A Model for Critical Thinking Measurement of Dental Student Performance

Elements of a Model for Measuring Critical Thinking

The two elements of the model now in use are 1) a repeating set or “cell” of minimal actions measured in critical thinking as shown in Figure 1⇓, and 2⇓) an agreed upon set of minimally essential steps in the critical thinking process applied to patient assessment and treatment planning as shown in Figure 2⇓.^12,13 The critical thinking measurement cell reflects the smallest set of interdependent actions from which some assessment of critical thinking can be made. The cell is repeated, creating a framework for more general assessments of student thinking abilities. The cell has only five components, making it practical for widespread use.

Figure 1.

Schematic showing the model for measurement of critical thinking abilities

Note: Two cells of interrelated activities and measures are shown. A cell is applied to each step in the process of patient assessment and treatment planning shown in Figure 2⇓.

Figure 2.

List of minimally essential steps in patient assessment and treatment planning

Note: The list is applied to cases and patients across the four years and across disciplines.

The critical thinking measurement cell has two dimensions, as shown in Figure 1⇑. One dimension is demonstration of the critical thinking process by the student, and the second dimension is the faculty member’s objective and then subjective measurement of the student’s performance. Student demonstration of the steps in the critical thinking process is accomplished with the identification of a step (in the critical thinking process), followed by application of each step to an individual patient. Measurement of the student’s performance is accomplished with the objective measurement of the student’s identification of the step in the process, followed by the subjective measurement of the student’s application of the step to an individual patient.

To walk through the two dimensions of the measurement cell, the student is first expected to articulate the step in the process—for example, the chief complaint. The student either articulates the step (chief complaint) or does not, and the faculty member objectively measures the performance. The student then applies the step to the particular patient, and the faculty member subjectively measures the student’s performance. For example, for chief complaint, the student is expected to verbally describe the chief complaint as well as its significance to the faculty member and seek evidence from the literature that applies to the patient’s conditions where applicable. While the faculty member’s measurement of the student’s attainment of this step in the critical thinking process is subjective, it is highly focused and systematically repeated in every interaction with dental students across the four years and across clinical disciplines. The rationale for this sequence is that, for the student to demonstrate judgment in applying his or her analysis to any step, the student must first know that the step exists. The model is also suitable for self-assessment of student performance.

The number of facets involved in assessing the student’s performance in applying even one step of critical thinking to a patient is large. Some faculty members consciously assess facets such as accuracy, clarity, precision, relevance, depth, breadth, logic, significance, and fairness in making this subjective measurement. Not all faculty members systematically consider each of these facets in making the subjective measure of the student’s application of a step to the patient. We accept that the complexity of the subjective measure may preclude complete capture of all the inputs by the student and faculty member.

To complete the measurement cell, the faculty member then combines the objective and subjective measures into an evaluation of the student’s performance of the critical thinking step, incorporating consideration for the student’s level of development (year in school).

To continue the demonstration and measurement of the critical thinking process, the entire critical thinking measurement cell is repeated for each step outlined in Figure 2⇑. The process is repeated until all steps of patient assessment and treatment planning are completed. Both the critical thinking measurement cell and the list of minimally essential steps in patient assessment and treatment planning can be used across the four years and across clinical disciplines. Variations for respective disciplines will be also discussed subsequently. The systematic repetition of all the actions in the measurement cell gives a framework of the planning process. Systematic repetition of this chain of cells allows institutional inference of critical thinking abilities in patient care and can be used as a framework for assessing additional characteristics about students.

Examples of the Model

Example #1 is from a first-year course, Critical Thinking: Tools and Concepts, which includes a problem-based learning (PBL) patient exercise. In this example, the process is emphasized, with the specific case serving as the vehicle to demonstrate the process. There are two sessions for each case. The course also includes a definition of critical thinking, research article critique skills, the model shown in Figure 2⇑, elements of thought (and application), universal intellectual standards, and essential intellectual traits. A case is presented to a group of students. Each student is provided with a medical and dental history, summary of the clinical exam, and photographs and radiographs of the patient. Student performance is measured on the student’s demonstration of the patient assessment and planning process, with less emphasis on clinical judgment. In applying the steps in Figure 2⇑ to the case, most of the information gathered by students will be from the scientific and professional literature. For the specific case, students identify alternative assessments of the case and differential diagnoses. Students also systematically describe their methods and sources in seeking information, clinical gaps, and learning issues. The student group then divides the task list developed during the session. Students return for a second session to complete the case assessment. For articles brought by students relative to the case, students are asked to analyze the research design, the more important data, conclusions, assumptions, limitations for that article, and pertinence to the case.

Example #2 is from the third-year periodontics course, with an exercise that follows the schematic for critical thinking measurement and the treatment planning process in Figures 1⇑ and 2⇑. The exercise involves small groups, with each student presenting one of his or her assigned patients using a PowerPoint format. The student lists each step in the treatment planning process in Figure 2⇑ and then applies the step to the patient. The student is thus objectively measured for using each step and then subjectively measured on his or her ability to apply the step to that patient. Discussion and questions by fellow students and faculty members can occur at any point in the process. Inclusion of literature is expected where appropriate in the presentation. In the periodontics clinic, students also follow the steps in the treatment planning process in Figure 2⇑ and are measured as shown in Figure 1⇑. The expectation is for the student to use each step in the treatment planning process and to show progress toward competence in clinical judgment.

Example #3 is from the third-year oral surgery clerkship. Students present patients just prior to treatment as a means of pretreatment review. The faculty member expects the student to name a step in the treatment planning process (with objective measurement), followed immediately with application of the step to the patient (with subjective measurement). This faculty member will not allow the student to proceed until the student articulates the step—for example, chief complaint. To illustrate a different step in the process, treatment objectives must be articulated by the student, and the faculty member will not allow the student to proceed unless that step is named. Once named, the student is expected to apply the treatment objectives to the patient. The faculty member thus performs both an objective measure of the student’s ability to name the steps and a subjective measure in the student’s ability to apply the steps to that patient.

Example #4 is from the fourth-year comprehensive care course, with an exercise to prepare a patient for the clinic. Students first take an objective test listing the steps in the treatment planning process in Figure 2⇑. The list of steps is objectively measured. Students then join a small student group to present the patient. The student applies each step to the patient with the expectation of developing a definitive diagnosis and definitive treatment option or options. The student is thus measured in two steps as shown in Figure 1⇑. Students also systematically provide self-assessment.

These four examples show consistency in use of the essential elements in critical thinking measurement (Figure 1⇑) and minimally essential steps in patient assessment and treatment planning (Figure 2⇑). The examples also begin to show the many reinforcing variations across the four years, across clinical disciplines, and with individual faculty members. Each of our ten departments has some variation, but all still use the essential elements of objective and subjective measurement as well as the steps in treatment planning.

In each example, variability does not disrupt the use of the measurement cell nor the use of all the steps in patient assessment and treatment planning. Individual and institutional assessment can thus be achieved.

Issues Pertaining to the Model