비판적 사고를 비판적으로 바라보기: 능력인가 기질인가? (Med Educ, 2011)

비판적 사고를 비판적으로 바라보기: 능력인가 기질인가? (Med Educ, 2011)

Thinking critically about critical thinking: ability, disposition or both?

Edward Krupat,1 Jared M Sprague,2 Daniel Wolpaw,3 Paul Haidet,4 David Hatem5 & Bridget O’Brien6

의학교육의 성과에 대해서 이야기할 때 비판적 사고는 흔히 나오는 주제 중 하나이다. 그러나 'critical thinking'이라는 용어 자체는 LCME에도 ACGME에도 GMC에도 CanMEDS에도 나오지 않는다.

When discussing the desired outcomes of medical education, it is common for educators to voice the hope that their graduates will excel at critical thinking. However, for all the rhetoric directed toward this topic in academic medicine, the actual term ‘critical thinking’ is not once mentioned in the accreditation standards of the US Liaison Committee on Medical Education (LCME),1 the six competencies of the US Accreditation Council for Graduate Medical Education (ACGME),2 the outcomes and standards for undergraduate medical education of the UK General Medical Council (GMC) 3 or the CanMEDS doctor competency framework.4

반면 AACU는 CT를 중등교육 이후 교육에서 다루어야 할 주요 지적, 실용적 기술이라고 했으며, NLN은 CT를 학사과정 수준에서 반드시 길러야 할 필수 요소로 보았다.

By con- trast, the Association of American Colleges and Universities5 lists critical thinking as one of the major intellectual and practical skills to be fostered by post- secondary education and the National League of Nursing has identified critical thinking as an essential component of baccalaureate-level education that must be fostered and assessed as a criterion for continuing accreditation.6

의학 인증기준과 목적에서 CT에 대한 명확한 레퍼런스가 없는 것은 그것과 의미가 중복되는 보다 구체적인 용어를 사용하기 때문이다. LCME는 critical judgement, GMC는 critically evaluate- 등의 용어를 사용한다.

The absence of formal reference to ‘critical thinking’ in medical accreditation standards and goals can be partially accounted for by the adoption of more specific reference terms that have a clear overlap, such as the LCME’s interest in ‘critical judgement’ and the GMC’s expectation that doctors should be able to ‘…integrate and critically evaluate evidence’.1,3

이러한 관심에도 불구하고 CT는 개념적으로 명확하지 않고, 이에 대한 많은 질문에 대한 답도 불명확하다. 

Despite this interest, critical thinking suffers from a lack of conceptual clarity and numerous questions about it go unresolved. 

• Is critical thinking something one is ‘born with’, as has been implied by some commentators for interpersonal skills? 
• If it comes naturally – or if it does not – can it be acquired or enhanced through learning and practice prior to or during medical training? 
• If critical thinking can be ‘taught’, a term that subtly implies a particular perspective on it, how and when should this be done? 
• Where in the curriculum should it appear?15–19 
• And if educators verbally encourage high-level analysis and broad inquiry while instruction and assessment focus on facts and memorisation, do these conflicting messages about critical thinking become part of the hidden curriculum20–22 of medical school?

비판적 사고의 정의내린 문헌들을 보면 넓은 분야를 포괄하고 있다.

A review of definitions of critical thinking reveals a wide range of perspectives. 

Scriven and Paul,23 for instance, have described critical thinking as ‘the intellectually disciplined process of actively and skilfully conceptualising, applying, synthesising, and⁄ or evaluating information…’ 

Kurland24 indicates that critical thinking ‘is concerned with reason, intellectual honesty, and open-mindedness as opposed to emotionalism, intellectual laziness, and closed-mindedness’.

만약 의학교육자들이 좋은 비판적 사고자를 길러내고자 하는데 서로 다른 생각을 하고 있다면, 지원자를 가려내는 방식도, 교육과정에 대한 접근 방식도, 평가에 대한 방식도 다 다를 것이다.

If medical educators state the goal of graduating good critical thinkers with different definitions in mind, it is likely that they will use different methods to screen applicants, apply different curricular approaches to the fostering of critical thinking and devise different approaches to its assessment.

각 대학에서 우리는 의과대학생 교육에 활발하게 참여하면서 다양한 임상에서도 활동하고 있는 교수들을 purposefully sample하였다.

At each school we purposefully sampled doctor faculty members who were both actively involved in medical student education and maintained active clinical practices in a variety of specialties. 

• The former inclusion criterion was used to maximise the likelihood that respondents had previously been involved in thinking or discussion about critical thinking. 
• The latter was used so that the examples given by respondents might be directly rooted in years of observation and direct experience, and derive from a heterogeneous sample of medical perspectives.

질적 내용분석을 수행했다. 어떤 이론이나 프레임워크 없이 시작했으며, 카테고리에 대한 사전에 정해진 생각도 없었다. 대신 답변들을 읽으면서 내용에 따라 카테고리를 만들고 주요하게 드러나는 주제들을 찾아냈다. 

For the multiple purposes defined above, we used qualitative content analysis, a research method that interprets the content of text through ‘the systematic classification process of coding and identifying themes or patterns’.25 Consistent with Hsieh and Shannon’s ‘conventional’ approach,26 we did not start with any guiding theory or framework nor did we have any preconceived ideas about categories into which the definitions might be placed. Rather, we read the responses with the goals of creating coding categories based on content and identifying the predominant themes as they appeared.27 Only one definition, which consisted more of a rambling commentary than a definition, could not be coded.

진행 과정

정의

• We coded respondents’ definitions of critical thinking using an iterative process in which three authors (JMS, EK, BO’B) independently read the same sample of six definitions, proposed categories, and compared, discussed and consolidated lists to create a coding scheme. We then applied the codes to 42 definitions to refine, clarify and finalise the coding scheme and then to reconcile any coding differences in the initial 42 definitions. One author served as the primary coder (JMS) and two others (EK, BO’B) each coded two randomly selected samples of 12 definitions (24 in total) to check for consistency in coding.

• In the first, broader level of analysis, the primary and secondary coders were in agreement in the vast majority of cases. In the relatively few instances in which disagreement occurred, discrepancies concerned whether a definition should be double-coded rather than indicating a lack of consensus about the category into which the definition fell. In each of these cases, consensus was reached through discussion among the coders. 

시나리오 분석

• These authors (EK, JMS, BO’B) used a similar approach in their coding of the scenarios. After an initial review of the scenarios, the first level of coding,on which this paper primarily focuses, asked if fundamental themes could be found in the scenarios describing critical thinking and those in which it was absent. A more in-depth analysis of the scenarios led us to create a set of categories of specific behaviours described as characterising critical think- ing and a set of behaviours illustrating its absence. 

• Initially, we attempted to code the actions described in the scenarios according to the categories used for the definitions, but found that these categories did not adequately capture the content of the scenarios. Thus, we randomly selected a sample of 12 scenarios and generated a new set of coding categories by having each of the three authors independently generate a list of categories which was then discussed,refined and consolidated. We applied this coding scheme to an additional set of scenarios, discussed and reconciled our coding, and added sub-categories to primary categories as needed. One author (EK) coded all 97 scenarios; a second author (JMS) coded 32, and a third author (BO’B) coded 15 of the scenarios to check for coding consistency. As with the definitions, the coders were in agreement most of the time for the primary coding dimension (which concerned the fundamental differences in the thinking and actions of those described as demonstrating critical thinking and those described as not doing so). In the few incidents of disagreement, the coders reviewed, discussed and reconciled the differences.

Definitions of critical thinking

가장 흔한 정의는 Process에 대한 것

We found three distinct ways in which respondents framed the definition of critical thinking. The most common way of describing critical thinking was as a process (n = 42).

두 번째는 Skill이나 Ability로 보는 관점

Almost as common were those definitions that framed critical thinking as a ‘skill’ or ‘ability’ (n = 40),

Process나 Ability는 Bloom의 기준에 따르자면 고차원적인 정신행동이 포함됨

Both the ‘process’ and ‘ability’ definitions made consistent reference to higher-order mental activities (e.g. synthesis, analysis, interpretation) involved in making sense of information, much like those described by Bloom.28

세 번째 종류는 개개인의 특질(trait)이나 습관(habit)으로 보는 것.

The third type of definition stood out as very different in character in that it referred to characteristics of the individual, personality traits or habits of mind rather than to process or ability. We refer to these as dispositional definitions.

혼합된 정의를 내린 사람도 있음.

Examples of hybrid definitions follow. The first of these describes a combination of process and dispo- sitional definitions and the second refers to a com- bination of disposition plus ability:

Manifestations of critical thinking in clinical practice

다수의견

In the cases they provided, the vast majority of respondents described biomedical clinical challenges that involved formulating diagnoses or making treat- ment decisions. 

소수의견

However, a minority of respondents described, alone or in combination with standard biomedical challenges, scenarios that involved efforts...

• to activate and engage patients, 
• to assure patient safety, 
• to deal with ethical or professional challenges, or 
• to resolve conflicts around the use of limited resources.

The presence of mindful and self-reflective behaviour emerged somewhat more strongly in the scenarios than in the definitions.

Manifestations of the absence of critical thinking in clinical practice

위와 단순 반대되는 사례도 있었으나 완전히 다른 것도 있었음.

Although some descriptions of doctors who did not exhibit critical thinking were exact opposites of the above, the majority of these characterisations were notably different.

Numerous instances were offered in which doctors failed to look beyond the obvious and demonstrated behaviour that was neither self-aware nor self-critical.

Although not common, the absence of critical thinking sometimes reflected a poor knowledge base or an inability to manage complexity (‘…would not be able to produce a broad differential...cannot analyse the available information to determine the correct diagnosis’). 

In the vast majority of scenarios, however, questions about knowledge or skills did not arise because the clinicians described acted by rote, failed to look beyond the obvious, neglected to collect adequate information or made overly quick decisions.

Discussion

이 연구의 추동력: CT에 대한 다양한 관점, 합의의 부재, 이런 것으로 인한 생산적 토론의 어려움

The impetus for this project grew out of the casual observation that many differing viewpoints about critical thinking exist, and the belief that this unacknowledged lack of consensus constitutes a major block to productive discussion and the development of successful strategies to foster and assess critical thinking.

CT를 세 가지 다른 식으로 정의내리고 있었음.

In this study, clinician-educators defined critical thinking in three different ways. The two predominant perspectives, which focus on process and ability, have a great deal of overlap. 

• Process: The former describes what critical thinking entails (the processes of syn- thesis, analysis, etc.), 
• Ability: whereas the latter extends this definition a step further by indicating that engaging in these processes involves some form of ability. 
• 이렇게 정의내릴 때는 가르칠 수 있다고 생각한다는 의미
  Defining critical thinking as an ability suggests that, like other skills and abilities, it can be ‘taught’ and ‘learned’ through some form of instruction. 
• Disposition: By contrast, conceptualising critical thinking as a disposition has very different implications about what lies at its heart, where it comes from and whether it is appropriate to conceive of it as a ‘teachable skill’.
• 이렇게 정의내릴 때는 가르칠 수 있는지에 대해서 관점이 다름

Ability-Disposition의 구분은 Teaching-as-transmission과 Teaching-as-enculturation의 차이이기도 하다.

The ability-disposition distinction highlights the difference between teaching knowledge and skills, referred to as teaching-as-transmission, versus teaching attitudes, modifying personality and changing behaviour, referred to as teaching-as-enculturation.29,30 

지식을 준다고 향상되지 않는 것들이 있다. Dispositional 한 관점에서는 정보를 주거나 사실을 바로잡아 주는 것과는 다른 접근이 필요하다.

Traits such as open-mindedness, flexibility and curiosity are not likely to be increased by giving people knowledge to absorb or cognition-based tasks to master. According to the dispositional perspective,we would foster critical thinking by 

• encouraging self-awareness and mindfulness, 
• modelling open discussion and inquiry, 
• accepting doubt and uncertainty, and 
• encouraging students to value the activity of asking the right questions, 

rather than giving them information or assessing them according to the factual correctness of their answers. 

disposition 관점에서 대답한 의사의 수는 매우 적어서 시나리오가 아니었다면 이러한 정의는 주석에 그칠 뻔 했다. 그러나 시나리오에서 의사들은 CT를 다양한 범위의 기술과 disposition으로 묘사했다.

Because so few of the participating doctors used the dispositional interpretation in their definitions, it would represent little more than a footnote were it not for the content of the scenarios. In the scenarios, clinicians demonstrating critical thinking were described as demonstrating a range of desirable skills and dispositions:

시나리오에서 드러난 CT를 하지 않는 의사의 모습. 인지적 수전노(cognitive miser)처럼 행동한다. 문제를 푸는데 인지적 노력을 거의 들이지 않고 지름길만 찾음.

The pattern of behaviours described for those who did not exhibit critical thinking was clear and consistent, but quite different. These doctors typically acted as ‘cognitive misers’,31 a term used by social psychologists to describe people when they take mental shortcuts and engage in heuristic thinking, thereby expending the minimum cognitive effort necessary to solve a problem.

Perkins의 '좋은 사고'에 대한 프레임워크. 

the triadic framework offered by Per- kins et al.32,33 provides a conceptual scaffolding upon which all of the responses can be placed. The conceptual framework described by Perkins et al.,32,33 which they call ‘good thinking’, was developed completely outside of medicine; however, it encom- passes virtually all of our findings. Perkins et al.,32,33 propose that good (i.e. critical) thinking requires three elements: 

(i) sensitivity; 

(ii) inclination, and 

(iii) ability. 

각 요소는 그 이전 단계의 요소가 없다면 불가능하거나 무관해진다.

Without each prior element, the next becomes impossible or irrelevant.

• Sensitivity has to do with awareness of the flow of events, such as ‘a possibly hasty causal inference, a sweeping generalisation, a limiting assumption to be challenged…’32 When clinicians are insensitive, they lack a basic awareness that there is something to be gained by collecting additional information, that alternatives exist beyond those that present them- selves immediately, or even that there is value in considering the full range of alternatives. They seem not to have a metacognitive capacity. Without this foundation, critical thinking is unlikely to occur and good clinical reasoning is unlikely to be exhibited.
• Once clinicians are aware or sensitive, however, they must be ‘…inclined to invest effort in thinking the matter through…’.32 If the clinician is not sufficiently committed to making such a cognitive or emotional investment, if he or she acts as a cognitive miser, then the third factor will never come into play. 
• Finally, ability refers to the ‘capability to think effectively about the matter in a sustained way…’.32 In medicine, this involves knowing how to frame questions and the ability to integrate information and apply one’s knowledge. This implies the need for a strong knowl- edge base, but goes well beyond it.

시나리오 사례에서 보면 3번째 보다는 첫번째 혹은 두 번째 요소가 부족한 경우가 많음.

In most instances, however, the clinicians described as not thinking critically in our respondents’ scenarios failed to demonstrate one of the first two elements rather than the third.

CT가 잘 발휘되기 위해서도 위의 세 가지 요소는 마찬가지이며, 다만 피로나 시간의 압박 같은 상황적 요인들이 CT의 발현을 억제할 수도 있긴 하다.

However, according to Perkins et al.,32,33 in order for cognitive processes and abilities to become relevant, we must first presume that sensitivity and inclination have been satisfied. If students and doctors do not have sufficient self-awareness of and sensitivity to complexity, and unless they are motivated not to settle for the obvious and are willing to commit the effort required to engage in the work of critical thinking, their knowledge, skills and abilities may never come into play. Parenthetically, it is interesting to note that although situational factors such as fatigue and time pressure play significant roles in exacerbating tendencies toward imperfect information processing,38–41 the non-critical thinking clinicians in the scenarios were almost never characterisedas being rushed or tired. 

입학, 교육, 평가에 대한 함의

In light of the model described by Perkins et al.,32,33 we believe that the findings have potentially broad implications for medical school admissions, curricu- lum and assessment protocols. 

• 첫째, CT를 세 가지 중 무엇으로 볼 것이냐? 입학때 스크리닝 해야 할 것인가?
  First, we can ask whether critical thinking, as a personal predisposition or a cognitive ability, should be considered as part of the admissions and screening process for prospective medical students.

• 보다 복잡성과 불확실성을 포용하게 해야함.
  Second, the model proposed by Perkins et al.32,33 suggests that teaching cognitive skills to students who lack sensitivity and inclination is not likely to bring about the desired results. To foster critical thinking, and thereby good clinical reasoning, we should teach students to embrace complexity and be open to uncertainty, rather than to shy away fromor eliminate these issues.

• 평가방법때문에 misguide될 수 있음.
  Third, our current assessment methods may also be misguided in that they place students in testing situations that focus almost exclusively on cognitive skills and leave little space in which sensitivity or in clination might manifest themselves.

---

Med Educ. 2011 Jun;45(6):625-35. doi: 10.1111/j.1365-2923.2010.03910.x.

Thinking critically about critical thinking: ability, disposition or both?

Krupat E1, Sprague JM, Wolpaw D, Haidet P, Hatem D, O'Brien B.

Author information

• 1Center for Evaluation, Harvard Medical School, Boston, Massachusetts 02115, USA. ed_krupat@hms.harvard.edu

Abstract

OBJECTIVES:

The objectives of this study were to determine the extent to which clinician-educators agree on definitions of critical thinking and to determine whether their descriptions of critical thinking in clinical practice are consistent with these definitions.

METHODS:

Ninety-seven medical educators at five medical schools were surveyed. Respondents were asked to define critical thinking, to describe a clinical scenario in which critical thinking would be important, and to state the actions of a clinician in that situation who was thinking critically and those of another who was not. Qualitative content analysis was conducted to identify patterns and themes.

RESULTS:

The definitions mostly described critical thinking as a process or an ability; a minority of respondents described it as a personaldisposition. In the scenarios, however, the majority of the actions manifesting an absence of critical thinking resulted from heuristic thinking and a lack of cognitive effort, consistent with a dispositional approach, rather than a lack of ability to analyse or synthesise.

CONCLUSIONS:

If we are to foster critical thinking among medical students, we must reconcile the way it is defined with the manner in which clinician-educators describe critical thinking--and its absence--in action. Such a reconciliation would include consideration of clinicians' sensitivity to complexity and their inclination to exert cognitive effort, in addition to their ability to master material and process information.

© Blackwell Publishing Ltd 2011.

PMID:

 

21564200

 

[PubMed - indexed for MEDLINE]