The ability to think critically is desired by EMS providers at every level and may largely be a measure of success, yet the concept isn't easily defined, quantified or taught. This month's article will discuss the concepts of critical thinking and critical decision-making. Next month's case presentations will give readers an opportunity to apply the concepts presented here.
Critical thinking isn't limited to medicine. It is used in many parts of our daily lives. Consider an everyday event that occurred recently:
When I tried to start my car, it didn't want to catch. When it finally started, it bucked and sputtered. Then the check-engine light came on. I was about to go to a meeting two hours away and was hesitant to drive it.
The car was relatively new and well-maintained. There were no odors, no unusual sounds and no stains on the floor indicating leaking fluids. The gas gauge was between 1/8 full and empty. It had been rainy for weeks.
I questioned whether I should take the car on the trip or bring it to the shop and decided that driving it wouldn't cause damage. Bringing it to the shop would cost hundreds in diagnostics that I didn't want to pay if not necessary.
I drove it to a gas station, put in some dry gas, then filled the tank. I drove it around town for a few minutes to see if the car ran better. It did. The check-engine light went off, and I drove to the meeting uneventfully.
This real-life example demonstrates the components of a critical thinking process: identifying a problem (chief complaint), gathering facts (history and physical exam), identifying possibilities and narrowing them to probabilities (differential diagnosis), developing a plan, evaluating risks vs. benefits, and implementing the plan. This article will focus on the thinking process, i.e., how to get to the treatment choices, rather than the treatment itself.
In Rosen's Emergency Medicine, Chapman, et al, describe the critical thinking process as having three parts: medical inquiry (history, physical exam and diagnostic testing), clinical decision-making (a cognitive process that evaluates information to diagnose or manage a patient's condition) and clinical reasoning, which involves both medical inquiry and clinical decision-making.
In fact, proper decisions are made after evaluating necessary, accurate information. The relationship between decision-making and reasoning is a continuous process—a feedback loop rather than a straight line from assessment to care. New information is evaluated as it is obtained and applied to the body of knowledge about the patient's condition.
The concept of critical thinking is more than a process; it is a mindset. This discussion is a good time to revisit the difference between a technician and a clinician. In the context of this article, the ability to apply clinical reasoning to a patient problem belongs exclusively to the clinician.
A technician is not expected to use high levels of reasoning skills. Technicians are strictly protocol driven and respond in a specific way when a certain group of signs and symptoms appear.
Clinicians gather pertinent information from many sources, carefully evaluate that information and develop a treatment plan from protocols or a series of protocols that will benefit the patient.
1. BE A CLINICIAN
There is a difference between a clinician and a technician in EMS (see sidebar at end of article). Part of the difference involves the provider's training and experience. The second, and perhaps the most important, is the clinician's mind-set.
Clinicians aren't satisfied by observing superficial information or apparent patterns. They look at each patient as a challenge and seek out pertinent assessment information, even on the patients who appear to have an obvious presenting problem.