In Stage 1 (years 1 and 2) students expect their instructors to give them information in a clear, organized manner and tell them what is right and wrong. Then in Stage 2 (typically the beginning of year 3), students begin to realize that some things are not known and that there is actually some ambiguity in knowledge. Much resistance accompanies this stage because ordinarily students are used to being told the answer rather than having to seek it on their own. Finally, in Stage 3 students begin to demonstrate a reasoned process of decision-making. Students learn that in the context of a specific patient, some judgments may be better or worse.

As a clinical instructor, one of your goals is to help students progress to a point where they can develop judgment based on sound reasoning, that is, going beyond fact or mere opinion. Although facts are ordinarily used in reasoning, good reasoning is more than just stating facts. And a position that is well reasoned can not be described as simply opinion.

1, 2, 3 The transition from Stage 1 to Stage 2 requires students to recognize that there is uncertainty on many questions. It also requires the students to realize that you are not there to provide correct answers, but that you will assist them in discovering solutions. The transition from Stage 2 to Stage 3 requires students to recognize that, despite uncertainty, one can still often select one or more choices or solutions that are superior to others. The following are a few things you can do to help the students with their transition:

• show students the extent and scope of legitimate uncertainty in the areas that you teach (no one can think critically about something that seems unquestionably true)

• clearly explain why there may be different approaches to managing a situation (because students may be resistant to uncertainty at this point, they may question an instructor’s competence if merely told that there are multiple approaches without explanation)

• share (model) your thought processes so students can see your reasoned approach to a situation

• provide feedback (guide students’ thinking/reasoning with your comments; use as reinforcement)

• seize opportunities to question students to better determine how they understand situations

• provide students the opportunity to practice reasoning/problem-solving -- these are learned, not intrinsic, skills

• applying many of the suggested communication techniques on the back of this newsletter will also help with the students’ transition through their intellectual stages

Derived from CE Nelson (1994). Critical thinking and collaborative learning. In K Bosworth & SJ Hamilton (Eds), Collaborative learning: Underlying processes and effective techniques (pp. 45-58). San Francisco, CA: Jossey-Bass Publishers.

Editor’s Note: My thanks to Dr. Roger Berkow, MD and Dr. Nathan Smith, MD for reviewing this issue of Teaching Tips.