Why We Need Critical Thinking in EMS

One of the most difficult challenges in EMS education is teaching critical thinking and the ability to apply it in the field. Unfortunately, much EMS education has centered upon rote learning, regurgitation of facts and passing multiple-choice exams. None of these promote excellent prehospital care.

Educators have struggled for decades to learn how to teach critical thinking skills. Unfortunately, many EMS educators have lacked a firm foundation in education theory and process. This is not a criticism but a fact. Many good EMS educators became such through necessity rather than design. Many never were exposed to learning theories and the psychology of learning concepts, and have through necessity explored the literature and become self-taught in education theory.

I am one of those. In spite of having a bachelor's degree in music education, I was unaware of modern theories of adult learning until I had been teaching EMS folks for a few years. The first time I was exposed to Bloom's taxonomy of learning domains, I was captivated. I'd never thought there were different types of learning. When I understood that learning falls into the three categories now recognized (cognitive, affective and psychomotor), I began to think about how I was approaching my teaching, and I began to change. I first looked at Bloom's hierarchy of learning domains and realized I was only addressing the lowest order in cognitive learning in my courses.

Bloom lists skills in the cognitive domain as follows, from lowest to highest: knowledge, comprehension, application, analysis, synthesis and evaluation.

EMS education has tended to focus on knowledge and comprehension rather than application. It should be apparent that in the field, application is what we do every day. Yet, how are we teaching our students to apply their knowledge, analyze it, create new approaches and evaluate what they've done? The answer is, I regret, not very well.

To address that failing, I began to focus on ways to help students develop the skills needed to learn and apply knowledge in a meaningful way, which is what summarizes Bloom's ideas. Recently, Bloom's concepts have been revised, and now they are stated in terms of student outcomes instead of instructional criteria. The new outcomes are:

1) Knowledge (remember);

2) Understand (describe, explain);

3) Apply;

4) Analyze;

5) Evaluate;

6) Create.

Looking at what we do in EMS, the application is clear. We do everything listed, and analyzing, evaluating and creating are the most important. I found that problem-based learning holds the most promise, when combined with techniques such as team or group learning, in helping students get to where they can use information to analyze, evaluate and create.

Problem-based learning is a simple concept: Give the students a problem and ask them to solve it. Provide them with all the tools to do that, and they will rise to the occasion. What I mean is that one of the first things we must impart to our students is that information is available in many forms, and no one information source is adequate. This strikes at the heart of traditional EMS education, where a textbook is chosen, and the course is structured around that text.

The truth is, no one textbook is adequate. All EMS texts have their strong points and weak points. As an instructor, I have learned I must use all the current texts, plus standard works in emergency medicine such as Tintinalli's Emergency Medicine, Goldfrank's Toxicologic Emergencies, Harrison's Principles of Internal Medicine, the Merck Manual and so forth. So why not let students know there are many sources of information besides their texts, and encourage them to visit and learn from those sources? Today there is a wealth of information available online. Google is a fundamentally important tool, and it leads to learning about sources such as eMedicine, the National Institute of Health's Web pages, the Centers for Disease Control and Prevention, the Mayo Clinic's data and so forth. For students to use these tools, classrooms must have either hardwire or Wi-Fi capability. In community colleges, most classrooms now have that. I encourage my students to bring their computers to class and use them during both lectures and group/team learning. Adult learners are accustomed to multitasking, and the more you can encourage and allow them to do that, the better. Yes, that flies in the face of traditional learning. It does not bother me at all that while I'm lecturing and firing off questions, my students are Googling and finding the answers. That's what it's all about. When a student comes up with a new source of information, a new JAMA or NEJM or eMedicine article, I'm thrilled. They are now functioning as EMS professionals.

How does this work in a class? Here's my paradigm:

The class is divided into teams of four or five. I pick the teams based upon my evaluation of the relative strengths and weaknesses of the students. Ideally, a team of four would consist of a very strong student, two average students, and one with some possible deficiencies.

Instruction is structured so that lecture is minimized and group work is maximized. Studies have shown that when students work in teams to solve problems, they do better both individually and as team members than they would if working alone with the same information.

I typically send them, at least a week in advance, the PowerPoint presentation I've constructed for the topic, along with a work-study instrument that asks them to solve many problems based on the factual information in the text, and selected links to information. I also require that they complete the workbook for the chapter in the text we're covering.

The work-study project will lead into the next phase, scenario training. Written scenarios are given, and the groups work to solve them. Each group must submit the completed work-study project together with the assigned scenario problems.

Finally, real-time scenarios are run using either student "patients" or manikins. Cases are based upon the basic didactic information, but they always have problem-solving built in, and there are multiple levels of scenarios from simple to complex. It is important to require students to work the scenarios as much like they would in the field as possible. Everything is done in real time. Nothing is simulated that can be done in real time. If a team member asks, "What is the blood pressure?" there is no answer unless the BP cuff is attached and inflated and the stethoscope is in the right place.

There are several things I've learned about scenario practice. First, start with simple scenarios designed only to teach the basics. For example, if you're running a ventricular fibrillation scenario, do not add in any complicating issues such as inability to get an IV, inability to intubate, etc., until the students can run the simple code flawlessly. Start scenario practice as early as possible. Do it every class period. Then add in complications.

I strongly believe in instant reinforcement. By this I mean that after the scenario has been run, the team critiques itself. Then the other students watching can add constructive advice, and the same team then runs the exact same scenario again--this time to eliminate mistakes. I have found this technique to work very well. Depending upon time constraints and availability of other instructors to run multiple scenarios at the same time, we may take a scenario and run it multiple times with the same team, each time adding in a complication. This works wonders in teaching critical thinking and application in the field.

Another technique is to video-record the scenarios and let everybody watch them. There's nothing as devastating as watching your own performance. But be careful not to make this a negative process. Keep it light. Keep it on target. Make it a win/win situation.

Problems with this sort of teaching come with measurement of individual progress as opposed to group progress. We must ultimately pass or fail individuals, not groups. There are well-constructed methods for doing this, but I leave that for another time. There are many resources available that deal with evaluation in group learning.

William E. "Gene" Gandy, JD, LP, is an EMS educator and consultant from Tucson, AZ, and a member of EMS Magazine's editorial advisory board.