critical thinking in medicine book

Science-Based Medicine

Exploring issues and controversies in the relationship between science and medicine

Critical Thinking in Medicine

Cognitive Errors and Diagnostic Mistakes is a superb new guide to critical thinking in medicine written by Jonathan Howard. It explains how our psychological foibles regularly bias and betray us, leading to diagnostic mistakes. Learning critical thinking skills is essential but difficult. Every known cognitive error is illustrated with memorable patient stories.

Rodin’s Thinker is doing his best to think but if he hasn’t learned critical thinking skills, he is likely to make mistakes. The human brain is prone to a multitude of cognitive errors.

Critical thinking in medicine is what the Science-Based Medicine ( SBM ) blog is all about. Jonathan Howard has written a superb book, Cognitive Errors and Diagnostic Mistakes: A Case-Based Guide to Critical Thinking in Medicine , that epitomizes the message of SBM . In fact, in the Acknowledgements, he credits the entire team at SBM for teaching him “an enormous amount about skepticism and critical thinking”, and he specifically thanks Steven Novella, Harriet Hall (moi!), and David Gorski.

Dr. Howard is a neurologist and psychiatrist at NYU and Bellevue Hospital. The book is a passionate defense of science and a devastating critique of Complementary and Alternative Medicine ( CAM ) and pseudoscience. Its case-based approach is a stroke of genius. We humans are story-tellers; we are far more impressed by stories than by studies or by textbook definitions of a disease. Dr. Howard points out that “Anecdotes are part of the very cognition that allows us to derive meaning from experience and turn noise into signal.” They are incredibly powerful from an emotional standpoint. That’s why he chose to begin every discussion of a cognitive error with a patient’s case, an anecdote.

CAM knows how effective this can be; that’s why it relies so heavily on anecdotes. When doctors think of a disease, they are likely to think of a memorable patient they treated with that disease, and that patient’s case is likely to bias their thinking about other patients with the same disease. If there is a bad outcome with a treatment, they will remember that and may reject that treatment for the next patient even if it is the most appropriate one. Dr. Howard uses patient stories to great advantage, first providing the bare facts of the case and then letting the patient’s doctors explain their thought processes so we can understand exactly where and why they went wrong. Then he goes on to explain the psychology behind the cognitive error, with study findings, other examples, and plentiful references. If readers remember these cases, they might avoid similar mishaps.

An encyclopedia of cognitive errors

The book is encyclopedic, running to 30 chapters and 588 pages. I can’t think of anything he failed to mention, and whenever an example or a quotation occurred to me, he had thought of it first and included it in the text. I couldn’t begin to list all the cognitive errors he covers, but they fall roughly into these six categories:

• Errors of overattachment to a particular diagnosis
• Errors due to failure to consider alternative diagnoses.
• Errors due to inheriting someone else’s thinking.
• Errors in prevalence perception or estimation.
• Errors involving patient characteristics or presentation context.
• Errors associated with physician affect, personality, or decision style.

A smattering of examples

There is so much information and wisdom in this book! I’ll try to whet your appetite with a few excerpts that particularly struck me.

• Discussing an issue with others who disagree can help us avoid confirmation bias and groupthink.
• Negative panic: when a group of people witness an emergency and fail to respond, thinking someone else will.
• Reactance bias: doctors who object to conventional practices and want to feel independent may reject science and embrace pseudoscience.
• Cyberchondria: using the Internet to interpret mundane symptoms as dire diagnoses.
• Motivated reasoning: People who “know” they have chronic Lyme disease will fail to believe 10 negative Lyme tests in a row and then believe the 11 th test if it is positive.
• The backfire effect: “encountering contradictory information can have the paradoxical effect of strengthening our initial belief rather than causing us to question it.”
• Biases are easy to see in others but nearly impossible to detect in oneself.
• Checklists for fake diseases take advantage of the Forer effect . As with horoscopes and cold readings, vague, nonspecific statements convince people that a specific truth about them is being revealed. Fake diseases are unfalsifiable: there is no way to rule them out.
• When presenting risk/benefit data to patients, don’t present risk data first; it will act as an “anchor” to make them fixate on risk.
• The doctor’s opinion of the patient will affect the quality of care.
• Randomness is difficult to grasp. The hot hand and the gambler’s fallacy can both fool doctors. If the last two patients had disease X and this patient has similar symptoms, the doctor will think he probably has disease X too. Or if the doctor has just seen two cases of a rare disease, it will seem unlikely that the next patient with similar symptoms will have it too.
• Apophenia : the tendency to perceive meaningful patterns with random information, like seeing the face on Mars.
• Information bias: doctors tend to think the more information, the better. But tests are indicated only if they will help establish a diagnosis or alter management. They should not be ordered out of curiosity or to make the clinician feel better. Sometimes doctors don’t know what to do with the information from a test. This should be a lesson for doctors who practice so-called functional medicine : they order all kinds of nonstandard tests whose questionable results give no evidence-based guidance for treating the patient. Doctors should ask “How will this test alter my management?” and if they can’t answer, they shouldn’t order the test.
• Once a treatment is started, it can be exceedingly difficult to stop. A study showed that 58% of medications could be stopped in elderly patients and only 2% had to be re-started.
• Doctors feel obligated to “do something” for the patient, but sometimes the best course is to do nothing. “Just don’t do something, stand there.” At the end of their own life, 90% of doctors would refuse the treatments they routinely give to patients with terminal illnesses.
• Incidentalomas: when a test reveals an unsuspected finding, it’s important to remember that abnormality doesn’t necessarily mean pathology or require treatment.
• Fear of possible unknown long-term consequences may lead doctors to reject a treatment, but that should be weighed carefully against the well-known consequences of the disease itself.
• It’s good for doctors to inform patients and let them participate in decisions, but too much information can overwhelm patients. He gives the example of a patient with multiple sclerosis whose doctor describes the effectiveness and risks of 8 injectables, 3 pills, and 4 infusions. The patient can’t choose; she misses the follow-up appointment and returns a year later with visual loss that might have been prevented.
• Most patients don’t benefit from drugs; the NNT tells us the Number of patients who will Need to be Treated for one person to benefit.
• Overconfidence bias: in the Dunning-Kruger effect, people think they know more than the experts about things like climate change, vaccines and evolution. Yet somehow these same people never question that experts know how to predict eclipses.
• Patient satisfaction does not measure effectiveness of treatment. A study showed that the most satisfied patients were 12% more likely to be admitted to the hospital, had 9% higher prescription costs, and were 26% more likely to die.
• The availability heuristic and the frequency illusion: “Clinicians should be aware that their experience is distorted by recent or memorable [cases], the experiences of their colleagues, and the news.” He repeats Mark Crislip’s aphorism that the three most dangerous words in medicine are “in my experience”.
• Illusory truth: people are likely to believe a statement simply because they have heard it many times.
• What makes an effective screening test? He covers concepts like lead time bias, length bias, and selection bias. Screening tests may do more harm than good. The PSA test is hardly better than a coin toss.
• Blind spot bias: Everyone has blind spots; we recognize them in others but can’t see our own. Most doctors believe they won’t be influenced by gifts from drug companies, but they believe others are unconsciously biased by such gifts. Books like this can make things worse: they give us false confidence. “Being inclined to think that you can avoid a bias because you [are] aware of it is a bias in itself.”
• He quotes from Contrived Platitudes: “Everything happens for a reason except when it doesn’t. But even then you can in hindsight fabricate a reason that will satisfy your belief system.” This is the essence of what CAM does, especially the versions that attribute all diseases to a single cause.

Some juicy quotes

Knowledge of bias should contribute to your humility, not your confidence.

Only by studying treatments in large, randomized, blinded, controlled trials can the efficacy of a treatment truly be measured.

When beliefs are based in emotion, facts alone stand little chance.

CAM , when not outright fraudulent, is nothing more than the triumph of cognitive biases over rationality and science.

Reason evolved primarily to win arguments, not to solve problems.

He includes a thorough discussion of the pros and cons of limiting doctors’ work hours, with factors most people have never considered, and a thorough discussion of financial motivations.

The book is profusely illustrated with pictures, diagrams, posters, and images from the Internet like “The Red Flags of Quackery” from sci-ence.org. Many famous quotations are presented with pictures of the person quoted, like Christopher Hitchens and his “What can be asserted without evidence can be dismissed without evidence”.

He never goes beyond the evidence. Rather than just giving study results, he tells the reader when other researchers have failed to replicate the findings.

We rely on scientific evidence, but researchers are not immune from bias. He describes the many ways research can go astray: 235 biases have been identified that can lead to erroneous results. As Ioannidis said, most published research findings are wrong. But all is not lost: people who understand statistics and the methodologies of science can usually distinguish a good study from a bad one.

He tells the infamous N-ray story. He covers the file drawer effect, publication bias, conflicts of interest, predatory journals, ghostwriting, citation plagiarism, retractions, measuring poor surrogates instead of meaningful clinical outcomes, and outright fraud. Andrew Wakefield features prominently. Dr. Howard’s discussions of p-hacking, multiple variables, random chance, and effect size are particularly valuable. HARKing is Hypothesizing After the Results are Known. It can be exploited to create erroneous results.

He tells a funny story that was new to me. Two scientists wrote a paper consisting entirely of the repeated sentence “Get me off your fucking mailing list” complete with diagrams of that sentence. It was rated as excellent and was accepted for publication!

Conclusion: Well worth reading for doctors and for everyone else

As the book explains, “The brain is a self-affirming spin-doctor with a bottomless bag of tricks…” Our brains are “pattern-seeking machines that fill in the gaps in our perception and knowledge consistent with our expectations, beliefs, and wishes”. This book is a textbook explaining our cognitive errors. Its theme is medicine but the same errors occur everywhere. We all need to understand our psychological foibles in order to think clearly about every aspect of our lives and to make the best decisions. Every doctor would benefit from reading this book, and I wish it could be required reading in medical schools. I wish everyone who considers trying CAM would read it first. I wish patients would ask doctors to explain why they ordered a test.

The book is not inexpensive. The price on Amazon is $56.99 for both softcover and Kindle versions. But it might be a good investment: you might save much more money that that by applying the principles it teaches, and critical thinking skills might even save your life. Well-written, important, timely, easy, and entertaining to read, lots of illustrations, packed with good stuff. Highly recommended.

Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, Women Aren't Supposed to Fly .

• Posted in: Book & movie reviews , Critical Thinking , Neuroscience/Mental Health , Science and Medicine
• Tagged in: bias , CAM , cognitive errors , diagnostic mistakes , Jonathan Howard

Posted by Harriet Hall

1st Edition

How to Think in Medicine Reasoning, Decision Making, and Communication in Health Sciences and Professions

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Description

Mastery of quality health care and patient safety begins as soon as we open the hospital doors for the first time and start acquiring practical experience. The acquisition of such experience includes much more than the development of sensorimotor skills and basic knowledge of sciences. It relies on effective reason, decision making, and communication shared by all health professionals, including physicians, nurses, dentists, pharmacists, and administrators. How to Think in Medicine, Reasoning, Decision Making, and Communications in Health Sciences is about these essential skills. It describes how physicians and health professionals reason, make decision, and practice medicine. Covering the basic considerations related to clinical and caregiver reasoning, it lays out a roadmap to help those new to health care as well as seasoned veterans overcome the complexities of working for the well-being of those who trust us with their physical and mental health. This book provides a step-by-step breakdown of the reasoning process for clinical work and clinical care. It examines both the general and medical ways of thinking, reasoning, argumentation, fact finding, and using evidence. It explores the principles of formal logic as applied to clinical problems and the use of evidence in logical reasoning. In addition to outline the fundamentals of decision making, it integrates coverage of clinical reasoning risk assessment, diagnosis, treatment, and prognosis in evidence-based medicine. Presented in four sections, this book discusses the history and position of the problem and the challenge of medical thinking; provides the philosophy interfacing topics of interest for health sciences professionals including the probabilities, uncertainties, risks, and other quantifications in health by steps of clinical work; decision making in clinical and community health care, research, and practice; Communication in clinical and community care including how to write medical articles, clinical case studies and case reporting, and oral and written communication in clinical and community practice and care.

Table of Contents

Milos Jenicek, MD, PhD is Professor of Epidemiology and Evidence-Based Medicine at McMaster University in Hamilton, Ontario, Canada. He is also Professor Emeritus at the Université de Montreal, Adjunct Professor at McGill University and Fellow of the Royal College of Physicians and Surgeons of Canada. In 2009, he was elected Fellow of the Royal Society of Medicine, London, UK. He contributes to the evolution of epidemiology as a general method of objective reasoning and decision making in medicine. To further enhance his teaching and research, he has committed himself to short sabbaticals during which he visited Harvard and John Hopkins, Yale, North Carolina at Chapel Hill and Uniformed Services at Bethesda Universities. He also lectured and visited numerous institutions in Hong Kong, Singapore, Japan, South Korea, Portugal, Brazil, France, Switzerland, Morocco, Czech Republic, Singapore and Kuwait. Earlier in his career, he spent three years of University teaching and field practice of preventive medicine and public health in North Africa, which has given him valuable insight and understanding of the realities in this part of the world. Milos Jenicek is a consultant to various national and international public and private bodies, Editorial Consultant for the Journal of Clinical epidemiology and the Case Reports & Clinical Practice Review and honorary editorial board member of Evidence-Based Preventive Medicine. In addition to numerous scientific papers, Dr. Jenicek is the author of twelve books, his most recent Evidence-Based Practice published by AMA Press in 2005, A Physician’s Self-Paced Guide to Critical Thinking (2006, AMA Press); Improving Communication and Decision Making in Research and Practice, (AMA Press, 2009) and Medical Error and Harm: Understanding, Prevention and Control (CRC Press, 2009). Dr. Jenicek’s current interests include the development of methodology and applications of logic and critical thinking in health sciences, enhancement of evidence-based medicine and evidence-based public health, health policies, program evaluation, and decision oriented (bedside) clinical research.

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Evidence-based practice : logic and critical thinking in medicine

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Milestones of critical thinking: a developmental model for medicine and nursing

Affiliation.

• 1 Dr. Papp is professor and associate dean, Penn State College of Medicine, Hershey, Pennsylvania. Dr. Huang is associate professor of medicine, Harvard Medical School, and director of assessment, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts. Dr. Lauzon Clabo is dean and professor, MGH Institute of Health Professions School of Nursing, Boston, Massachusetts. Dr. Delva is chair and professor, Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada. Dr. Fischer is associate professor of medicine and associate dean for undergraduate medical education, University of Massachusetts Medical School, Worcester, Massachusetts. Dr. Konopasek is associate professor of pediatrics (education), Weill Cornell Medical College, and designated institutional official, NewYork-Presbyterian Hospital, New York, New York. Dr. Schwartzstein is Ellen and Melvin Gordon professor of medicine and medical education and faculty associate dean for medical education, Harvard Medical School, vice president for education, Beth Israel Deaconess Medical Center, and executive director, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts. Dr. Gusic is professor of pediatrics, Dolores and John Read professor of medical education, and executive associate dean for educational affairs, Indiana University School of Medicine, Indianapolis, Indiana.
• PMID: 24667504
• DOI: 10.1097/ACM.0000000000000220

Critical thinking is essential to a health professional's competence to assess, diagnose, and care for patients. Defined as the ability to apply higher-order cognitive skills (conceptualization, analysis, evaluation) and the disposition to be deliberate about thinking (being open-minded or intellectually honest) that lead to action that is logical and appropriate, critical thinking represents a "meta-competency" that transcends other knowledge, skills, abilities, and behaviors required in health care professions. Despite its importance, the developmental stages of critical thinking have not been delineated for nurses and physicians. As part of a task force of educators who considered different developmental stage theories, the authors have iteratively refined and proposed milestones in critical thinking. The attributes associated with unreflective, beginning, practicing, advanced, accomplished, and challenged critical thinkers are conceived as independent of an individual's level of training. Depending on circumstances and environmental factors, even the most experienced clinician may demonstrate attributes associated with a challenged thinker. The authors use the illustrative case of a patient with abdominal pain to demonstrate how critical thinking may manifest in learners at different stages of development, analyzing how the learner at each stage applies information obtained in the patient interaction to arrive at a differential diagnosis and plan for evaluation. The authors share important considerations and provide this work as a foundation for the development of effective approaches to teaching and promoting critical thinking and to establishing expectations for learners in this essential meta-competency.

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Nonfiction Books » Philosophy Books

The best books on critical thinking, recommended by nigel warburton.

Thinking from A to Z by Nigel Warburton

Do you know your straw man arguments from your weasel words? Nigel Warburton , Five Books philosophy editor and author of Thinking from A to Z,  selects some of the best books on critical thinking—and explains how they will help us make better-informed decisions and construct more valid arguments.

Interview by Cal Flyn , Deputy Editor

Thinking, Fast and Slow by Daniel Kahneman

Factfulness: Ten Reasons We're Wrong About The World — And Why Things Are Better Than You Think by Hans Rosling

Black Box Thinking: The Surprising Truth About Success by Matthew Syed

The Art of Thinking Clearly by Rolf Dobelli

Critical Thinking: Your Guide to Effective Argument, Successful Analysis and Independent Study by Tom Chatfield

Calling Bullshit: The Art of Skepticism in a Data-Driven World by Carl Bergstrom & Jevin West

1 Thinking, Fast and Slow by Daniel Kahneman

2 factfulness: ten reasons we're wrong about the world — and why things are better than you think by hans rosling, 3 black box thinking: the surprising truth about success by matthew syed, 4 the art of thinking clearly by rolf dobelli, 5 critical thinking: your guide to effective argument, successful analysis and independent study by tom chatfield, 6 calling bullshit: the art of skepticism in a data-driven world by carl bergstrom & jevin west.

W e’re here to talk about critical thinking. Before we discuss your book recommendations, I wonder if you would first explain: What exactly is critical thinking, and when should we be using it?

But that’s just one element of critical thinking. Critical thinking is broader, though it encompasses that. In recent years, it’s been very common to include discussion of cognitive biases—the psychological mistakes we make in reasoning and the tendencies we have to think in certain patterns which don’t give us reliably good results. That’s another aspect: focussing on the cognitive biases is a part of what’s sometimes called ‘informal logic’, the sorts of reasoning errors that people make, which can be described as fallacious. They’re not, strictly speaking, logical fallacies, always. Some of them are simply psychological tendencies that give us unreliable results.

The gambler’s fallacy is a famous one: somebody throwing a die that isn’t loaded has thrown it three times without getting a six, and then imagines that, by some kind of law of averages, the fourth time they’re more likely to get a six, because they haven’t yet got one yet. That’s just a bad kind of reasoning, because each time that you roll the dice, the odds are the same: there’s a one in six chance of throwing a six. There’s no cumulative effect and a dice doesn’t have a memory. But we have this tendency, or certainly gamblers often do, to think that somehow the world will even things out and give you a win if you’ve had a series of losses. That’s a kind of informal reasoning error that many of us make, and there are lots of examples like that.

I wrote a little book called Thinking from A to Z which was meant to name and explain a whole series of moves and mistakes in thinking. I included logic, some cognitive biases, some rhetorical moves, and also (for instance) the topic of pseudo-profundity, whereby people make seemingly deep statements that are in fact shallow. The classical example is to give a seeming paradox—to say, for example ‘knowledge is just a kind of ignorance,’ or ‘virtue is only achieved through vice.’ Actually, that’s just a rhetorical trick, and once you see it, you can generate any number of such ‘profundities’. I suppose that would fall under rhetoric, the art of persuasion: persuading people that you are a deeper thinker than you are. Good reasoning isn’t necessarily the best way to persuade somebody of something, and there are many devious tricks that people use within discussion to persuade people of a particular position. The critical thinker is someone who recognises the moves, can anatomise the arguments, and call them to attention.

So, in answer to your question: critical thinking is not just pure logic . It’s a cluster of things. But its aim is to be clear about what is being argued, what follows from the given evidence and arguments, and to detect any cognitive biases or rhetorical moves that may lead us astray.

Many of the terms you define and illustrate in Thinking from A to Z— things like ‘straw man’ arguments and ‘weasel words’—have been creeping into general usage. I see them thrown around on Twitter. Do you think that our increased familiarity with debate, thanks to platforms like Twitter, has improved people’s critical thinking or made it worse?

I think that improving your critical thinking can be quite difficult. But one of the ways of doing it is to have memorable labels, which can describe the kind of move that somebody’s making, or the kind of reasoning error, or the kind of persuasive technique they’re using.

For example, you can step back from a particular case and see that somebody’s using a ‘weak analogy’. Once you’re familiar with the notion of a weak analogy, it’s a term that you can use to draw attention to a comparison between two things which aren’t actually alike in the respects that somebody is implying they are. Then the next move of a critical thinker would be to point out the respects in which this analogy doesn’t hold, and so demonstrate how poor it is at supporting the conclusion provided. Or, to use the example of weasel words—once you know that concept, it’s easier to spot them and to speak about them.

Social media, particularly Twitter, is quite combative. People are often looking for critical angles on things that people have said, and you’re limited in words. I suspect that labels are probably in use there as a form of shorthand. As long as they’re used in a precise way, this can be a good thing. But remember that responding to someone’s argument with ‘that’s a fallacy’, without actually spelling out what sort of fallacy it is supposed to be, is a form of dismissive rhetoric itself.

There are also a huge number of resources online now which allow people to discover definitions of critical thinking terms. When I first wrote Thinking from A to Z , there weren’t the same number of resources available. I wrote it in ‘A to Z’ form, partly just as a fun device that allows for lots of cross references, but partly because I wanted to draw attention to the names of things. Naming the moves is important.

“People seem to get a kick out of the idea of sharing irrelevant features—it might be a birthday or it might be a hometown—with somebody famous. But so what?”

The process of writing the book improved my critical thinking quite a lot, because I had to think more precisely about what particular terms meant and find examples of them that were unambiguous. That was the hardest thing, to find clear-cut examples of the various moves, to illustrate them. I coined some of the names myself: there’s one in there which is called the ‘Van Gogh fallacy,’ which is the pattern of thought when people say: ‘Well, Van Gogh had red hair, was a bit crazy, was left-handed, was born on the 30th of March, and, what do you know, I share all those things’—which I do happen to do—‘and therefore I must be a great genius too.’

I love that. Well, another title that deals with psychological biases is the first critical thinking book that you want to discuss, Daniel Kahneman’s Thinking Fast and Slow . Why did you choose this one?

This is an international bestseller by the Nobel Prize-winning behavioural economist—although he’s principally a psychologist—Daniel Kahneman. He developed research with Amos Tversky, who unfortunately died young. I think it would have been a co-written book otherwise. It’s a brilliant book that summarizes their psychological research on cognitive biases (or its patterns of thinking) which all of us are prone to, which aren’t reliable.

There is a huge amount of detail in the book. It summarizes a lifetime of research—two lifetimes, really. But Kahneman is very clear about the way he describes patterns of thought: as using either ‘System One’ or ‘System Two.’ System One is the fast, intuitive, emotional response to situations where we jump to a conclusion very quickly. You know: 2 + 2 is 4. You don’t think about it.

System Two is more analytical, conscious, slower, methodical, deliberative. A more logical process, which is much more energy consuming. We stop and think. How would you answer 27 × 17? You’d have to think really hard, and do a calculation using the System Two kind of thinking. The problem is that we rely on this System One—this almost instinctive response to situations—and often come out with bad answers as a result. That’s a framework within which a lot of his analysis is set.

I chose this book because it’s a good read, and it’s a book you can keep coming back to—but also because it’s written by a very important researcher in the area. So it’s got the authority of the person who did the actual psychological research. But it’s got some great descriptions of the phenomena he researches, I think. Anchoring, for instance. Do you know about anchoring?

I think so. Is that when you provide an initial example that shapes future responses? Perhaps you’d better explain it.

That’s more or less it. If you present somebody with an arbitrary number, psychologically, most people seem prone when you ask them a question to move in the direction of that number. For instance, there’s an experiment with judges. They were being asked off the cuff: What would be a good sentence for a particular crime, say shoplifting? Maybe they’d say it would be a six-month sentence for a persistent shoplifter.

But if you prime a judge by giving an anchoring number—if you ask, ‘Should the sentence for shoplifting be more than nine months?’ They’re more like to say on average that the sentence should be eight months than they would have been otherwise. And if you say, ‘Should it be punished by a sentence of longer than three months?’ they’re more likely to come down in the area of five , than they would otherwise.

So the way you phrase a question, by introducing these numbers, you give an anchoring effect. It sways people’s thinking towards that number. If you ask people if Gandhi was older than 114 years old when he died, people give a higher answer than if you just asked them: ‘How old was Gandhi when he died?’

I’ve heard this discussed in the context of charity donations. Asking if people will donate, say, £20 a month returns a higher average pledge than asking for £1 a month.

People use this anchoring technique often with selling wine on a list too. If there’s a higher-priced wine for £75, then somehow people are more drawn to one that costs £40 than they would otherwise have been. If  that was the most expensive one on the menu, they wouldn’t have been drawn to the £40 bottle, but just having seen the higher price, they seem to be drawn to a higher number. This phenomenon occurs in many areas.

And there are so many things that Kahneman covers. There’s the sunk cost fallacy, this tendency that we have when we give our energy, or money, or time to a project—we’re very reluctant to stop, even when it’s irrational to carry on. You see this a lot in descriptions of withdrawal from war situations. We say: ‘We’ve given all those people’s lives, all that money, surely we’re not going to stop this campaign now.’ But it might be the rational thing to do. All that money being thrown there, doesn’t mean that throwing more in that direction will get a good result. It seems that we have a fear of future regret that outweighs everything else. This dominates our thinking.

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What Kahneman emphasizes is that System One thinking produces overconfidence based on what’s often an erroneous assessment of a situation. All of us are subject to these cognitive biases, and that they’re extremely difficult to remove. Kahneman’s a deeply pessimistic thinker in some respects; he recognizes that even after years of studying these phenomena he can’t eliminate them from his own thinking. I interviewed him for a podcast once , and said to him: ‘Surely, if you teach people critical thinking, they can get better at eliminating some of these biases.’ He was not optimistic about that. I’m much more optimistic than him. I don’t know whether he had empirical evidence to back that up, about whether studying critical thinking can increase your thinking abilities. But I was surprised how pessimistic he was.

Interesting.

Unlike some of the other authors that we’re going to discuss . . .

Staying on Kahneman for a moment, you mentioned that he’d won a Nobel Prize, not for his research in psychology per se but for his influence on the field of economics . His and Tversky’s ground-breaking work on the irrationality of human behaviour and thinking forms the spine of a new field.

Let’s look at Hans Rosling’s book next, this is Factfulness . What does it tell us about critical thinking?

Rosling was a Swedish statistician and physician, who, amongst other things, gave some very popular TED talks . His book Factfulness , which was published posthumously—his son and daughter-in-law completed the book—is very optimistic, so completely different in tone from Kahneman’s. But he focuses in a similar way on the ways that people make mistakes.

We make mistakes, classically, in being overly pessimistic about things that are changing in the world. In one of Rosling’s examples he asks what percentage of the world population is living on less than $2 a day. People almost always overestimate that number, and also the direction in which things are moving, and the speed in which they’re moving. Actually, in 1966, half of the world’s population was in extreme poverty by that measure, but by 2017 it was only 9%, so there’s been a dramatic reduction in global poverty. But most people don’t realise this because they don’t focus on the facts, and are possibly influenced by what they may have known about the situation in the 1960s.

If people are asked what percentage of children are vaccinated against common diseases, they almost always underestimate it. The correct answer is a very high proportion, something like 80%. Ask people what the life expectancy for every child born today is, the global average, and again they get it wrong. It’s over 70 now, another surprisingly high figure. What Rosling’s done as a statistician is he’s looked carefully at the way the world is.

“Pessimists tend not to notice changes for the better”

People assume that the present is like the past, so when they’ve learnt something about the state of world poverty or they’ve learnt about health, they often neglect to take a second reading and see the direction in which things are moving, and the speed with which things are changing. That’s the message of this book.

It’s an interesting book; it’s very challenging. It may be over-optimistic. But it does have this startling effect on the readers of challenging widely held assumptions, much as Steven Pinker ‘s The Better Angels of Our Nature has done. It’s a plea to look at the empirical data, and not just assume that you know how things are now. But pessimists tend not to notice changes for the better. In many ways, though clearly not in relation to global warming and climate catastrophe, the statistics are actually very good for humanity.

That’s reassuring.

So this is critical thinking of a numerical, statistical kind. It’s a bit different from the more verbally-based critical thinking that I’ve been involved with. I’m really interested to have my my assumptions challenged, and Factfulness is a very readable book. It’s lively and thought-provoking.

Coming back to what you said about formal logic earlier, statistics is another dense subject which needs specialist training. But it’s one that has a lot in common with critical thinking and a lot of people find very difficult—by which I mean, it’s often counter-intuitive.

One of the big problems for an ordinary reader looking at this kind of book is that we are not equipped to judge the reliability of his sources, and so the reliability of the conclusions that he draws. I think we have to take it on trust and authority and hope that, given the division of intellectual labour, there are other statisticians looking at his work and seeing whether he was actually justified in drawing the conclusions that he drew. He made these sorts of public pronouncements for a long time and responded to critics.

But you’re right that there is a problem here. I believe that most people can equip themselves with tools for critical thinking that work in everyday life. They can learn something about cognitive biases; they can learn about reasoning and rhetoric, and I believe that we can put ourselves as members of a democracy in a position where we think critically about the evidence and arguments that are being presented to us, politically and in the press. That should be open to all intelligent people, I think. It is not a particularly onerous task to equip yourself with a basic tools of thinking clearly.

Absolutely. Next you wanted to talk about Five Books alumnus Matthew Syed ‘s Black Box Thinking .

Yes, quite a different book. Matthew Syed is famous as a former international table tennis player, but—most people probably don’t know this—he has a first-class degree in Philosophy, Politics and Economics (PPE) from Oxford as well.

This book is really interesting. It’s an invitation to think differently about failure. The title, Black Box Thinking, comes from the black boxes which are standardly included in every passenger aircraft, so that if an accident occurs there’s a recording of the flight data and a recording of the audio communications as the plane goes down. When there’s a crash, rescuers always aim to recover these two black boxes. The data is then analysed, the causes of the crash, dissected and scrutinized, and the information shared across the aeronautic industry and beyond.

Obviously, everybody wants to avoid aviation disasters because they’re so costly in terms of loss of human life. They undermine trust in the whole industry. There’s almost always some kind of technical or human error that can be identified, and everybody can learn from particular crashes. This is a model of an industry where, when there is a failure, it’s treated as a very significant learning experience, with the result that airline travel has become a very safe form of transport.

This contrasts with some other areas of human endeavour, such as, sadly, much of healthcare, where the information about failures often isn’t widely shared. This can be for a number of reasons: there may be a fear of litigation—so if a surgeon does something unorthodox, or makes a mistake, and somebody as a result doesn’t survive an operation, the details of exactly what happened on the operating table will not be widely shared, typically, because there is this great fear of legal comeback.

The hierarchical aspects of the medical profession may have a part to play here, too. People higher up in the profession are able to keep a closed book, and not share their mistakes with others, because it might be damaging to their careers for people to know about their errors. There has been, historically anyway, a tendency for medical negligence and medical error, to be kept very quiet, kept hidden, hard to investigate.

“You can never fully confirm an empirical hypothesis, but you can refute one by finding a single piece of evidence against it”

What Matthew Syed is arguing is that we need to take a different attitude to failure and see it as the aviation industry does. He’s particularly interested in this being done within the healthcare field, but more broadly too. It’s an idea that’s come partly from his reading of the philosopher Karl Popper, who described how science progresses not by proving theories true, but by trying to disprove them. You can never fully confirm an empirical hypothesis, but you can refute one by finding a single piece of evidence against it. So, in a sense, the failure of the hypothesis is the way by which science progresses: conjecture followed by refutation, not hypothesis followed by confirmation.

As Syed argues, we progress in all kinds of areas is by making mistakes. He was a superb table-tennis player, and he knows that every mistake that he made was a learning experience, at least potentially, a chance to improve. I think you’d find the same attitude among musicians, or in areas where practitioners are very attentive to the mistakes that they make, and how those failures can teach them in a way that allows them to make a leap forward. The book has a whole range of examples, many from industry, about how different ways of thinking about failure can improve the process and the output of particular practices.

When we think of bringing up kids to succeed, and put emphasis on avoiding failure, we may not be helping them develop. Syed’s argument is that we should make failure a more positive experience, rather than treat it as something that’s terrifying, and always to be shied away from. If you’re trying to achieve success, and you think, ‘I have to achieve that by accumulating other successes,’ perhaps that’s the wrong mindset to achieve success at the higher levels. Perhaps you need to think, ‘Okay, I’m going to make some mistakes, how can I learn from this, how can I share these mistakes, and how can other people learn from them too?’

That’s interesting. In fact, just yesterday I was discussing a book by Atul Gawande, the surgeon and New Yorker writer, called The Checklist Manifesto . In that, Gawande also argues that we should draw from the success of aviation, in that case, the checklists that they run through before take-off and so on, and apply it to other fields like medicine. A system like this is aiming to get rid of human error, and I suppose that’s what critical thinking tries to do, too: rid us of the gremlins in machine.

Well, it’s also acknowledging that when you make an error, it can have disastrous consequence. But you don’t eliminate errors just by pretending they didn’t occur. With the Chernobyl disaster , for instance, there was an initial unwillingness to accept the evidence in front of people’s eyes that a disaster had occurred, combined with a fear of being seen to have messed up. There’s that tendency to think that everything’s going well, a kind of cognitive bias towards optimism and a fear of being responsible for error, but it’s also this unwillingness to see that in certain areas, admission of failure and sharing of the knowledge that mistakes have occurred is the best way to minimize failure in the future.

Very Beckettian . “Fail again. Fail better.”

Absolutely. Well, shall we move onto to Rolf Dobelli’s 2013 book, The Art of Thinking Clearly ?

Yes. This is quite a light book in comparison with the others. It’s really a summary of 99 moves in thinking, some of them psychological, some of them logical, some of them social. What I like about it is that he uses lots of examples. Each of the 99 entries is pretty short, and it’s the kind of book you can dip into. I would think it would be very indigestible to read it from cover to cover, but it’s a book to keep going back to.

I included it because it suggests you can you improve your critical thinking by having labels for things, recognising the moves, but also by having examples which are memorable, through which you can learn. This is an unpretentious book. Dobelli doesn’t claim to be an original thinker himself; he’s a summariser of other people’s thoughts. What he’s done is brought lots of different things together in one place.

Just to give a flavour of the book: he’s got a chapter on the paradox of choice that’s three pages long called ‘Less is More,’ and it’s the very simple idea that if you present somebody with too many choices, rather than freeing them and improving their life and making them happier, it wastes a lot of their time, even destroys the quality of their life.

“If you present somebody with too many choices, it wastes a lot of their time”

I saw an example of this the other day in the supermarket. I bumped into a friend who was standing in front of about 20 different types of coffee. The type that he usually buys wasn’t available, and he was just frozen in this inability to make a decision between all the other brands that were in front of him. If there’d only been one or two, he’d have just gone for one of those quickly.

Dobelli here is summarising the work of psychologist Barry Schwartz who concluded that generally, a broader selection leads people to make poorer decisions for themselves. We think going into the world that what we need is more choice, because that’ll allow us to do the thing we want to do, acquire just the right consumable, or whatever. But perhaps just raising that possibility, the increased number of choices will lead us to make poorer choices than if we had fewer to choose between.

Now, that’s the descriptive bit, but at the end of this short summary, he asks ‘So what can you do about this practically?’ His answer is that you should think carefully about what you want before you look at what’s on offer. Write down the things you think you want and stick to them. Don’t let yourself be swayed by further choices. And don’t get caught up in a kind of irrational perfectionism. This is not profound advice, but it’s stimulating. And that’s typical of the book.

You can flip through these entries and you can take them or leave them. It’s a kind of self-help manual.

Oh, I love that. A critical thinking self-help book .

It really is in that self-help genre, and it’s nicely done. He gets in and out in a couple of pages for each of these. I wouldn’t expect this to be on a philosophy reading list or anything like that, but it’s been an international bestseller. It’s a clever book, and I think it’s definitely worth dipping into and coming back to. The author is not claiming that it is the greatest or most original book in the world; rather, it’s just a book that’s going to help you think clearly. That’s the point.

Absolutely. Let’s move to the final title, Tom Chatfield’s Critical Thinking: Your Guide to Effective Argument, Successful Analysis and Independent Study . We had Tom on Five Books many moons ago to discuss books about computer games . This is rather different. What makes it so good?

Well, this is a different kind of book. I was trying to think about somebody reading this interview who wants to improve their thinking. Of the books I’ve discussed, the ones that are most obviously aimed at that are Black Box Thinking , the Dobelli book, and Tom Chatfield’s Critical Thinking . The others are more descriptive or academic. But this book is quite a contrast with the Dobelli’s. The Art of Thinking Clearly is a very short and punchy book, while Tom’s is longer, and more of a textbook. It includes exercises, with summaries in the margins, it’s printed in textbook format. But that shouldn’t put a general reader off, because I think it’s the kind of thing you can work through yourself and dip into.

It’s clearly written and accessible, but it is designed to be used on courses as well. Chatfield teaches a point, then asks you to test yourself to see whether you’ve learnt the moves that he’s described. It’s very wide-ranging: it includes material on cognitive biases as well as more logical moves and arguments. His aim is not simply to help you think better, and to structure arguments better, but also to write better. It’s the kind of book that you might expect a good university to present to the whole first year intake, across a whole array of courses. But I’m including it here more as a recommendation for the autodidact. If you want to learn to think better: here is a course in the form of a book. You can work through this on your own.

It’s a contrast with the other books as well, so that’s part of my reason for putting it in there, so there’s a range of books on this list.

Definitely. I think Five Books readers, almost by definition, tend towards autodidacticism, so this is a perfect book recommendation. And, finally, to close: do you think that critical thinking is something that more people should make an effort to learn? I suppose the lack of it might help to explain the rise of post-truth politics.

It’s actually quite difficult to teach critical thinking in isolation. In the Open University’s philosophy department, when I worked there writing and designing course materials, we decided in the end to teach critical thinking as it arose in teaching other content: by stepping back from time to time to look at the critical thinking moves being made by philosophers, and the critical thinking moves a good student might make in response to them. Pedagogically, that often works much better than attempting to teach critical thinking as a separate subject in isolation.

This approach can work in scientific areas too. A friend of mine has run a successful university course for zoologists on critical thinking, looking at correlation and cause, particular types of rhetoric that are used in write ups and experiments, and so on, but all the time driven by real examples from zoology. If you’ve got some subject matter, and you’ve got examples of people reasoning, and you can step back from it, I think this approach can work very well.

But in answer to your question, I think that having some basic critical thinking skills is a prerequisite of being a good citizen in a democracy . If you are too easily swayed by rhetoric, weak at analysing arguments and the ways that people use evidence, and prone to all kinds of biases that you are unaware of, how can you engage politically? So yes, all of us can improve our critical thinking skills, and I do believe that that is an aspect of living the examined life that Socrates was so keen we all should do. [ end of the original interview. Update below ]

———————————-

It’s been just over two years since you explained to us what critical thinking is all about. Could you update us on any books that have come out since we first spoke?

Calling Bullshit by Carl Bergstrom and Jevin West started life as a course at the University of Washington. It is a book—a handbook really—written with the conviction that bullshit, particularly the kind that is circulated on the Internet, is damaging democracy , and that misinformation and disinformation can have very serious consequences. Bullshitters don’t care about truth. But truth is important, and this book shows why. It is focussed on examples from science and medicine, but ranges more widely too. It’s a lively read. It covers not just verbal bullshit, bullshit with statistics (particularly in relation to big data) and about causation, but also has a chapter on bullshit data visualisations that distract from the content they are about, or present that data in misleading ways. Like all good books on critical thinking this one includes some discussion of the psychology of being taken in by misleading contributions to public debate.

In How To Make the World Add Up , Tim Harford gives us ten rules for thinking better about numbers, together with a Golden Rule (‘Be curious’). Anyone who has listened to his long-running radio series More or Less will know how brilliant Tim is at explaining number-based claims – as I read it, I hallucinated Tim’s reassuring, sceptical, reasonable, amused, and  patient voice. He draws on a rich and fascinating range of examples to teach us (gently) how not to be taken in by statistics and poorly supported claims. There is some overlap with Calling Bullshit , but they complement each other. Together they provide an excellent training in how not to be bamboozled by data-based claims.

December 4, 2020

Five Books aims to keep its book recommendations and interviews up to date. If you are the interviewee and would like to update your choice of books (or even just what you say about them) please email us at [email protected]

Nigel Warburton

Nigel Warburton is a freelance philosopher, writer and host of the podcast Philosophy Bites . Featuring short interviews with the world's best philosophers on bite-size topics, the podcast has been downloaded more than 40 million times. He is also our philosophy editor here at Five Books , where he has been interviewing other philosophers about the best books on a range of philosophy topics since 2013 (you can read all the interviews he's done here: not all are about philosophy). In addition, he's recommended books for us on the best introductions to philosophy , the best critical thinking books, as well as some of the key texts to read in the Western canon . His annual recommendations of the best philosophy books of the year are among our most popular interviews on Five Books . As an author, he is best known for his introductory philosophy books, listed below:

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Cognitive Errors and Diagnostic Mistakes

A Case-Based Guide to Critical Thinking in Medicine

• © 2019
• Jonathan Howard 0

Neurology and Psychiatry, NYU Langone Medical Center, New York, USA

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• First case-based book illustrating cognitive biases and their consequences in the practice of medicine
• Provides strategies on minimizing cognitive errors
• Engaging and easy-to-read

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About this book

This case-based book illustrates and explores common cognitive biases and their consequences in the practice of medicine. The book begins with an introduction that explains the concept of cognitive errors and their importance in clinical medicine and current controversies within healthcare. The core of the book features chapters dedicated to particular cognitive biases; cases are presented and followed by a discussion of the clinician's rationale and an overview of the particular cognitive bias. Engaging and easy to read, this text provides strategies on minimizing cognitive errors in various medical and professional settings.

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“First, know thyself”: cognition and error in medicine

Cognitive Errors

Diagnostic Errors and Their Associated Cognitive Biases

• Cognitive errors
• Misdiagnosis
• Diagnostic error
• Patient safety
• Best practices in healthcare
• Aggregate bias

Table of contents (30 chapters)

Front matter, introduction.

Jonathan Howard

Ambiguity Effect

Bandwagon effect and authority bias, confirmation bias, motivated cognition, the backfire effect, curse of knowledge, decision fatigue, feedback sanction, financial bias, forer effect, framing effect and loss aversion, affective error, gambler’s fallacy and hot hand fallacy, hasty generalization, survival bias, special pleading, and burden of proof, hindsight bias and outcome bias, illusionary correlation, false causation, and clustering illusion, in-group favoritism, information bias, nosology trap, omission bias, authors and affiliations, about the author.

Jonathan Howard MD

Assistant Professor, Neurology and Psychiatry

NYU Langone Medical Center

New York, NY

Bibliographic Information

Book Title : Cognitive Errors and Diagnostic Mistakes

Book Subtitle : A Case-Based Guide to Critical Thinking in Medicine

Authors : Jonathan Howard

DOI : https://doi.org/10.1007/978-3-319-93224-8

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Springer International Publishing AG, part of Springer Nature 2019

Softcover ISBN : 978-3-319-93223-1 Published: 06 December 2018

eBook ISBN : 978-3-319-93224-8 Published: 28 November 2018

Edition Number : 1

Number of Pages : XIII, 588

Number of Illustrations : 46 b/w illustrations, 200 illustrations in colour

Topics : General Practice / Family Medicine , Health Promotion and Disease Prevention , Drug Safety and Pharmacovigilance , Neurology

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Thinking About Medicine

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This introduction to the philosophy of medicine surveys the landscape of western philosophy as it pertains to healthcare in an accessible way. Written by a doctor for doctors and other health professionals, framing the 'toolbox' of philosophy within the community of medicine, it encourages examination of the implicit assumptions made in the construction of medical knowledge and practice.

Taking the reader step by step through the concepts that underpin modern philosophy, they will be challenged to reflect upon the premises within clinical practice which might benefit from scrutiny and challenge, including the nature of scientific knowledge, the limits of our biomedical model, the cultural and relational context, and the failure to recognise or manage adequately the fact/value distinction in medicine and healthcare.

The book is an ideal textbook for students of medicine and medical philosophy and will also be of interest to bioethicists, medical sociologists, clinical commissioners and to practicing clinicians in medicine and the allied health professions seeking to improve their understanding of philosophy and ethics and sharpen their critical thinking skills.

TABLE OF CONTENTS

Chapter | 2  pages, thinking about medicine: introduction, part section 1 | 106  pages, chapter 4chapter 1 | 17  pages, epistemology part i: problems with knowing, chapter chapter 2 | 17  pages, epistemology part ii: reasoning – ways of knowing, chapter chapter 3 | 26  pages, the philosophy of science i, chapter chapter 4 | 25  pages, antirealist epistemology, chapter chapter 5 | 19  pages, putting the evidence into evidence-based medicine, part section 2 | 114  pages, what is there to know about, chapter 110chapter 6 | 21  pages, ontology of disease, chapter chapter 7 | 28  pages, values – moral theory, chapter chapter 8 | 19  pages, ethics – moral problems, moral actions, chapter chapter 9 | 30  pages, the conscious self i, chapter chapter 10 | 14  pages, the moral self, part section 3 | 74  pages, knowing about healthcare, chapter 224chapter 11 | 34  pages, a philosophy of health, chapter chapter 12 | 24  pages, medicine, society and issues of power i, chapter chapter 13 | 14  pages, the philosophy of public health i, part section 4 | 19  pages, final thoughts, chapter 298chapter 14 | 8  pages, further study, chapter chapter 15 | 9  pages.

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Medical Student Guide For Critical Thinking

Critical thinking is an essential cognitive skill for every individual but is a crucial component for healthcare professionals such as doctors, nurses and dentists. It is a skill that should be developed and trained, not just during your career as a doctor, but before that when you are still a medical student.

To be more effective in their studies, students must think their way through abstract problems, work in teams and separate high quality from low quality information. These are the same qualities that today's medical students are supposed to possess regardless of whether they graduate in the UK or study medicine in Europe .

In both well-defined and ill-defined medical emergencies, doctors are expected to make competent decisions. Critical thinking can help medical students and doctors achieve improved productivity, better clinical decision making, higher grades and much more.

This article will explain why critical thinking is a must for people in the medical field.

Definition of Critical Thinking

You can find a variety of definitions of Critical Thinking (CT). It is a term that goes back to the Ancient Greek philosopher Socrates and his teaching practice and vision. Critical thinking and its meaning have changed over the years, but at its core always will be the pursuit of proper judgment.

We can agree on one thing. Critical thinkers question every idea, assumption, and possibility rather than accepting them at once.

The most basic definition of CT is provided by Beyer (1995):

"Critical thinking means making reasoned judgements."

In other words, it is the ability to think logically about what to do and/or believe. It also includes the ability to think critically and independently. CT is the process of identifying, analysing, and then making decisions about a particular topic, advice, opinion or challenge that we are facing.

Steps to critical thinking

There is no universal standard for becoming a critical thinker. It is more like a unique journey for each individual. But as a medical student, you have already so much going on in your academic and personal life. This is why we created a list with 6 steps that will help you develop the necessary skills for critical thinking.

1. Determine the issue or question

The first step is to answer the following questions:

• What is the problem?
• Why is it important?
• Why do we need to find a solution?
• Who is involved?

By answering them, you will define the situation and acquire a deeper understanding of the problem and of any factors that may impact it.

Only after you have a clear picture of the issue and people involved can you start to dive deeper into the problem and search for a solution.

2. Research

Nowadays, we are flooded with information. We have an unlimited source of knowledge – the Internet.

Before choosing which medical schools to apply to, most applicants researched their desired schools online. Some of the areas you might have researched include:

• If the degree is recognised worldwide
• Tuition fees
• Living costs
• Entry requirements
• Competition for entry
• Number of exams
• Programme style

Having done the research, you were able to make an informed decision about your medical future based on the gathered information. Our list may be a little different to yours but that's okay. You know what factors are most important and relevant to you as a person.

The process you followed when choosing which medical school to apply to also applies to step 2 of critical thinking. As a medical student and doctor, you will face situations when you have to compare different arguments and opinions about an issue. Independent research is the key to the right clinical decisions. Medical and dentistry students have to be especially careful when learning from online sources. You shouldn't believe everything you read and take it as the absolute truth. So, here is what you need to do when facing a medical/study argument:

• Gather relevant information from all available reputable sources
• Pay attention to the salient points
• Evaluate the quality of the information and the level of evidence (is it just an opinion, or is it based upon a clinical trial?)

Once you have all the information needed, you can start the process of analysing it. It’s helpful to write down the strong and weak points of the various recommendations  and identify the most evidence-based approach.

Here is an example of a comparison between two online course platforms , which shows their respective strengths and weaknesses.

When recommendations or conclusions are contradictory, you will need to make a judgement call on which point of view has the strongest level of evidence to back it up. You should leave aside your feelings and analyse the problem from every angle possible. In the end, you should aim to make your decision based on the available evidence, not assumptions or bias.

4. Be careful about confirmation bias

It is in our nature to want to confirm our existing ideas rather than challenge them. You should try your best to strive for objectivity while evaluating information.

Often, you may find yourself reading articles that support your ideas, but why not broaden your horizons by learning about the other viewpoint?

By doing so, you will have the opportunity to get closer to the truth and may even find unexpected support and evidence for your conclusion.

Curiosity will keep you on the right path. However, if you find yourself searching for information or confirmation that aligns only with your opinion, then it’s important to take a step back. Take a short break, acknowledge your bias, clear your mind and start researching all over.

5. Synthesis

As we have already mentioned a couple of times, medical students are preoccupied with their studies. Therefore, you have to learn how to synthesise information. This is where you take information from multiple sources and bring the information together. Learning how to do this effectively will save you time and help you make better decisions faster.

You will have already located and evaluated your sources in the previous steps. You now have to organise the data into a logical argument that backs up your position on the problem under consideration.

6. Make a decision

Once you have gathered and evaluated all the available evidence, your last step  is to make a logical and well-reasoned conclusion.

By following this process you will ensure that whatever decision you make can be backed up if challenged

Why is critical thinking so important for medical students?

The first and most important reason for mastering critical thinking is that it will help you to avoid medical and clinical errors during your studies and future medical career.

Another good reason is that you will be able to identify better alternative options for diagnoses and treatments. You will be able to find the best solution for the patient as a whole which may be different to generic advice specific to the disease.

Furthermore, thinking critically as a medical student will boost your confidence and improve your knowledge and understanding of subjects.

In conclusion, critical thinking is a skill that can be learned and improved.  It will encourage you to be the best version of yourself and teach you to take responsibility for your actions.

Critical thinking has become an essential for future health care professionals and you will find it an invaluable skill throughout your career.

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“Clear and concise, ... this book is helpful for anyone looking to enhance their critical thinking skills.” — University of Houston Law Center O'Quinn Law Library

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To the conspiracy-minded alternative health practitioner, everything was great until the Flexner Report was published. Humanity was crushing diseases with herbal remedies and natural potions until 1910 when the “medical-industrial complex” came together and  “criminalized natural therapies.”  We are now afflicted by Rockefeller medicine, where ill citizens are hooked on expensive drugs that never heal them and the truth about the benefits of herbs is being hidden by paid-off politicians and academics.

This alleged fall from paradise can all be blamed on the original sin of that darn Flexner Report.

I would wager that most of the people hurling insults at this century-old book have never actually read it; I did, because I wanted to know what the fuss was all about.

The Flexner Report was commissioned because the state of medical education in the United States and Canada was dire. A young educator was hired to visit all of North America’s medical colleges and report back, which led to much-needed changes and some unfortunate consequences.

And, yes, he did have some harsh words for what he called “the unconscionable quacks.”

A medical degree  and  a free trip to Europe!

There is a reason why leeches and purging agents are now rarely used in medicine: the discipline has evolved over the millennia, and Abraham Flexner found himself at the beginning of a new and exciting era.

Medicine in the Western tradition began with Hippocrates and Galen. It began with dogma. “Facts,” Flexner wrote in his report, “had no chance if pitted against the word of the master.” Those who despise modern medicine will claim it has remained dogmatic to this day; but while practitioners can be set in their ways and new findings can linger before they are adopted, we are far from the pontifical medicine of old.

With the rapid development of anatomy in the 1500s, medicine moved from dogma to empiricism. This meant that instead of doctors simply parroting what they had been taught by the rock stars of their field, they would learn from their own experience. They would observe and they would treat accordingly. This approach was more welcoming to discovery, but it was still hard for doctors of that era to properly disentangle diseases that superficially looked the same.

What propelled the discipline forward was science. We came to realize that the human body obeys the laws of biology: it grows, reproduces itself, and dies in predictable ways, and by understanding this underlying biology, the doctor would be better able to prevent and treat disease. Scientific research fed clinical practice, and the medical student, no longer limited to watching, would  do  as well.

Like medicine, medical training itself had changed over the centuries. It started as a system of apprenticeship, where a trainee became indentured at a young age to a doctor and ran his errands. Eventually, he would get to learn the secrets of his master’s trade. In Europe, the teaching of medicine would move to the lecture halls, which were host to anatomy demonstrations, and many American students would cross the Atlantic to benefit from this enrichment in Paris or Edinburgh. It wouldn’t take long before American doctors saw a way to sprout a similar system stateside and reap its financial benefits.

They were called proprietary schools. They were privately owned, with their teachers splitting the profits among themselves. They could rent a cheap hall, get some inexpensive benches, and recruit students who didn’t even have a high school diploma. “A school that began in October,” Flexner wrote, “would graduate a class the next spring.” Their facilities were poorly stocked, with barely-existing laboratories. The money that didn’t end up in the founders’ pockets was used to make all sorts of wild promises in the advertising material. One of these medical colleges swore it would gift its graduates a trip to Europe!

Following this explosion in questionable proprietary medical schools in the mid-1800s, change was thankfully afoot, but something major was needed around which this change could crystallize.

Quality over quantity

The Flexner Report’s actual title is  Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching.  It was commissioned by industrialist Andrew Carnegie’s policy and research foundation. Much has been made of the report’s ties to Carnegie and to Rockefeller, whose own foundation alongside eight others would pour a lot of money to implement the solutions proposed in the Flexner Report. Flexner’s brother, Simon, was also a friend of John D. Rockefeller, Jr, and he directed the Rockefeller Institute for Medical Research for more than three decades. Seen through our modern lens, this friendly alliance between medical education and capitalistic interest can trigger a fair amount of skepticism, if not outright conspiracy theories. It was in the wealthy elite’s interest to downplay the impact of social disparities on health and to promote the simpler idea that the human body was a machine whose broken parts could be mended by the right science-informed technician. But as we’ll see, the report itself did not stick to this narrow viewpoint.

Abraham Flexner, whom the Carnegie Foundation recruited for this massive work, was not a doctor; he was a teacher. Born in Louisville, Kentucky, Flexner studied Greek, Latin and philosophy as an undergrad at Johns Hopkins, and this university made a profound mark on him. It would become the template for Flexner’s medical education revolution.

After teaching high school, Flexner opened his own private preparatory school, which served as a laboratory for his educational convictions. After receiving a Master’s degree in philosophy from Harvard, exploring Europe, and writing a book on American education, he was recruited by the head of the Carnegie Foundation. His mission: to tour the 150 medical schools in the United States and Canada and report back in writing on what their problems were and how to solve them. Already, the deceptive marketing of many of these schools and their deficient scientific education was known; Flexner was to document it. His report was scathing.

Flexner wrote of the dissection rooms where cadavers were as dry as tanned leather. He denounced the medical colleges claiming to have access to a hospital for their students when that was not the case. Many schools did not have full-time faculty and lacked proper laboratories. At the North Carolina Medical College, in Charlotte, Flexner was told that asking about laboratories was futile: their students were “all thumbs,” better suited to be farmers.

His year-and-a-half survey of North America resulted in a three-tiered list of medical colleges.

Sixteen were in tier one, requiring at least two years of college for admission and doing their best to meet the standard set by the Johns Hopkins Medical School. Fifty were salvageable and required of their student applicants a high school diploma. The rest, mostly found in the south of the United States, was a complete loss, in his opinion. “For the law, if enforced, would stamp them out.” (In case my colleagues are curious, he admired McGill’s own medical school, calling it “excellent” and being impressed by its anatomical and pathological museums, as well as its library. Its medical budget at the time was a mere $77,000.)

Flexner’s short-term solution to the proliferation of inadequate, for-profit medical schools was to shut them down and fund the ones that had stricter standards and that were affiliated with a university. He recommended quality over quantity, with fewer but better equipped schools graduating fewer physicians that were better trained. His influential book-length report was used to justify an influx of $154 million in the medical education system over the course of nearly two decades.

While prioritizing quality is commendable, the consequences of the Flexner Report were not all positive. Almost all women’s and historically Black medical colleges  shut down in its wake , and women were nearly eliminated from the physician workforce until the 1970s. Medical schools were consolidated in large urban centres and required more money and education to get in, which meant that middle- and upper-class white men had an easier time becoming physicians. And closing a bad medical college in the American South might have been smart in the short term, but if it was not replaced by a better school, it simply created an educational desert.

But if the Flexner Report was focused on improving  medical  education, why are so many homeopaths and naturopaths mad about it?

Made-up minds

In chapter 10 of his report, Flexner goes for the jugular of what he calls the “medical sects.” Those were competing philosophies of medicine, like homeopathy, osteopathy, and eclectic medicine (a plant-based approach). Flexner correctly observes that unlike the doctor who wants facts and not dogma, “the sectarian […] begins with his mind made up.” He denounces the contradiction in many of the best sectarian colleges, where students underwent two years of chemistry, biology, and physics, before entering clinical training and suddenly being introduced to a pseudoscientific principle that contradicted what they had just learned.

Flexner was not single-handedly responsible for shutting these colleges down. In the ten years before the publication of his report, the 22 homeopathic colleges in the U.S. were trimmed down to 15. Much like the scientific revolution changing medicine, the Flexner Report did not begin the transformation but simply galvanized it.

Yet, Flexner, perceived as the hatchet man that tore down much of the medical education infrastructure, has become a lightning rod for misconceptions and bad arguments. He is sometimes accused of having denigrated the value of public health, which is simply false. In his report he writes of bad environmental conditions that breed disease, such as a contaminated water and food supply. The good doctor’s role, he writes on page 68, “is equally to heal the sick and to protect the well. The public health laboratory belongs, then, under the wing of the medical school.” To make the point even clearer, Flexner notes that “the physician’s function is fast becoming social and preventive, rather than individual and curative.”

And while a hyperfocus on science as the answer to medical problems can lead to inhumane treatment (and certainly had a role to play in eugenics and unconscionable medical experiments like Tuskegee’s), Flexner understood the importance of care. His ideal doctor required “insight and sympathy” in order to heal. That priority may have gotten lost in the implementation of his plan, but it is present in the report, black on white.

When the sectarians he condemns criticize his report, they often claim that he transformed medicine from a holistic view of the entire body into a myopic practice that only focused on broken body parts. This is a convenient argument for them. As scientific research nourished clinical practice, our body of medical knowledge grew, forcing doctors to specialize. But there is no real growth in so-called alternative medicine. There is no  need  to specialize when you believe there is only one true cause to all diseases. Whether it’s an alleged chiropractic subluxation or a blockage of the supposed life force called qi, it’s just an obstruction. All these practitioners need to do is find the source of the blockage and declog the pipe, much like a plumber. As Flexner pointed out, though, this is not science but dogma masquerading as knowledge.

As for the loss of holism in medicine, it still exists in family medicine, and especially in group practices, where integrating knowledge from specialties is commonplace. But given the incredible amount of knowledge generated in scientific medicine, it is absurd to expect every doctor to know everything.

The Flexner Report of 1910 was an imperfect catalyst that helped move medicine into its science-informed era. It would take many more decades, though, before the randomized controlled clinical trial was adopted as a gold standard for determining the worth of a treatment or preventative. The report also exacerbated inequalities in access to medical education in an attempt to reward the most rigorous institutions. Nonetheless, it argued that the best place for medical education was not in a privately owned and poorly regulated makeshift school but in a university, where foundational research could provide new solutions to the healer.

The kind of quackery that Flexner decried has not really gone away, despite what he predicted, and its practices certainly have not been criminalized.  Osteopathy  raised its standards in the United States and became, for all intents and purposes, equivalent to medicine. Homeopathic colleges are rare but  their hyperdiluted concoctions  are still widely available. Some dubious professions, like naturopaths, have acquired an unearned legitimacy in some states and provinces, and the concept of integrative medicine—of adding junk practices to actual medicine to get some sort of best of both worlds—has unfortunately made  massive strides in academia .

The battle against medical sectarianism has not been won. There is a lot of work left to do.

Take-home message: - The Flexner Report, published in 1910, crystallized a revolution in North America toward teaching a type of medicine that was strongly influenced by scientific discoveries - The claim that Flexner downplayed the importance of public health and preventive medicine in his report because he was working for the Carnegie Foundation is simply false - The claim that medicine stopped treating the whole person after the Flexner Report came out but that natural healers still do is false: family medicine is holistic; medical specialties exist because of our increased knowledge; and natural healing practices have no need to specialize since they often believe there is one true cause to every disease, which is wrong

@CrackedScience

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Why Brilliant People Believe Nonsense: A Practical Text for Critical and Creative Thinking

J. Steve Miller , Kennesaw State University Follow Cherie K. Miller , Kennesaw State University Follow

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Description

The information explosion has made us information rich, but wisdom poor. Yet, to succeed in business and in life, we must distinguish accurate from bogus sources, and draw valid conclusions from mounds of data. This book, written for a general adult audience as well as students, takes a new look at critical thinking in the information age, helping readers to not only see through nonsense, but to create a better future with innovative thinking.

Readers should see the practicality of enhancing skills that make them more innovative and employable, especially in a day when companies increasingly seek original thinkers, global visionaries, and thought leaders. Targeting high school seniors and college freshmen, but useful to all adult readers, the authors examine surprising and costly mental errors made by respected business leaders, entertainment moguls, musicians, civic leaders, generals and academics. Then, the authors draw practical applications to help readers avoid such mistakes and think more creatively in each field.

Although written in an engaging and popular style, over 600 end notes provide authority to this content-rich document. Thus writers, researchers, teachers, and job seekers should find it a useful starting point for research into this important field. Home school teachers and public school educators will find an accompanying free website with lesson plans and teaching tips. It's also a low-cost alternative to expensive texts. (The hard copy is priced reasonably and a pdf of the entire book will be offered free to students on their digital platforms.) Each chapter ends with thought questions and tips for further research.

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Acworth, GA

logic, critical thinking, creative thinking, innovation, wisdom, research, creativity, innovative, innovate, statistics, common sense

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Authors: J. Steve Miller, the primary author, is president of Legacy Educational Resources, teaches at Kennesaw State University, and has taught audiences from Atlanta to Moscow. His former books have won numerous awards and have been translated into many languages. Cherie K. Miller holds a masters degree in professional writing, has written several books and many articles, and works with the Interdisciplinary Studies program at KSU.

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Critical Thinking Skills for Dummies (Paperback)

• Description
• About the Author
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Learn how to argue points effectively, analyze information, and make sound judgments

The ability to think clearly and critically is a lifelong benefit that you can apply in any situation that calls for reflection, analysis, and planning. Being able to think systematically and solve problems is also a great career asset. Critical Thinking Skills For Dummies helps you hone your thinking abilities and become a better communicator. You'll find hands-on, active instruction and exercises that you can put to work today as you navigate social media and news websites, chat with AI, fact-check your own and others' views, and more. Become a thinking machine, with this Dummies guide.

• Identify other people's arguments and conclusions--and spot holes in them
• Evaluate evidence and produce more effective arguments in any situation
• Read between the lines of what people say and form your own judgments
• Apply critical thinking to school or college assignments to improve your academic performance

This is the perfect Dummies title for students, researchers, and everyone who seeks to improve their reasoning and analysis ability.

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Materialism and Empirio-criticism

Critical comments on a reactionary philosophy [1], book information.

• Written: February 1908—October 1908; Supplement to Chapter IV, Section I—in March 1909
• Published: May 1909 in Moscow as a separate book by Zveno Publishers . Published according to the text of the 1909 edition checked with the 1920 edition.
• Source: Lenin Collected Works , Progress Publishers, 1972 , Moscow, Volume 14 , pages 17-362
• Translated: Abraham Fineberg
• Transcription; Markup: D. Walters ; Alyx Mayer
• License: Lenin Internet Archive 1999, 2014. You may freely copy, distribute, display and perform this work per the terms of the Attribution-ShareAlike 2.0 license; as well as make derivative and commercial works. Please credit “Marxists Internet Archive” as your source.
• Preface to the First Edition
• Preface to the Second Edition
• In Lieu of An Introduction

1. The Theory of Knowledge of Empirio-Criticism and of Dialectical Materialism - I

• Sensations And Complexes Of Sensations
• “The Discovery of the World-Elements”
• The Principal Co-Ordination and “Naive Realism”
• Did Nature Exist Prior to Man?
• Does Man Think With The Help of the Brain?
• The Solipsism of Mach and Avenarius

2. The Theory of Knowledge of Empirio-Criticism and of Dialectical Materialism - II

• The “Thing-In-Itself,” or V. Chernov Refutes Frederick Engels
• “Transcendence,” Or Bazarov “Revises” Engels
• L. Feuerbach and J. Dietzgen on the Thing-In-Itself
• Does Objective Truth Exist?
• Absolute and Relative Truth, or the Eclecticism of Engels as Discovered by A. Bogdanov
• The Criterion of Practice in the Theory of Knowledge

3. The Theory of Knowledge of Dialectical Materialism and of Empirio-Criticism - III

• What Is Matter? What Is Experience?
• Plekhanov’s Error Concerning The Concept “Experience”
• Causality And Necessity In Nature
• The “Principle Of Economy Of Thought” And The Problem Of The “Unity Of The World”
• Space And Time
• Freedom and Necessity

4. The Philosophical Idealists as Comrades-In-Arms and Successors of Empirio-Criticism

• The Criticism of Kantianism from the Left and From the Right
• How the “Empirio-Symbolist” Yushkevich Ridiculed the “Empirio-Criticist” Chernov
• The Immanentists as Comrades-In-Arms of Mach and Avenarius
• Whither is Empirio-Criticism Tending?
• A. Bogdanov’s “Empirio-Monism”
• The “Theory of Symbols” (or Hieroglyphs) and the Criticism of Helmholtz
• Two Kinds of Criticism of Dühring
• How Could J. Dietzgen Have Found Favour with the Reactionary Philosophers?

5. The Recent Revolution in Natural Science and Philosophical Idealism

• The Crisis in Modern Physics
• “Matter Has Disappeared”
• Is Motion Without Matter Conceivable?
• The Two Trends in Modern Physics and English Spiritualism
• The Two Trends in Modern Physics, and German Idealism
• The Two Trends in Modern Physics and French Fideism
• A Russian “Idealist Physicist”
• The Essence and Significance of “Physical” Idealism

6. Empirio-Criticism and Historical Materialism

• The Excursions of the German Empirio-Criticists Into The Field of the Social Sciences
• How Bogdanov Corrects and “Develops” Marx
• Suvorov’s “Foundations Of Social Philosophy”
• Parties in Philosophy and Philosophical Blockheads
• Ernst Haeckel and Ernst Mach
• Supplement to Chapter Four, Section I

[1] The book Materialism and Empirio-criticism. Critical Comments on a Reactionary Philosophy was written by Lenin during February to October 1908 in Geneva and London. It was published in Moscow in May 1909 by the Zveno Publishers. The manuscript of the book and Lenin’s preparatory material for it have so far not been found.

The book is the outcome of a prodigious amount of creative scientific research carried out by Lenin during nine months. His main work on the book was carried out in Geneva libraries, but in order to obtain a detailed knowledge of the modern literature of philosophy and natural science be went in May 1908 to London, where he worked for about a month in the library of the British Museum. The list of sources quoted or mentioned by Lenin in his book exceeds 200 titles.

In December 1908 Lenin went from Geneva to Paris where he worked until April 1909 on correcting the proofs of his book. He had to agree to tone down some passages of the work so as not to give he tsarist censorship an excuse for prohibiting its publication. It was published in Russia under great difficulties. Lenin insisted on the speedy issue of the book, stressing that “not only literary but also serious political obligations” were involved in its publication.

Lenin’s work Materialism and Empirio-criticism played a decisive part in combating the Machist revision of Marxism. It enabled the philosophical ideas of Marxism to spread widely among the mass of party members and helped the party activists and progressive workers to master dialectical and historical materialism.

This classical work of Lenin’s has achieved a wide circulation in many countries, and has been published in over 20 languages.

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Mission To Moscow Paperback – January 1, 2011

• Print length 420 pages
• Language English
• Publisher Nabu Press
• Publication date January 1, 2011
• Dimensions 7.44 x 0.86 x 9.69 inches
• ISBN-10 1179304756
• ISBN-13 978-1179304755
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Product details

• Publisher ‏ : ‎ Nabu Press (January 1, 2011)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 420 pages
• ISBN-10 ‏ : ‎ 1179304756
• ISBN-13 ‏ : ‎ 978-1179304755
• Item Weight ‏ : ‎ 1.6 pounds
• Dimensions ‏ : ‎ 7.44 x 0.86 x 9.69 inches

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