critical thinking because they are more vigilant to potentially risky situations and because the value of "first, do no harm" dominates in the health professions.


   Materials and Methods
Top
 Abstract
 Teaching and Learning about...
 Materials and Methods
Results
 Discussion
 References
 
The research reported here is based on multiple sources of data, ranging from classical psychometric analysis of performance and aptitude tests to detailed descriptions of course material and experiences and direct quotations from field notes compiled by the author from observation or teaching in parts of over 100 seminars. This rich foundation is necessary to support investigation of the complexity of critical thinking in context.

The critical thinking course at the University of the Pacific dental school is allotted ten hours in the quarter immediately preceding the last quarter of the school’s three-year curriculum. Formal instruction consists of four one-hour lectures, each based on a reading assignment, and a seminar presentation. Each student also participates in a single one-hour seminar and prepares individual written assignments. By spreading the seminars across the six weeks of the course when lectures were not given and by using multiple teams of faculty members each week, seminar size is kept at between four and six students. This permits sufficient time for students to make their presentations (see Table 1Go for the topics assigned) and to provide student critiques of each other’s work. Faculty teams consist of two or three faculty members, almost always clinical faculty members in specialty disciplines. Early experience showed the importance of multiple faculty members (even with a small number of students) because the tasks of both directing discussion and providing verbal and written feedback are demanding. Faculty members are trained in leading discussions. Observation by the course director revealed that the number of questions is approximately equal to the number of statements made by faculty members and that it is exceedingly rare that a faculty member speaks more than two consecutive sentences.


View this table:
[in this window]
[in a new window]

  		Table 1. Data sources gathered in investigating a course in critical thinking
 
Work samples gathered during the course included the following:

  1. Summaries written by students of the four lecture-related readings, faculty assessments of seminar presentations, a single-sentence statement from each student of the role science is expected to play in their practices, and a 500-word critique of an assigned advertisement. (See Table 1Go.) The above-mentioned items constituted the basis for assigning grades in the course. Of the four summaries related to readings for the lectures, the first was a warm-up, and the final three were scored for logical reasoning evidenced in describing "the strongest conclusion that can be defended based on the article or advertisement." Critical thinking errors were also coded in the final written critique of an advertisement.
  2. Students completed three inventories that were not graded but were scored to better understand their critical thinking skills. (See Figure 1Go.) One was a traditional, eighteen-item multiple-choice test of research design and interpretation of the literature. Three parallel forms of the test were used. The second inventory was either the first seventeen or the last seventeen items on the California Critical Thinking Skills Test, a commercially available test of logic that does not require knowledge of any specific content domain. The final inventory was a twenty-item personality questionnaire created by the author for purposes of this research. Nine of the items on the personality inventory were patterned on the work of Smith et al.,47 reflecting the classical dimensions of "achievement motivation" and "fear of failure." The reminder of the inventory contained eleven items from Higgins et al.49 measuring the constructs of "promotion" and "prevention" orientation.
  3. Additionally, for each of the four readings that students summarized in conjunction with course lectures, students were required to highlight or underline concepts they could not confidently define and return these marked-up articles to the course director. The course director provided definitions of highlighted concepts to students with two days of each lecture, from his own knowledge or in consultation with other faculty members, as well as frequency counts on unfamiliar concepts.


Figure 1
View larger version (115K):
[in this window]
[in a new window]

  		Figure 1. Representative items from test of knowledge of the scientific dental literature

 

   Results
Top
 Abstract
 Teaching and Learning about...
 Materials and Methods
 Results
Discussion
 References
 
The results are grouped and will be presented under these eight headings: distribution of knowledge 1) among faculty members and 2) in the school in general; 3) logical errors detected among students; 4) components of the course grade; predictors of course grade, including 5) knowledge of scientific approach and the dental literature, 6) logical reasoning aptitude, and 7) personality orientation; and 8) student satisfaction with the course.

Distribution of Knowledge
Observation of almost thirty faculty members in more than 100 seminar sessions challenges the hypothesis that critical thinking skills in dentistry are well established in the faculty at the school studied and that they can be transmitted directly by faculty members to students. Two trends emerged in the data collected for the critical thinking course at the University of the Pacific: 1) critical thinking skills in the application of science to dental practice are not the same as research expertise, and 2) knowledge, including knowledge of dentistry generally, is not uniformly distributed throughout the faculty.

Faculty as Experts
Twenty-eight faculty members have participated in seminars in the critical thinking course during the past eight years. Only two of these individuals had conducted funded research. Of the twenty-three faculty members in the school who are biomedical scientists (individuals with Ph.D. degrees in biological sciences) or who have been funded, none has led a complete set of four critical thinking seminars. This is not an indictment against the interests of these faculty members. It is a self-assessment of the difference in logical approach between conducting research and assessing the applicability of science to dental practice. As one biomedical researcher said at the end of helping to lead a single seminar session, "I don’t feel I am qualified to help much with these students. The kind of science I do is fundamentally different from the decisions dentists have to make about whether to use various products or procedures. I am unfamiliar with many of the tests in the dental literature."

Faculty members modeled a practice-oriented, open-minded, reasoned approach to evaluating claims found in the literature. They often asked students to go beyond first impressions. Some faculty members were observed to have their "favorite faults in the literature"; one universally cautioned that larger samples were required; another urged that all commercially supported research should be disregarded. Because the seminar sessions had multiple faculty members present, such hobbyhorses were placed in context.

The Lumpiness Hypothesis
Traditional, teacher-centered approaches to dental education draw our attention away from the uneven distribution in what is actually known by individuals in dental schools. Seminar observation and work with articles in which students (and then faculty members) identified concepts that were unfamiliar to them are summarized to show that 1) dental knowledge is unevenly distributed among faculty members in dental schools; 2) faculty members assume that such knowledge is uniformly distributed, with a small variance, among students; 3) gaps in knowledge are seldom recognized and often of no practical consequence; and 4) mechanisms exist to protect against much of the damage that could be caused by gaps in knowledge.

Students were asked to identify unfamiliar concepts in the four journal articles or sets of advertisements they read. (See Figure 2Go.) The vast majority of concepts (76 percent) identified by students as being unfamiliar were ones related to biomedical disciplines. Research or statistical concepts and clinical terms were less unfamiliar—13 percent and 11 percent, respectively. A small fraction of the unfamiliar terms were common English words, such as "curator," "differential," or "facet," used in unusual circumstances or never learned by some students.


Figure 2
View larger version (90K):
[in this window]
[in a new window]

  		Figure 2. Sample of feedback related to concepts students found unfamiliar in course readings

 
Where concepts were unknown by the course director, the course director consulted faculty members in appropriate disciplines. In as many as three-quarters of the cases, faculty members could not provide satisfactory definitions. For example, the term "chromophore" was defined by faculty members as "something that makes bleaching work," "some sort of chemical," and "I don’t know." In that particular case, the fourth dentist who was consulted said he would let the course director know and, twenty minutes later, provided a two-paragraph email describing the concept in great detail. "Substance P" was discussed meaningfully by three of seven dentists asked; one of the four who had no clear idea of what "substance P" is was a practicing endodontist. A common response among faculty members in the biomedical sciences was "that’s not in my discipline. You’ll have to ask Dr. X (in a different biomedical sciences department)." As a general rule, there were always one or more faculty members who could provide authoritative and detailed definitions of the terms identified by students as being unfamiliar. However, the distribution of familiarity with concepts was very uneven among both students and faculty members. Some of the terms in the literature, as confirmed by correspondence with the authors, were neologisms.

In contrast to the skewed distribution of familiarity with dental concepts appearing in the literature and in advertisements that emerged from the review of unknown terms identified in this course, it is the author’s experience that faculty members tend to function on the premise that students have acquired a uniform and complete set of dental concepts. It is apparent that students are assumed to be substitutable across courses, but faculty members are not. Paradoxically, faculty teachers expect, and work to produce, a range of student performance. The consequences of specialized faculty and designed uneven distribution of knowledge and skill among students makes lumpiness inevitable.

The third part of the "lumpiness hypothesis" is that gaps in knowledge seldom matter. In the first place, gaps are underrecognized. Nine terms identified as unfamiliar by fewer than 10 percent of students (and thus presumed familiar to more than 90 percent of students) were included on the test of knowledge given to students as part of the course. Despite students’ receiving written definitions of these terms prior to the test, the average score for these items was 56 percent—somewhat above a one-in-four blind guess but certainly not close to the 90+ percent who failed to identify these terms as being unfamiliar when encountering them in the literature.

One important reason why lumpiness is under-recognized is that context often supplies the missing scaffolding necessary for effective functioning in the absence of conceptual understanding. The sense of a journal article or decisions regarding products or procedures can be understood without knowing the meaning of every concept germane to the topic. As an example, of the seven faculty members who were asked and who use CDT4 codes in their billing, none could identify what the three initials "C," "D," and "T" stand for.

The final part of the "lumpiness hypothesis" is that individuals, both students and faculty members, protect themselves from appearing to have lumpy knowledge. The most common form of this shielding was to report what the person does know about any related topic rather than state, "I do not know the information you are seeking."

Critical Thinking and Course Grade
Logic errors on course projects were common (see Table 2Go). Only 17 percent of students avoided all errors on the five assignments (three summary papers, the statement on the role of science in practice, and the critique of the advertisement). The most common error (71 percent) was unsupported criticism of a claim made in an article ("There might have been bias" [without explaining what that bias could be or why it would be reasonable to expect bias]). Logical non sequiturs were also made by more than half the students. An example of this logical error would be the criticism that a significant difference for treatment intervention involving a drug and prophylaxis compared to a prophylaxis alone is inconclusive because there is no control group. Another type of non sequitur was stating a true fact as a conclusion of an article when it functioned as an assumption. (It may be true that substance P mediates pain, but if the data in the study do not test this claim, it cannot be a conclusion of the study.) "Thin arguments" involve incomplete reasoning; for example, "Other (unspecified) studies might come to different conclusions," "The study was pretty good," or "The group that received the treatment was better" (where the comparison group was not specified). Arguments by definition were the least common form of error. Examples included "I will only provide the best care" or "I will not use the product mentioned in the ad because it is ineffective" (without giving reasons for this assertion).


View this table:
[in this window]
[in a new window]

  		Table 2. Description of variables: errors in critical thinking and components of course grade
 
These four types of logical errors encountered appear to be independent of each other, but all contributed to the overall score for making errors in critical thinking. Argument by definition was commonly associated with the assignment to state a personal philosophy for the role of science in practice (some students simply said they would do whatever is right). Thin arguments and non sequiturs contributed to low scores in several of the course assignments. Overall propensity to make critical thinking errors was generally and significantly associated with lower course grades.

All scored components of the course contributed significantly but uniquely to the total course score and grade. The written critique of the advertisement, the statement of practice philosophy regarding the role of science, seminar presentations, and the short summaries of articles were only minimally associated with each other. Critical thinking appears to be a multifaceted construct.

Predictors of Critical Thinking Performance
Outcomes on all six instruments investigated as possible predictors of critical thinking performance tended to fall toward the midrange of possible scores, with reasonably high internal consistency on all instruments. The internal characteristics of these measures are shown in Table 3Go; the associations among these measures, logical errors, and course performance are shown in Table 4Go. Generally, the instruments measure six distinct characteristics (one test of aptitude, one test of knowledge, and four tests of different orientations or personality dispositions). The Seeking Success and Avoiding Failure pair and the Promotion Orientation and the Prevention Orientation pair of personality constructs were not poles on related dichotomies. Each of the four orientation measures tested for a different construct.


View this table:
[in this window]
[in a new window]

  		Table 3. Description of variables: predictors of critical thinking
 

View this table:
[in this window]
[in a new window]

  		Table 4. Correlations between predictor variables and errors of logic and performance in the critical thinking course
 
In clinic, students are rated by faculty members in each of the eight final quarters for two general characteristics and in five technical disciplines. As shown in Table 5Go, overall performance in the critical thinking course is significantly associated with clinical competency ratings for Clinical Judgment and for Patient Management and for all disciplines except removable prosthodontics.


View this table:
[in this window]
[in a new window]

  		Table 5. Correlations between predictor variables and competency ratings of clinical performance
 
Student Satisfaction with Course
Student satisfaction data can be used to further reveal affective dimensions of critical thinking. All courses at the University of the Pacific dental school are evaluated using standardized rating forms. The critical thinking course was rated overall 44, on a T-score scale (standardized mean of 50 and standard deviation of 10), meaning that students judged the course about half a standard deviation below the norm compared to other third-year lecture or seminar courses.

A feature typical of the course rating forms at the University of the Pacific is a question asking students to rank order five personal course outcome goals (preparation for course final exam and for National Boards, contribution to dental techniques and clinical skills, and stimulation of thinking). There was a significant (r=.34) correlation between overall course rating and students’ placing high value on having their thinking stimulated. Considering only those students who ranked "learning dental techniques and learning clinical skills" as the primary goals in taking such courses, critical thinking earned a T-score of 37 (a straight C average on the overall course rating, which is expressed as a grade). Among those rating "stimulate my thinking" as the principle motive for taking lecture courses, the T-score was 67, a straight A average and one of the highest course ratings for any course.


   Discussion
Top
 Abstract
 Teaching and Learning about...
 Materials and Methods
 Results
 Discussion
References
 
Critical thinking involves some degree of comfort and facility managing gaps in understanding and reinterpreting clinical situations. The traditional pedagogies of dental education provide necessary foundations on which critical thinking can be learned, but they are not sufficient for creating individuals who think critically.

"Telling," the first dental education pedagogy, puts value on clear, authoritative, well-structured, efficient presentations of cognitive material. Telling students about dental diseases and the steps in the diagnosis and treatment planning process is not equivalent to teaching diagnosis, and learning the principles of veracity and nonmaleficence or understanding the American Dental Association (ADA) Code of Conduct is not the same as practicing ethically. Learning the logic of experimental design is only a possible first step in critical thinking. Too great an emphasis on the first pedagogy may encourage habits antithetical to critical thinking. Appeal to authority, efficiency, impatience with ambiguity, and privileging the impersonal are not useful equipment for critical thinking. Several pages ago, for example, an appropriate but uncommon word was used—neologism. The first pedagogy would encourage many readers to skip over or wall off that term as unfamiliar and therefore not useful; some may even have blamed the author for failing to communicate at the readers’ level as they did in dental school when concepts were not immediately clear. Some readers who have the critical thinking habit used the dictionary to fill a gap or reinterpret a situation through learning.

The second pedagogy in dental education involves practice to an ideal. Demonstration and feedback, along with early standardization with later realistically diverse contexts, are useful. Again, there is much in the modeling and skill-building of the second pedagogy that is fundamental for acquiring critical thinking. Again, we should go further. The ideal in dentistry tends to vary across contexts and experts—often to the confusion of students who may solve their problem by refining their own standards in their individual practices. Multiple models and experience in less than ideal conditions are helpful for learning critical thinking. This article may trouble some readers who begin with a specific concept of critical thinking and are uncomfortable that the data presented do not confirm their understanding.

A third, largely so far undefined pedagogy would be useful in dental education. Its method would involve working collaboratively to better understand clinical challenges. The discussion section probes and interprets the data presented above to reveal some elements in this approach to critical thinking.

The experiences described in this article make a case for a broader interpretation of both critical thinking and its teaching. Specifically, the evidence gathered in this study is consistent with a third pedagogical model that is grounded in the day-to-day lives of dental students and, by extension, to the practice requirements of dentists. A corollary assumption is that the traditional unit of analysis in dental education (the individual student in the course setting) may not be most appropriate for full understanding of what it means to incorporate critical thinking into practice. It may also be necessary to understand the learning and performance context in order to explain critical thinking.

Discussions of growth in critical thinking as a dentist may wish to address the following results observed in teaching the critical thinking course at the University of the Pacific:

  1. Most students exhibited a range of faults in their critical thinking performance.
  2. Although students have failed and been required to retake the critical thinking course at the University of the Pacific and faculty members have been denied tenure because of inadequate scholarship, the overall level of critical thinking is viewed as acceptable.
  3. Knowledge, especially knowledge of clinical, biomedical, and scientific reasoning, was not uniformly distributed among students or faculty members.
  4. Students significantly underestimated the magnitude of gaps in their knowledge.
  5. The capacity to function in a critical thinking course and in clinic was found to be independent of knowledge about the research enterprise.
  6. The capacity to function in a critical thinking course and in clinic was observed to be independent of critical thinking (logical) aptitude.
  7. Faculty members appeared to be no different from students in their knowledge of scientific reasoning.
  8. Critical thinking performance was a significant predictor of clinical competency ratings.
  9. Personality orientation, especially motivation to maximize number of successful experiences (independent of the number of failures), predicted performance in both the critical thinking course and in clinic generally.
  10. Student satisfaction with didactic efforts to present material was largely a reflection of their expectations about the purpose of such courses.

It should be noted that the title of this article does not speak to either teaching or learning—only to observations of critical thinking performance. It is likely that there is only the thinnest of connections between the course director’s research skills and student performance. There was an r=.613 correlation between lecture attendance and course performance. (Overall course attendance was approximately 80 percent.) Similarly, it may not be possible to claim with confidence that students are actually learning to think critically. It has been found generally that scores on tests of the scientific method remain similar across the three years at Pacific. The direction of influence of the small but significant associations between performance in the critical thinking course and clinical performance course could be argued.

Understanding the Findings
The lumpiness of knowledge presents a challenge for both a conception of the dental school (and, by extension, the profession) as a practice grounded in comprehensive rationality, with the corollary that professional education is the process of transferring this uniform knowledge base to initiates. Hypothesis #1 was not confirmed as stated.

Hypothesis #1
The most straightforward view of teaching critical thinking in dental schools involves the assumptions that faculty members are competent in conducting research and applying it to practice and that the most effective method for teaching these skills is to explain and model them for students. The uneven distribution of scientific and research knowledge in the school raises questions about the sufficiency of this pedagogy.

A deep norm in education is that skill development can be imparted didactically,50,51 or at least must begin with formal instruction from a faculty member expert. The basic form of the proposition is that experts can instruct novices in disciplines such as critical thinking. While the plausibility of this position cannot be ruled out a priori, there is no evidence showing that such instruction is either necessary or sufficient in each part of the dental curriculum. The controversy stimulated by Bertolami over what it means to teach ethics has a parallel deep structure to the case of teaching critical thinking.52–55 As reported in this article, evidence failed to confirm the hypothesis that knowledge of scientific reasoning predicted critical thinking performance in simulated situations (or clinically). This is a strong test of the hypothesis because the knowledge-level variable was attained knowledge, not amount of knowledge presented by the instructor. In the same fashion, demonstrated logical aptitude failed to predict important dental school performance.

It may even be the case that lumpiness of knowledge and manufactured grade ranges in measured student learning serve strategic ends. Pace and extent of information diffusion have been identified as characteristics of organizational success.50 Tacit knowledge is recognized as providing strategic advantage to those who control it.56–58 Of note in the literature on knowledge diffusion is the value of social networks,59 loose coupling,60 and structural holes.61 Structural holes are the gaps in knowledge flow that create lumpiness. They confer power, prestige, and economic advantage on those who can manage the gaps.62 There may be advantages to maintaining and even creating gaps across organizations or within different parts of them. There is a previously underrecognized power dimension in the scientific or research foundations for critical thinking. Practitioners, including some clinical faculty members, may seek to balance this power differential by distancing themselves from or devaluing such skills.

This view is confirmed by Colombotos,63 who studied dissemination of professional knowledge among physicians. He hypothesized that physicians prefer "fuzzy" science to its exact alternative because the former provides the respectability in the eyes of the public that the profession needs, at the same time that it leaves sufficient room for individual choice among practitioners.

The uneven distribution of knowledge within dentistry, or at least dental education, remains a quiet concern. There is massive redundancy built into dentistry. As Schön4,5 remarked, among all professionals, consistency or reliability is more important than creativity. At the same time, dentists practice independently, avoiding frequent necessity for comparing their work with others, hence also reducing the need to provide explanations.64 In the educational setting, faculty members are not always expected to provide reasons to students in the clinical context; and students are not expected to challenge faculty members on the clinic floor—even when faculty members disagree with each other. In other words, there is a norm in clinical dentistry that gaps in grounded performance—lumpiness—are tolerated or expected.

Hypotheses #2 and #3
These hypotheses suggested that critical thinking performance is a function of knowledge of the underlying science of research design, statistics, and conventions in the dental literature and that aptitude for logic enhances this performance. Neither hypothesis found support in the current study.

An alternative hypothesis that appears consistent with the data is that student performance is heavily determined by the requirements of the task as interpreted. Students may interpret the task of passing a course in critical thinking and some clinical faculty members and practitioners may interpret required critical thinking performance differently from those with a greater investment in the research enterprise.65–67 Both may use the same tools, but for slightly different purposes.

Nobel laureate Herbert Simon68 has proposed that searching for optimal solutions to problems is an unusual behavior, occurring predominantly in artificial contexts such as pure research. Under normal conditions, individuals proceed based on preprogrammed routines. They initiate searches when their habits strike an obstacle (but not always) and then search for the first solution that satisfies the practical constraints under which one is working. We "satisfice." Kuiper et al.69 reviewed the literature in computer search strategies of grade school students. Normally, their search continues only until they achieve their first effective hit. Orientation toward learning and practice (the construct measured by the personality orientations in this study) may partially explain what it means to be "satisficed" for each student—hence how science will be used.

It is possible that the University of the Pacific dental school, which is known as a "clinical rather than a research school," does not provide the right kind of culture to support the application of research-based critical thinking to clinical practice. It must be borne in mind that it was only research "knowledge" and "logical aptitude" that failed to transfer to the practice context. Pacific has an average of forty dental students each year presenting their research at the California Dental Association, ADA, Hinman, and other meetings. It may nonetheless be valid to insist that the overall context of a school contributes heavily to the interpretation students make of what they are learning. Williams et al., in their multischool study of critical thinking among dental hygiene students, found that the best predictor of National Board performance was the program that students attended.43

On this view, the school as a whole and the interactions between students and their contexts become the unit of analysis.70–72 Evaluation in dental education means almost exclusively measuring only student performance. This habit may mislead us to assume that it is the only meaningful source of variance. Research in other fields helps explain why the "conduit" view of didactic and modeling by experts may be a weak model for understanding the way science is incorporated into students’ professional skill base.73 Research on dissemination of science in medicine74–76 and other fields77–80 demonstrates that factors such as ease of use, supporting opinion among peers, and information source heavily influence information use and perceived value. Accuracy and conformance to conventions of the discipline are not recognized as factors likely to influence information dissemination.81

Hypotheses #4 and #5
Personality orientation was observed to play a significant role in critical thinking and clinical performance (confirming Hypotheses #4 and #5). This is only unexpected if critical thinking is considered to be a strictly rational activity. Patel et al.82 describes how the assumed relationship between logical structure imposed by expert physicians on education approximately matches the learning structure medical students give this same material. Chamberlain et al.83 have recently reported some fairly robust associations between personality constructs and clinical performance in dentistry, as have others in medicine.84–86

A potential explanation is that dental practice is at least partially teleological, as opposed to logical in nature. The telos—the end for which something exists—would lead to forward reasoning from task as interpreted to action, rather than from principles to their application (backward thinking).4,5 Practitioners may value scientific information for what it makes permissible rather than what it dictates in practice.63 The difference in satisfaction with the course reported by students thus seems to depend on their sense of what the American Pragmatist philosopher William James called the "cash value" of knowledge.87

Also consistent with this line of reasoning is the finding that personality orientation is a better predictor of critical thinking performance than is knowledge of science or logical aptitude. The purpose or intended use may be as important a part of learning as the content itself. This point was demonstrated years ago with regard to patients’ learning oral hygiene habits. Boyer88 found that patients who acquired appropriate levels of flossing skill because they were afraid of negative health outcomes quickly dropped the habit. Those who learned to please the dentist or hygienist or for other social reasons maintained the habit longer, but eventually more than half of them relapsed. Only those patients who learned flossing as an additional expression of an already existing general pro-health lifestyle persisted. This line of thinking challenges the positivistic view that knowledge is knowledge and the critical question is how much of it can be transferred.

At least in realistic situations, the alternative view must be considered that how something is learned and for what purpose makes a difference and that level of material mastery (as given by test scores) is an insufficient characterization of what it means to learn. Kieser et al.89 reported higher test knowledge between dental hygiene students who approached a PBL unit with an orientation toward deep learning than those taught the same way but who were characterized as having a superficial approach to learning the material. Critical thinking could be conceived as the logical bridge connecting desired practice with scientific grounding—but the bridge might be built from practice to science or even from both ends simultaneously.

Professionals care about the value of what they know—and whether what they do not know is important. Jon Wagner begins his essay on ignorance in education research with the poser, "Ignorance is a better starting place than truth for assessing the usefulness of education research. Attention to truth alone reflects a classic distortion of means over ends" (p. 15).90 Where should this be the case more than in research on critical thinking? Our approaches to this point have placed too great an emphasis on what experts know and too little of how nonexperts come to recognize that there is a hole in what they know and what they should do about it. We have also placed too little emphasis on power and personal identity as dimensions of scientific knowledge. A suggestive case study along these lines is Susan Star’s ethnographic report on the battle between two camps of brain researchers to decide which of them was "more scientific than thou."91 The competency view of critical thinking is that learning is more than the accumulation of new knowledge or skills; it also includes supporting values and the capacity to use all three to respond appropriately in practice contexts.34,92

Synthesizing the Findings
Unfolding this notion further, it is possible that the proper unit of analysis for understanding both critical thinking and clinical practice is not the individual student or dentist and his or her mental armamentarium. The proper unit of analysis might be what students believe is useful in context. This is a three-way relationship involving 1) knowledge, 2) the purposes of the user, and 3) application contexts. Most educators to this point have focused on knowledge alone or knowledge in artificial contexts created by teachers. It is likely that critical thinking is not the sum of these three components, but their interaction.93

This attempt to understand critical thinking would certainly be consistent with recent writings on the "learning organization."94–99 There is also a line of research centered around situated learning, a view that sees the learner as providing a compelling context for learning.100–107 Some recent writers on technology,108,109 especially in medicine, believe that the flow of practical innovation is from the practitioner to the academic and commercial communities. "Lumpiness" of knowledge in the entire school and the relatively greater predictive power of personal orientation and clinical effectiveness than logical aptitude or knowledge of the structure of science suggest a need to alter our approach to teaching critical thinking.

On this view, effective teaching of critical thinking would require a different model than what is traditional for the biomedical and clinical sciences.110,111 The signature pedagogies of dental education have included lectures (with multiple-choice testing) and demonstration and practice of clinical procedures (with observation of outcomes). The first of these pedagogies is appropriate where a theoretical structure is created by accretion and has a free-standing organic whole, as in the biomedical sciences. Dentists know about chromophores and peptides, can identify reasonable statements others make about them, and can (if the circumstances are appropriate) form expectations about what might happen in clinical settings where these entities are involved. But very few have ever seen a chromophore or a peptide, and fewer still would be inclined to seek independent verification of the information they were taught. Such knowledge grounded in authority, which the Greeks called logos, is achieved incrementally and accepted based on its consistency with existing, relevant knowledge structure.

The second signature pedagogy emphasizes practice with feedback to develop skills, including psychomotor, interpersonal, learning, and others. This matches what the Greeks called techne. This is the term used in the Hippocratic Oath to describe what physicians do. The term is translated as either art or craft.

The experiences described in this article suggest that neither didactic nor structured practice are sufficient to develop effective habits of critical thinking.112 More is involved than can be controlled by faculty members in traditional settings; students bring more to the learning experience than they do in lecture or laboratory learning. They want to know more than "Is this consistent with what others say about the subject?" and "Can I produce these results?" They are concerned with "Is this useful?" and "Can I meaningfully incorporate this with my personal view of practice?" Students are not so much learning something new as changing existing habits.

The concept of practical habits applies to faculty as well as students. It probably applies as well to communication and other behavioral skills, computers and other sources of information, ethics, diagnosis, practice management, all case-based and problem-based programs, and many other aspects of dentistry. In these disciplines, learning is organized around purposeful, indented use of knowledge, skills, and values in practice. Learners always have the choice of reshuffling their mental furniture to make room for the material, changing the world in which they work to accommodate the implications of what is presented, debating the ideas, walling them off as facts to be remembered in some rote fashion, or ignoring them (with or without rationalization). This third approach to learning is more widespread in dental education than typically acknowledged: it is the essence of all learning that dentists do after graduation.

This third pedagogy current exists111,113 and is extensively practiced in dental education, albeit for the most part tacitly in the spaces between courses and in the clinic. It is recognized in the education literature under the heading of praxis—the science of practice or the integration and application of all of one’s knowledge to practical solution of commonly encountered problems. The underlying theory was called, in ancient Greek, phroneis; today, we would call it reflective practice.114–119


   REFERENCES
Top
 Abstract
 Teaching and Learning about...
 Materials and Methods
 Results
 Discussion
 References
 

  1. Chambers DW. The reason for being reasonable. Contact Point 2003; 83(August):11.
  2. Chambers DW. Righteousness and reason. J Am Coll Dent 2003; 70(1):2–3.[Medline]
  3. Boland RJ, Singh J, Salipante P, Aram JD, Fay SY, Kanawattanachai P. Knowledge representations and knowledge transfer. Acad Mgmt J 2001; 44(2):393–417.
  4. Schön DA. Educating the reflective practitioner: toward a new design for teaching and learning in the professions. San Francisco: Jossey-Bass, 1987.
  5. Schön DA. The reflective practitioner: how professionals think in action. New York: Basic Books, 1983.
  6. Baum BJ. Can biomedical science be made relevant in dental education? A North American perspective. Eur J Dent Educ 2003; 7:49–55.[Medline]
  7. Baum BJ. Will dentistry be left behind at the healthcare station? J Am Coll Dent 2004; 71(2):27–30.[Medline]
  8. Bertolami CN. The role and importance of research and scholarship in dental education and practice. J Dent Educ 2002; 66(8):918–24.[Abstract]
  9. DePaola DP. Nurturing a culture of innovation. J Dent Res 2004; 84(6):446.
  10. DePaola DP, Holmstrup P, Lamster IB, Rifkin B. Research and the dental student. Eur J Dent Educ 1999; 3:45–51.
  11. DePaola DP, Slavkin HC. Reforming dental health professions education: a white paper. J Dent Educ 2004; 68(11):1139–50.[Abstract/Free Full Text]
  12. Elstein AS, Shulman LS, Sprafka SA. Medical problem solving: an analysis of clinical reasoning. Cambridge: Harvard University Press, 1978.
  13. Gordon SM, Heft MW, Dionne RA, Jeffcoat MK, Alfano MC, Valachovic RW, Lipton JA. Capacity for training in clinical research: status and opportunities. J Dent Educ 2003; 67(6):622–9.[Abstract]
  14. Hendricson WD, Cohen PA. Oral health care in the 21st century: implications for dental and medical education. Acad Med 2001; 76:1181–206.[Medline]
  15. Iacopino AM, Lynch DP, Taft T. Preserving the pipeline: a model dental curriculum for research non-intensive institutions. J Dent Educ 2004; 68(1):44–9.[Abstract]
  16. Ismail AI. Dental education at the crossroads: the crisis within. J Dent Educ 1999; 63(4):327–30.[Medline]
  17. Kassebaum DK, Hendricson WD, Taft T, Haden NK. The dental curriculum at North American dental institutions in 2002–03: a survey of current structure, recent innovations, and planned changes. J Dent Educ 2004; 68(9):914–31.[Abstract/Free Full Text]
  18. Masella RS, Thompson TJ. Dental education and evidence-based educational best practices: bridging the great divide. J Dent Educ 2004; 68(12):1266–71.[Abstract/Free Full Text]
  19. Melcher AH. Do faculties of dentistry belong in universities? J Dent Educ 1984; 48(9):492–5.[Medline]
  20. Slavkin HC. The human genome, implications for oral health and diseases, and dental education. J Dent Educ 2001; 65(5):463–79.[Abstract]
  21. Stachenko P, Niederman R, DePaola D. Basic and clinical research: issues of cost, manpower needs, and infrastructure. J Dent Educ 2002; 66(8):927–38.[Medline]
  22. Tabak LA. Conducting and putting science into practice: the future of oral health research, dental education, and dental practice. J Am Coll Dent 2002; 69(3):27–31.[Medline]
  23. Thompson JN, Moskowitz J. Preventing the extinction of the clinical research ecosystem. JAMA 1997; 278:241.[Abstract/Free Full Text]
  24. Valachovic RW. Making science clinically relevant. J Dent Educ 1997; 61:434–6.[Abstract]
  25. Varmus H. Getting ready for genome-based medicine. New Engl J Med 2002; 347:1526–7.[Free Full Text]
  26. Wise GE. The road less traveled: the decline in numbers of clinical researchers. J Dent Res 1997; 76:1428–9.[Free Full Text]
  27. Berwick DM. Disseminating innovations in health care. JAMA 2003; 289:1969–75.[Abstract/Free Full Text]
  28. Greiner AC, Knebel E, eds. Health professions education: a bridge to quality. Washington, DC: National Academy Press, 2003.
  29. Hallinan MT. Bridging the gap between research and practice. Sociology of Education 1996;Suppl:131–4.
  30. Holzner B, Marx J. Knowledge application: the knowledge system in society. Boston: Allyn & Bacon, 1979.
  31. Ponce JE. The role of research in the economics of dental education. In: Brown LJ, Meskin LH, eds. The economics of dental education. Chicago: American Dental Association, 2004:149–78.
  32. Rosenberg LE. Physician-scientists: endangered and essential. Science 1999; 283:331–2.[Free Full Text]
  33. Shepherd KR, Nihill P, Botto RW, McCarthy MW. Factors influencing pursuit and satisfaction of academic dentistry careers: perceptions of new dental educators. J Dent Educ 2001; 65(9):841–8.[Abstract]
  34. Chambers DW. Toward a competency-based curriculum. J Dent Educ 1993; 57(11):790–3.[Medline]
  35. Chambers DW. Competencies: a new view of becoming a dentist J Dent Educ 1994; 58(5):342–5.[Medline]
  36. Chambers DW. Competency-based dental education in context. Eur J Dent Educ 1998; 2:8–13.[Medline]
  37. Chambers DW. Issues in transferring preclinical skill learning to the clinical context. J Dent Educ 1987; 51(5): 238–43.[Abstract]
  38. Brown JS, Duguid P. Organizational learning and communities of practice: toward a unified view of working, learning, and innovation. Organization Sci 1991; 2:40–57.
  39. Corwin RG, Louis KS. Organizational barriers to the utilization of research. Admin Sci Q 1982; 27:623–40.
  40. Hayes DP. The growing inaccessibility of science. Nature 1992; 356:11–6.
  41. Peterson DR. Connection and disconnection of research and practice in the education of professional psychologists. Am Psychol 1991; 46:422–9.
  42. White BA. On translating new biologic-based interventions into dental practice. J Am Coll Dent 2003; 70(4):30–4.[Medline]
  43. Williams KB, Schmidt C, Tilliss TSI, Wilkins K, Glasnapp DR. Predictive validity of critical thinking skills and disposition for the National Board Dental Hygiene Examination: a preliminary investigation. J Dent Educ 2006; 70(5):536–44.[Abstract/Free Full Text]
  44. Williams KB, Glasnapp DR, Tilliss TS, Osborn J, Wilkins K, Mitchell S, et al. Predictive validity of critical thinking skills for initial clinical dental hygiene performance. J Dent Educ 2003; 67(11):1180–92.[Abstract]
  45. Dweck CS. Motivational processes affecting learning. Am Psychol 1986; 41(10):1040–8.
  46. Dweck CS. Mindset: the new psychology of success. New York: Random House, 2006.
  47. Smith CP, ed. Achievement-related motives in children. New York: Russell Sage Foundation, 1969.
  48. Higgins ET, Spiegel S. Promotion and prevention strategies for self-regulation. In: Baumeister RF, Vohs KD, eds. Handbook of self-regulation: research, theory, and applications. New York: The Guilford Press, 2004.
  49. Higgins ET, Friedman RS, Harlow RE, Idson LC, Ayduk ON, Taylor A. Achievement orientation from subjective histories of success: promotion pride and prevention pride. Eur J Soc Psychol 2001; 31:3–23.
  50. Gibbons DE. Network structure and innovation ambiguity effects on diffusion in dynamic organizational fields. Acad Mgmt Rev 2004; 47(6):938–51.
  51. Tenkasi RV, Mohrman SA. Technology as collaborative learning. In: Backer TE, David SL, Soucy G, eds. Reviewing the behavioral science knowledge base on technology transfer. Washington, DC: National Institute of Health Research, 1995:147–67.
  52. Bertolami CN. Why our ethics curricula don’t work. J Dent Educ 2004; 68(4):414–25.[Abstract]
  53. Bertolami CN. Further dialogue on ethics in dental education: a response to the Koerber et al. and Jenson articles. J Dent Educ 2005; 69(2):229–31.[Abstract/Free Full Text]
  54. Jenson LE. Why our ethics curricula do work. J Dent Educ 2005; 69(2):225–8.[Abstract/Free Full Text]
  55. Koerber A, Botto RW, Pendleton DD, Albazzaz MB, Doshi SJ, Rinando VA. Enhancing ethical behavior: views of students, administrators, and faculty. J Dent Educ 2005; 69(2):213–24.[Abstract/Free Full Text]
  56. Allee V. The knowledge evaluation. Boston: Butterworth-Heinemann, 1987.
  57. Chambers DW. Tacit knowledge. J Am Coll Dent 1998; 65(3):44–8.[Medline]
  58. Nonaka I, Takeuchi H. The knowledge-creating company. New York: Oxford University Press, 1995.
  59. Kilduff M, Tsai W, Hanke R. A paradigm too far? A dynamic stability recognition of the social network research program. Acad Mgmt Rev 2006; 31(4):1031–48.
  60. Granovetter MS. Threshold models of collective behavior. Am J Sociology 1978; 83:1420–43.
  61. Burt RS. Structural holes. Cambridge: Harvard University Press, 1992.
  62. Burt RS. Secondhand brokerage: evidence on the importance of local structure for managers, bankers, and analysts. Acad Mgmt Rev 2007; 50(1):119–48.
  63. Colombotos JL. Information transfer in dentistry: dilemmas and contradictions. J Am Coll Dent 1989; 56:54–8.
  64. Chambers DW. The role of dentists in dentistry. J Dent Educ 2001; 65(12):1430–40.[Abstract]
  65. Quinn JB. Strategies for change: logical incrementalism. Homewood, IL: Richard D. Irwin, 1980.
  66. Chambers DW. The lost innocence of research. J Am Coll Dent 2004; 71(2):2–3.[Medline]
  67. Chambers DW. Lessons from badly behaved technology transfer to a professional context. Int J Technol Trans Comm 2005; 4(1):63–78.
  68. Simon H. Theories of bounded rationality. In: McGuire CB, Radner R, eds. Decision and organization. New York: American Elsevier, 1972:161–76.
  69. Kuiper E, Volman M, Terwel J. The web as an information resource in K–12 education: strategies for supporting students in searching and processing information. Rev Educ Res 2005; 75(3):285–328.
  70. Kline P, Saunders B. Ten steps to a learning organization. Arlington, VA: Great Ocean Publications, 1993.
  71. McClelland JL, Rumelhart DE. Distributed memory and the representation of general and specific information. J Exp Psychol 1985; 114:159–88.
  72. Chambers DW, Leknius C, Reid L. Predicting technology transfer from data in research on technology development. Int J Technol Trans Comm 2005; 4(3):318–40.
  73. Reddy MJ. The conduit metaphor. In: Ortony A, ed. Metaphor and thought. Cambridge, England: Cambridge University Press, 1979:164–201.
  74. Colman JS, Katz E, Mensel H. The diffusion of an innovation among physicians. Sociometry 1957; 20:253–70.[Medline]
  75. Colman JS, Katz E, Mensel H. Social processes in physicians’ adoption of a new drug. J Chron Dis 1959; 9: 1–19.[Medline]
  76. Ferguson JH. NIH consensus conferences: dissemination and impact. Ann N Y Acad Sci 1993; 703:180–98.[Medline]
  77. Boland JS, Tenkasi RV, Te’eni D. Designing information technology to support distributed cognition. Organization Sci 1994; 5:456–75.
  78. Katz E, Lazarsfeld PF. Personal influence: the part played by people in the flow of mass communication. New York: The Free Press, 1955.
  79. Mohrman S, Gibson C, Mohrman A. Doing research that is useful to practice: a model and empirical exploration. Acad Mgmt J 2001; 44:357–75.
  80. Rynes SL, Bartunek JM, Daft RL. Across the great divide: knowledge creation and transfer between practitioners and academics. Acad Mgmt Rev 2001; 44(2):340–55.
  81. Rogers EM. Diffusion of innovations. 4th ed. New York: The Free Press, 1995.
  82. Patel VL, Arocha JF, Chaudhari S, Karlin DR, Briedis DJ. Knowledge integration and reasoning as a function of instruction in a hybrid medical curriculum. J Dent Educ 2005; 69(11):1186–208.[Abstract/Free Full Text]
  83. Chamberlain TC, Catano VM, Cunningham DP. Personality as a predictor of professional behavior in dental school: comparisons with dental practitioners. J Dent Educ 2005; 69(11):1222–37.[Abstract/Free Full Text]
  84. Project professionalism. Philadelphia: American Board of Internal Medicine, 1994.
  85. Gibson DD, Coldwell LL, Kiewit SF. Creating a culture of professionalism: an integrated approach. Acad Med 2000; 75:509–10.[Medline]
  86. Phelan S, Obershain S, Galey WR. Evaluation of the noncognitive professional traits of medical students. Acad Med 1993; 68:799–803.[Medline]
  87. James W. Pragmatism: a new name for some old ways of thinking (1907). Sioux Falls, SD: NuVision Publications, 2007.
  88. Boyer EMH. Compliance with dental regimens: a case study of an innovative dental practice. Doctoral dissertation, Columbia University, Graduate School of Arts and Sciences, 1980.
  89. Kieser J, Herbison P, Harland T. The influence of context on students’ approaches to learning: a case study. Eur J Dent Educ 2005; 9:150–6.[Medline]
  90. Wagner J. Ignorance in educational research, or how can you not know that? Educ Researcher 1993; 22(5):15–23.
  91. Star SL. Regions of the mind: brain research and the quest for scientific certainty. Palo Alto, CA: Stanford University Press, 1989.
  92. Glassman P, Chambers DW. Developing competency systems: a never-ending story. J Dent Educ 1998; 62(2):173–82.[Abstract]
  93. London MB. Work orientation in the classroom. J Mgmt Educ 1991; 15(3):313–24.
  94. Argyris C, Schön D. Organizational learning: a theory of action perspectives. Reading, MA: Addison-Wesley, 1978.
  95. Argyris C, Schön DA. Organizational learning II: theory, method, and practice. Reading, MA: Addison-Wesley, 1996.
  96. Buamard P. Tacit knowledge in organizations. London: Sage Publications, 1996.
  97. Boyatzis RE, Cowen SS, Kolb DA. Innovation in professional education: steps on a journey from teaching to learning. San Francisco: Jossey-Bass, 1995.
  98. Pfeffer J, Sutton RJ. The knowing-doing gap: how smart companies turn knowledge into action. Boston: Harvard Business School Press, 2000.
  99. Poole MS, DeSanctis G. Capturing the complexity in advanced technology use: adaptive structuration theory. Organization Sci 1994; 5:121–47.
  100. Senge PM. The fifth discipline. New York: Doubleday Currency, 1990.
  101. Anderson JR, Reder LM, Simon HA. Situated learning and education. Educ Researcher 1996; 25(4):5–11.
  102. Brown JS, Collins A, Duguid P. Situated cognition and the culture of learning. Educ Researcher 1989; 18:32–42.
  103. Ennis RH. Critical thinking and subject specificity: clarification and needed research. Educ Researcher 1989; 18(3):4–10.
  104. Lave J, Wenger E. Situated learning: legitimate peripheral participation. New York: Cambridge University Press, 1991.
  105. Mok AL. Professional innovation in post-industrial society. In: Freidson E, ed. The professions and their prospects. Beverly Hills, CA: Sage Publications, 1973:106–15.
  106. Perkins DM, Salomon G. Are cognitive skills context-bound? Educ Researcher 1989; 18:16–25.
  107. Prawat RS. The value of ideas: the immersion approach to the development of thinking. Educ Researcher 1991; 20(2):3–10,30.
  108. Resnick LB. Learning in school and out. Educ Researcher 1987; 16:13–20,54.
  109. Christensen CM. The innovator’s dilemma: when new technology causes great firms to fail. New York: HarperBusiness, 1997.
  110. von Hippel E. The sources of innovation. New York: Oxford University Press, 1988.
  111. Shulman LS. The wisdom of practice: essays on teaching, learning, and learning to teach. San Francisco: Jossey-Bass, 2004.
  112. Shulman LS, Keislar ER, eds. Learning by discovery: a critical appraisal. Chicago: Rand McNally, 1966.
  113. Chambers DW. What if Socrates were on the next accreditation site visit team? Contact Point 1997; 77(Autumn):9–12.[Medline]
  114. Leinhardt G. Capturing craft knowledge in teaching. Educ Researcher 1990; 19(2):18–25.
  115. Bolton G. Reflective practice: writing and professional development. London: Paul Chapman, 2001.
  116. Ghaye A, Ghaye K. Teaching and learning through critical reflective practice. London: David Fulton Publishers, 1998.
  117. Reynolds M, Vince E, eds. Organizing reflection. Burlington, VT: Ashgate, 2004.
  118. Taylor BJ. Reflective practice: a guide for nurses and midwives. Buckingham, England: Open University Press, 2000.
  119. Vaill PB. Learning as a way of being. San Francisco: Jossey-Bass, 1996.
  120. Wick CW, Leon LS. The learning edge. New York: McGraw-Hill, 1993.




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Chambers, D. W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chambers, D. W.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS