why is critical thinking important in clinical trials

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Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care

Ludovico furlan.

1 Department of Clinical Sciences and Community Health, University of Milan, Milan Italy

2 Department of Internal Medicine, General Medicine Unit, IRCCS Ca’ Granda Foundation, Ospedale Maggiore Policlinico, Milan Italy

Pietro Di Francesco

Giorgio costantino.

3 Department of Anaesthesia—Intensive Care Unit, Emergency Department and Emergency Medicine Unit, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Milan Italy

Nicola Montano

In recent years, the Choosing Wisely and Less is More campaigns have gained growing attention in the medical scientific community. Several projects have been launched to facilitate confrontation among patients and physicians, to achieve better and harmless patient‐centered care. Such initiatives have paved the way to a new “way of thinking.” Embracing such a philosophy goes through a cognitive process that takes into account several issues. Medicine is a highly inaccurate science and physicians should deal with uncertainty. Evidence from the literature should not be accepted as it is but rather be translated into practice by medical practitioners who select treatment options for specific cases based on the best research, patient preferences, and individual patient characteristics. A wise choice requires active effort into minimizing the chance that potential biases may affect our clinical decisions. Potential harms and all consequences (both direct and indirect) of prescribing tests, procedures, or medications should be carefully evaluated, as well as patients’ needs and preferences. Through such a cognitive process, a patient management shift is needed, moving from being centered on establishing a diagnosis towards finding the best management strategy for the right patient at the right time. Finally, while “thinking wisely,” physicians should also “act wisely,” being among the leading actors in facing upcoming healthcare challenges related to environmental issues and social discrepancies.

Content List – This is an article from the symposium: “When is too much too much and too little too little: Scientific evidence of limited workup”.

Clinical vignette

A 43‐year‐old woman with scleroderma was admitted to the Emergency Department (ED) complaining of fever and abdominal pain in the left upper quadrant. The attending physician performed an abdominal ultrasound examination that was negative. Blood exams showed significantly elevated C‐reactive protein so a urinary tract infection was suspected. Intravenous ciprofloxacin treatment was started. After 24 h, the patient felt much better, she had no pain nor fever and was discharged with the indication to continue oral antibiotic therapy. The next day, the patient returned to the ED complaining of pain at the forearm where the peripheral vein access had been placed. Superficial phlebitis was noticed and the physician in charge decided to perform a bedside ultrasound that showed thrombosis of the antecubital vein. Treatment with fondaparinux for a week was started. The patient was discharged in good clinical conditions; however, the following day, the patient was admitted again to the ED for a severe headache. The head computed tomography scan showed a cerebral hemorrhage, and she was transferred to the neurosurgery ward.

As shown by this simple but dramatic clinical case, even the most trivial and innocent medical decision may have catastrophic consequences. This is the reason why any intervention we perform (treatment or test) must be preceded by relevant clinical questions. Looking back at our case: (a) was the peripheral venous access necessary? (b) Was the ultrasound examination appropriate? (c) Was the consultation with the thrombosis specialist needed? (d) Was anticoagulant therapy appropriate? No single step of the diagnostic strategy was absolutely incorrect, but a cascade of small clinical decisions snowballed into dramatic and unexpected consequences.

The rationale

The call for action inspired by Brody in 2010 [ 1 ] led to the creation of the Choosing Wisely (CW) campaign, an initiative of the American Board of Internal Medicine Foundation (ABIM) launched in 2012 that was immediately followed by the seminal article by Grady and Redberg, “Less is More” [ 2 ], calling for a shift from the traditional paradigm “more care is better” towards care tailored to the patient's needs.

The main mission of this campaign was the promotion of conversations between clinicians and patients by helping patients to choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary. This was pursued through the publication of hundreds of “top 5 lists,” created by medical societies from 25 different countries, listing unnecessary or overused medical procedures, tests, or treatments, all based on recent evidence and good medical practice. Several studies testing the efficacy of the campaign in reducing medical waste and side effects have been performed or are ongoing [ 3 , 4 , 5 ].

However, in our opinion, CW represents an even broader and general concept expanding the borders of healthcare and medical decisions to include a new “way of thinking” that is more respectful not only of patients but of all economic and environmental resources. To choose wisely is to choose consciously and conscientiously. We would like to propose here a “medical” revisitation of the Cartesian philosophical concept “ Cogito ergo sum” (I think, therefore I am), which would sound, rephrasing St Augustine, like “Dubito, ergo sum [medicus]” (I doubt, therefore I am [a physician]).

Constantly enlarging healthcare systems, where the number of actors involved and the complexity of the relationships between them keeps increasing, tends to generate automated and impersonal clinical decisions. We wish for physicians to reacquire a central role in patient management, tailoring choices to their specific patients and involving them in the decisional process.

In the present review, we will discuss the fundamental issues hindering our capabilities to choose wisely, such as the difficulty in dealing with uncertainty, the fear of making errors, and the pitfalls of the evidence‐based approach, and we will discuss a possible roadmap to help modify our way of thinking and to overcome what is holding us back from doing so (Fig.  1 ).

Clinical reasoning—no single choice of performing tests or initiating treatment should be made without considering all the factors involved. Each test serves the purpose of increasing or reducing our probability of a diagnosis to help us choose, together with our patients, whether starting treatment could be beneficial.

Factors at play

Uncertainty.

Medicine is a highly inaccurate scientific field compared to other disciplines such as engineering or computer science [ 6 ]. The most accurate tests we use during a diagnostic workup boasts of a sensitivity and sensibility that is lower than 90%, leaving a great margin of error even when no human effort is involved [ 7 , 8 ]. Similarly, the most effective therapies for commonly encountered illnesses do not assure treatment success, even when given promptly [ 9 ].

The minimization of uncertainty in clinical decision making has become central to biomedical research over the past 50 years, driving the development of evidence‐based medicine (EBM), with millions of articles published every year.

However, the more knowledge is accumulated the more we perceive the differences in each clinical condition presented, in the underlying mechanisms and mostly, in each patient we meet [ 10 ]. The more we know, the more we understand how little of what we know is actually applicable to every single case. The concept seems obvious as this is one of the better‐known postulations of Western philosophy, as expressed by the Socratic motto “I know that I know nothing” [ 11 ], but in our hypertechnological and specialistic era, sometimes we tend to forget about this concept and dismiss it.

The feeling that an outcome can be predicted leads to a sense of security that is, unfortunately, often based on wrong assumptions. As William Osler said, “medicine is a science of uncertainty and an art of probability.” Uncertainty can make the physicians uncomfortable and communicating uncertainty to patients can feel like letting them down and not being able to predict what is happening to them. While it can be true that patients feel safer and more satisfied knowing their doctor is certain about the evolution of their condition [ 12 ], being able to communicate uncertainty can, in the long term, lead to an improvement in the patient–doctor relationship and trust [ 13 ].

Embracing uncertainty does not represent a rejection of EBM but instead supports its best use. As soon as we accept the hindrance that precludes us to be 100% accurate in our predictions, we can start implementing this type of thinking into practical skills of evaluating a situation and describing it to our patients. The probability of a response to therapy can be expressed as a numerical range with a qualitative estimate rather than a single number. For most diagnostic tests, we should emphasize that the result can only increase or diminish the probability of a diagnosis based on the likelihood ratio of the test, and cannot provide a definitive answer [ 14 , 15 , 16 ]. Thus, to better engage our patients, shared decision making, using the best available evidence as a tool, should be implemented [ 17 ], as when faced with hard choices, our patients may feel that their physician will be with them, no matter what the future holds.

Evidence‐based medicine

Not all clinical research is good research [ 6 ]. EBM aims for the idea that healthcare professionals should make conscientious, explicit, and judicious use of current best evidence in their everyday practice. EBM uses systematic reviews of the medical literature to evaluate the best evidence on specific clinical topics. This is the first and easiest to apply step, called “evidence synthesis.”

Selecting treatments and procedures based on updated evidence strikes as the best to provide the best care available for a patient. This can be held only if the supporting scientific evidence is of good quality and extrinsically applicable to the patients we are currently treating. Blindly applying results of clinical trials can be extremely dangerous, and therefore even guidelines should be considered critically and not as an unquestionable Bible.

The amount of weakly designed studies, skewered analysis, and straight‐up false data that gets published each year is astounding. Some of these studies present data that lacks credibility so blatantly that they earned the name “zombie trials” [ 18 ]. Moreover, even if millions of papers get published every year, the publication record is only a small part of the unpublished research data existent, with an abundance of inconclusive or controversial results, never to be shared [ 19 ].

Registered clinical trials showing negative results (where the treatment tested showed no effect) are statistically less likely to be published, and even when published they usually take, on average, 1 year more to get released than trials with positive results. [ 20 , 21 ]. It was also proven that statistically significant studies may be cited more than negative studies on the same topic, increasing the bias [ 22 ].

Another critical issue is the abundance of multiple guidelines, from different societies, on the same topic, which often cites different articles and meta‐analyses supporting their recommendations, which are sometimes discordant with each other, without a clear reason to justify the discrepancies. In addition, they may be heavily influenced by “expert” dogma and only a few of the recommendations provided are based on level A evidence [ 23 , 24 , 25 , 26 ].

Therefore, although being used to establish medical (and sometimes legal) standards of care, clinical guidelines are very far from being an unbiased and unequivocal tool. It's hard to imagine an improvement in the quality of research as long as financial conflicts of interest are associated with favorable recommendations of drugs and devices in clinical guidelines, advisory committee reports, opinion pieces, and even narrative reviews [ 27 ]. The Sars‐Cov‐2 pandemic worked like a magnifying glass in showing the limits and weaknesses of our research system. In the rush for publication, thousands of dubious papers have been released, only increasing the rampant confusion and despair that sprung in physicians forced to work without evidence [ 28 , 29 , 30 ].

Plenty of resources are currently available to improve doctors' ability to use EBM correctly, starting from critically reading manuscripts, comparing them to previously available data, all the way down to designing new trials that could improve patient outcome and satisfaction [ 31 , 32 , 33 ]. Critically approaching EBM means not stopping at the first step, that is, “evidence synthesis,” but rather continuing to the second one, which is “knowledge translation.” The evidence must be translated into practice by medical practitioners who select treatment options for specific cases based on the best research, patient preferences, and individual patient characteristics [ 34 ].

Medical errors

Medical errors are listed as the number three cause of death in the United States [ 35 ] and represent a huge cost in resources and a great risk for the unwilling patient finding himself a “victim” of the error. A wise choice requires active effort into minimizing the chance of making mistakes while considering that not all of them are predictable and thus preventable. Minimizing errors related to lack of knowledge , often only recognizable in hindsight (if not spotted at all) requires experience, continuous education, and update in the light of new available research and data. On the other hand, errors linked to inattention or carelessness could be reduced by investing in better work–life balance for healthcare providers, preserving enough good sleep, avoiding toxic workplace conditions, and supporting doctors' own mental and physical wellbeing [ 36 ].

In the last 30 years, medicine has tried to adopt tools and procedures from other fields to manage risks and minimize errors. For instance, the aviation safety procedures approach is often being used as a model to build up a safer healthcare system. While intrinsic limits are preventing the achievement of the same extremely high level of safeness [ 37 ], the use of checklists, personnel's fatigue risk management, and specialization training are all examples of features shared by both realities that improved avoidance of errors when implemented. [ 38 , 39 , 40 ]. One topic that was found to be lacking in doctors’ and interns’ apprenticeship, while well established in other professional activities, is “cognitive bias avoidance training.”

Cognitive biases (CB) are predictable, systematic patterns of deviation from the norm and/or rationality in judgment. The mind is prone to fall for these various cognitive traps especially while relying on heuristics, or mental shortcuts, using what is defined as “system 1” of cognitive process (as opposed to “system 2,” representing conscious analytical thoughts) [ 41 , 42 , 43 ]. The most commonly encountered CB in medicine include the anchoring effect and the confirmation bias (that could together be summarized as prematurely falling in love with a diagnosis), the gambler's fallacy (that makes it seem unlikely something will happen again if it recently happened many times), and the base rate neglect (overestimating or underestimating pretest probability when working up a diagnosis, skewing the Bayesian reasoning) but a long list of biases have been described and each one plays a role in increasing the risk for error making [ 44 , 45 ]. Pattern recognition is essential to clinical reasoning, especially in the context of emergencies, and one is easily tempted to think that these biases don't affect him, even if he can recognize them in others.

Learning to recognize and discuss the impact of cognitive bias from the early stage of medical education could significantly help avoid the consequences and costs of these mistakes [ 46 ].

Value‐based patient‐centered approach

What is important for the patients? When making choices, our perspective could be different from the patients’ and we should consider patients’ preferences and needs. What is important for us may be of limited value for the patient. Sharing our views and involving patients in decision making that is truly based on their needs should be a milestone when choosing wisely [ 47 ].

As physicians, we tend to make a diagnosis based on a disease‐centered point of view and then provide the best available cure. This may, nevertheless, be far from coinciding with what matters to the patient, particularly when multiple chronic conditions co‐exist [ 48 ]. For instance, from the perspective of a patient with chronic heart failure, the number of days spent at home may be a more accurate outcome for evaluating the quality of the provided cures rather than the rate of hospital admission [ 49 ]. Potentially, even the most extreme medical decisions may benefit from a positive confrontation. Is there any doctor that would raise doubts on the benefits of adrenaline in cardiac arrest? In a highly debated randomized controlled trial (RCT) published in New England Journal of Medicine on the use of epinephrine in out‐of‐hospital cardiac arrest [ 50 ], the authors actively involved patients and the public in the planning and development of the trial. The study showed a benefit of epinephrine use on short‐term survival but no significant differences in survival with favorable neurologic outcomes. Interestingly, when the community was involved in defining the priority of outcomes, 95% of respondents prioritized long‐term survival with favorable neurological outcomes instead of short‐term survival. There are several resources that clinicians could use to inform their patients of the risk and benefits of treatments, tests, and procedures. In a recent meta‐analysis, patients exposed to decision aids for screening or health treatment decisions showed increased knowledge, while the accuracy of risk perceptions and congruency between informed values and care choices did not show differences in terms of health outcomes compared to controls [ 51 ]. Some patients may be keen to discuss potential therapeutic options while others prefer not to be involved in decision making [ 52 ].

Involving patients in decision making does not mean giving up responsibility but rather including personal preferences into the physician's final decision on the matter.

Clinical decisions and consequences

Each time we make a clinical decision such as prescribing a treatment or a test, we expect benefits for our patients, but we must keep in mind that with every choice we may cause harm. Most of the time, we acknowledge direct potential adverse events but hardly identify potentially indirect risks, the long term, and social consequences of our choices. Several studies indicate that patients consistently overestimate the benefits and underestimate risks of the screening procedure, tests, and treatments [ 53 ] and there is still uncertainty about how good physicians are at understanding and communicating to patients the benefits and harms of tests and procedures [ 54 , 55 ].

Each time we make a decision, we set in motion a chain of reaction of which we should be aware. Even the cheapest, low‐risk test can have tremendous consequences for patients and healthcare. In a recent study, the American College of Cardiology highlighted the importance of avoiding preoperative routine electrocardiogram (EKG) in low‐risk noncardiac surgery [ 56 ], including such recommendations among its Choosing Wisely top five list. In another study [ 57 ] on over 110,000 patients undergoing cataract surgery in the USA, 16% of those who received a preoperative EKG underwent a series of further testing that accounted for an extra cost of $565 per patient and $35 million without evidence of disease. Incidental findings account for the largest part of inappropriate testing. In a study conducted by the American College of Physicians, 90% of interviewed physicians reported a cascade of tests after incidental findings that caused significant psychological, financial, and even physical consequences for their patients [ 58 ]. Cancer screening through prostate‐specific antigen (PSA), which is now no longer advised, has been estimated to have caused between 2.9% and 88.1% of prostate cancer overdiagnosis [ 59 ]. These findings are just a tiny dot in a much bigger picture since limited data are available on the impact of overdiagnosis and overtreatment [ 59 ]. The proposed CW approach has the first downstream effect of increasing the safety of our patients, balancing the risks and benefits of each intervention at the single‐person level.

The physician should never stop asking himself: “Why am I prescribing this test/treatment to my patient? Am I fully aware of the consequences of the result on my next clinical decisions?”

Diagnosis‐ versus management‐centered approach

Providing answers to our patients is a cognitive process passing through a critical appraisal of clinical information, checking the best available evidence, and considering the external factors involved (values, available resources, environmental factors, etc.). This clinical‐reasoning process should not just focus on providing a diagnosis. As brilliantly illustrated by a recent review on the subject by Cook et al. [ 60 ], reaching a diagnosis is not the final outcome a physician should seek; it is, in fact, the successful management of the patient. Nevertheless, most of the available literature focuses on the cognitive processes that lead ultimately to a diagnosis (diagnostic reasoning). Management reasoning, that is, the process of making decisions about patients’ treatment, follow up, need for hospitalization and resource allocation, is a less explored path with multiple aspects. Cook et al. [ 60 ] pointed out the main differences between the two approaches, as summarized in Table  1 . Focusing on patient management rather than reaching a diagnosis could possibly reduce overtesting and increase patient involvement in the decision process.

Diagnosis versus management

RCT, randomized controlled trial.

A practical example of the implications of using these two approaches is the management of patients with potential pulmonary embolism (PE). Several trials found a higher‐than‐expected prevalence of PE in patients admitted for syncope or exacerbation of chronic obstructive pulmonary disease (COPD) in the ED, suggesting a possible role for algorithms dedicated to the identification of PE in these groups of patients [ 61 , 62 ]. Further studies raised doubt on this potential approach. On one side, the study by Costantino et al. [ 63 ], collecting data from real‐world scenarios, concluded that not all patients warrant a diagnostic algorithm to exclude it, and the algorithm may increase false‐positive results and overtreatment, resulting in more adverse events. On the other side, the study by Jiménez et al. [ 64 ] on exacerbating COPD found no differences in terms of major clinical outcomes when randomizing patients for either standard care or an active strategy for diagnosing PE, showing how investing more into searching for a diagnosis might not be beneficial for patients.

The physician and the community

We assume to treat every patient the same way and give everyone the same care, but is this actually happening?

Access to education, housing, food and water quality, as well as inequity in wealth distribution are among the main determinants of patients’ health and have been related to the development of several diseases. [ 65 , 66 ]. These factors must therefore be considered in the frame of preventive medicine. A conscious physician incorporates in his thinking process the needs of his community. The devastating effect of population inequities in terms of socioeconomic determinants of health was highlighted by the Sars‐Cov‐2 pandemic, with enormous differences in patient outcomes based on social status. [ 67 , 68 ]. We cannot afford anymore to ignore these discrepancies among our population of patients.

Social determinants strictly correlate with the resilience of a population in tackling health and safety challenges. In this respect, one of the biggest threats we will face in the upcoming years is the impact of climate change on global health.

The 2020 edition of the yearly Lancet Countdown report on Health and Climate Change [ 69 ] showed alarming data on the direct effects of rising temperatures, with a drastic increase in heat‐related death (+53% for people aged 65 and above in the last two decades), a rise in exposure to wildfires, aggravating heart and lung conditions [ 70 ], and the diffusion of unhealthy diets, increasing cardiovascular risk [ 71 ]. We must realize that the voice of healthcare professionals is essential in driving forward progress on climate change and realizing the health benefits of responding strongly to the issue. In this regard, we, as authors, strongly endorse the call for emergency action recently published by a large team of editors of some of the most important health journals worldwide [ 72 ].

As physicians, we must act not only as healthcare providers but also as citizens’ advocates.

How to change the way we think

Acquiring the mindset necessary to choose wisely is a learning journey where we recognize the actors in a play, share our knowledge, and act consequently. We should work to set in motion an educational process that, directly and actively, involves students, physicians, stakeholders, and the public. The discussion and acquisition of these concepts and critical thinking should start during the first years of training of medical students and trainees. Spreading these ideas to patients, and to a greater extent also to the general public, will benefit feedback and increase trust between the parts. And first and foremost, educating ourselves as physicians will allow us to transpose these conceptual cues to clinical practice, supporting more conscious and safer care.

To initiate this process, we think we should focus our educational interventions on the following issues (Table  2 ):

• rediscussing our diagnosis‐centered approach in favor of a management‐reasoning approach, including choices about treatment, follow‐up visits, further testing, and allocation of limited resources, involving patients and their personal needs in making the choice [ 70 , 73 ];
• embracing uncertainty in the healthcare profession, grasping the concept of probability of disease and threshold for treatment, and acquiring the communication skills and empathy needed to transmit these concepts to patients.
• disputing the “publish or perish” dogma, to strive for better, more reliable, patient‐centered research. We should learn and teach how to write accurately, read critically, and research conscientiously.
• accepting that anyone, with no exceptions for healthcare providers, is bound to make mistakes. We should support systems that monitor medical errors, their consequences, and near‐miss cases with the aim of developing ways to avoid the same mistake rather than punishing the actors involved [ 74 ]. This will help stop the growth of a medical class terrified of legal consequences and prone to make decisions that protect themselves from malpractice lawsuits at the expense of patient safety and resource saving [ 75 , 76 ].

Steps towards choosing wisely

These primary steps will lead to a new way of thinking that will eventually allow the physician to get an advocate role within the society, trusted by the community as observers and reporters of the population's physical and mental wellbeing. Hence, acknowledgement of social discrepancies, environmental factors, and their role on global health will then become part of the clinical reasoning and the everyday practice of the physician of tomorrow.

Conclusions

The mission of the Choosing Wisely movement is not only to raise awareness in physicians of the risks of overdiagnosis and overtreatment but also to give the opportunity to rethink the way we treat patients.

Embracing such philosophy goes through tackling of several issues, including difficulty in dealing with uncertainty and medical errors, the limits of EBM, and shifting towards patient‐centered clinical reasoning focused on management rather than on diagnosis. Physicians should regain a central role in patient management and could be leading actors in facing upcoming healthcare challenges related to environmental issues and social discrepancies.

Thinking that doing more means doing better is perhaps a comfortable, but often dangerous, momentary lapse of reason.

Conflict of interests

The authors have no conflict of interests to declare.

Author contributions

Ludovico Furlan: conceptualization; data curation; investigation; resources; writing – original draft; writing – review and editing. Pietro Di Francesco: conceptualization; data curation; investigation; resources; writing – original draft; writing – review and editing. Nicola Montano: conceptualization; investigation; project administration; resources; supervision; writing – original draft; writing – review and editing. Giorgio Costantino: conceptualization; investigation; project administration; resources; supervision; writing – original draft; writing – review and editing.

Acknowledgments

The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Open Access Funding provided by Universita degli Studi di Milano within the CRUI‐CARE Agreement. [Correction added on 11 May 2022, after first online publication: Projekt CRUI‐CARE funding statement has been added.]

Furlan L, Francesco PD, Costantino G, Montano N. Choosing Wisely in clinical practice: embracing critical thinking, striving for safer care . J Intern Med. 2022; 291 :397–407. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Ludovico Furlan and Pietro Di Francesco contributed equally to this manuscript.

• Open access
• Published: 24 May 2023

Embracing critical thinking to enhance our practice

• Luis Martí-Bonmatí   ORCID: orcid.org/0000-0002-8234-010X 1  

Insights into Imaging volume  14 , Article number:  97 ( 2023 ) Cite this article

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Miguel de Cervantes, the great Spanish writer, once wrote that those “who read much and walk much, go far and know much" [ 1 ]. The same is true in medicine; reading and gathering experience are the main pillars on which one should develop the knowledge of solving clinical problems in the ever-changing field of healthcare. If properly done, these newly acquired skills will continuously enhance our critical thinking strategies with which we try to identify the best possible improvements in the clinical pathway of radiology. As gaps in knowledge are always present, medicine is rooted in consolidated knowledge based on validated scientific studies and clinical experience reproducibility and accuracy [ 2 ]. This represents our best approach to evidence-based decisions. Medical knowledge must be well-established before it can be considered as the basis for decision making and patients guidance in daily practice.

The practice of critical thinking helps us understand the disease manifestations and the related processes and actions that might be relevant to prevent, diagnose and treat diseases. To critically appraise the way we perform evidence-based practice, we must combine best quality research with clinical expertise. This link between exploration and practice will allow radiologists and related disciplines to impact the way medicine is practiced.

These concepts are the cornerstones of Insights into Imaging , and it is my privilege as editor-in-chief to describe in this editorial how the journal, and each author, can contribute quality through critical thinking, and hence improve the way we practice radiology by re-shaping our understandings.

It is universally recognized that, in medical imaging, strong levels of evidence are needed to assess the results of the different possible actions and to guide decisions (i.e., to demonstrate a sufficient causal relationship between a specific diagnostic criterion and a disease grading, or a given radiological intervention versus another option in a given condition) toward the most effective or safe outcome considering the benefit of patients and value-based healthcare pathways. Consequently, solid levels of evidence are required to assess the results of different possible actions derived from imaging findings. And, in doing so, we continuously generate more data in our diagnostic and therapeutic activities, whether they are processes or outcomes. This new information will then be transformed into new evidence, real world evidence. In this way, the observed relationship between action and outcome generates causality course actions that will improve our understanding of the best clinical pathways, eliminating the many confounding thoughts that we unconsciously carry during the process of learning and implementing our clinical practice.

Socratic inquiry and Skepticism as foundation. Critical thinking can be understood as the process of analyzing and questioning existing and established knowledge with the intention of improving it. Previous knowledge, either eminence- or evidence-based, should continuously be critically reconsidered and reevaluated for the benefit of the patients, as knowledge is always changing in Precision Medicine. In the real world of medical imaging, this critical thinking must be focused on the evaluation of the effectiveness and clinical impact of all those processes in which images are involved, from the acquisition with different modalities to the processing of the data, from the biological correlation of radiomics as an image biomarker to the therapeutic orientation, and finally in image-guided interventional treatments. Developing critical thinking helps to improve any medical discipline by asking ourselves how to establish better and more precise processes based on existing accumulated evidence, how to recognize and control the biases when approaching a clinical problem, and how to adapt the new clinical information in service of the best solutions. Socratic inquiry and a skeptic attitude can be used to consolidate the best knowledge and construct new associations to be more efficient and to approach excellence in our daily work. Critical thinking is therefore necessary to improve both clinical practice and research in radiology, avoiding disruptive uncertainties and wrong assumptions.

These “questioning and solving” skills require learning, practice, and experience [ 3 ], but mainly a recognition of the many uncertainties we do have despite the important scientific advances. Precisely, a good example of the importance of critical thinking is its contribution to Precision Medicine through medical imaging data and information. In daily practice, we should ask ourselves why should we accept a reliable diagnostic method that fails 15% of the time, or an appropriate treatment that is not effective in almost 25% of patients? As scientists, we can improve these clinical decisions in the daily practice. Artificial intelligence (AI) solutions integrating different imaging, clinical, molecular, and genetic data as inputs are being implemented as a suitable pathway to solve clinical problems. The design and methodology of these AI algorithms must allow for their explainability and critical thinking evaluation before they are implemented in clinical practice [ 4 ].

In summary, critical thinking develops evidence-based knowledge, provides continuous improvements, and avoids spurious technical and clinical misconceptions. Insights into Imaging is dedicated to manuscripts with a clear critical approach, focusing on excellence in clinical practice, evidence-based knowledge and causal reasoning in radiology. Science is based on long-lived critiques and authors are encouraged to systematically identify, analyze, and solve problems by identifying inconsistencies and correcting errors.

To foster this, Insights into Imaging welcomes critical thinking papers and will incorporate a new “Critical Relevance Statement” in all their publications, where authors are asked to summarize in one sentence the question they are trying to answer and the improvement they are providing to the issue at hand.

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De Cervantes M (1986) The adventures of don Quixote de la Mancha. New York, Farrar, Straus, Giroux

Martí-Bonmatí L (2021) Evidence levels in radiology: the insights into imaging approach. Insights Imaging 12(1):45. https://doi.org/10.1186/s13244-021-00995-7

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Ho YR, Chen BY, Li CM (2023) Thinking more wisely: using the Socratic method to develop critical thinking skills amongst healthcare students. BMC Med Educ 23(1):173. https://doi.org/10.1186/s12909-023-04134-2

Cerdá-Alberich L, Solana J, Mallol P et al (2023) MAIC-10 brief quality checklist for publications using artificial intelligence and medical images. Insights Imaging 14(1):11. https://doi.org/10.1186/s13244-022-01355-9

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Martí-Bonmatí, L. Embracing critical thinking to enhance our practice. Insights Imaging 14 , 97 (2023). https://doi.org/10.1186/s13244-023-01435-4

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Critical Thinking in Nursing

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Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

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Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

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Nevşehir Hacı Bektaş Veli University, Semra ve Vefa Küçük, Faculty of Health Sciences, Nursing Department, 2000 Evler Mah. Damat İbrahim Paşa Yerleşkesi, Nevşehir, Turkey

Şefika Dilek Güven

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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

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Chapter 3 discusses the decision-making process of choosing the study population. This is critical given that any study’s main goal is to make inferences that go beyond the individuals under study and can be used to explain the phenomenon in the broader population with shared characteristics or conditions. In this chapter, the definition of the target population is discussed—i.e. the portion of the general population from which a researcher wants to draw robust conclusions or inferences. The sampling process according to the study phase is also summarized, focusing on phase II and III clinical trials, as phase I trials are especially designed to assess safety, while phase IV trials are open-label studies, usually assessing post-marketing safety. The internal and external validity of a study is also discussed, as well as sampling methods, both probabilistic (simple random, systematic, stratified, cluster, or multistage sampling) and non-probabilistic (convenience, consecutive, and snowball sampling).

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The Importance of Critical Thinking Skills in Research

Why is Critical Thinking Important: A Disruptive Force

Research anxiety seems to be taking an increasingly dominant role in the world of academic research. The pressure to publish or perish can warp your focus into thinking that the only good research is publishable research!

Today, your role as the researcher appears to take a back seat to the perceived value of the topic and the extent to which the results of the study will be cited around the world. Due to financial pressures and a growing tendency of risk aversion, studies are increasingly going down the path of applied research rather than basic or pure research . The potential for breakthroughs is being deliberately limited to incremental contributions from researchers who are forced to worry more about job security and pleasing their paymasters than about making a significant contribution to their field.

A Slow Decline

So what lead the researchers to their love of science and scientific research in the first place? The answer is critical thinking skills. The more that academic research becomes governed by policies outside of the research process, the less opportunity there will be for researchers to exercise such skills.

True research demands new ideas , perspectives, and arguments based on willingness and confidence to revisit and directly challenge existing schools of thought and established positions on theories and accepted codes of practice. Success comes from a recursive approach to the research question with an iterative refinement based on constant reflection and revision.

The importance of critical thinking skills in research is therefore huge, without which researchers may even lack the confidence to challenge their own assumptions.

A Misunderstood Skill

Critical thinking is widely recognized as a core competency and as a precursor to research. Employers value it as a requirement for every position they post, and every survey of potential employers for graduates in local markets rate the skill as their number one concern.

Related: Do you have questions on research idea or manuscript drafting? Get personalized answers on the FREE Q&A Forum!

When asked to clarify what critical thinking means to them, employers will use such phrases as “the ability to think independently,” or “the ability to think on their feet,” or “to show some initiative and resolve a problem without direct supervision.” These are all valuable skills, but how do you teach them?

For higher education institutions in particular, when you are being assessed against dropout, graduation, and job placement rates, where does a course in critical thinking skills fit into the mix? Student Success courses as a precursor to your first undergraduate course will help students to navigate the campus and whatever online resources are available to them (including the tutoring center), but that doesn’t equate to raising critical thinking competencies.

The Dependent Generation

As education becomes increasingly commoditized and broken-down into components that can be delivered online for maximum productivity and profitability, we run the risk of devaluing academic discourse and independent thought. Larger class sizes preclude substantive debate, and the more that content is broken into sound bites that can be tested in multiple-choice questions, the less requirement there will be for original thought.

Academic journals value citation above all else, and so content is steered towards the type of articles that will achieve high citation volume. As such, students and researchers will perpetuate such misuse by ensuring that their papers include only highly cited works. And the objective of high citation volume is achieved.

We expand the body of knowledge in any field by challenging the status quo. Denying the veracity of commonly accepted “facts” or playing devil’s advocate with established rules supports a necessary insurgency that drives future research. If we do not continue to emphasize the need for critical thinking skills to preserve such rebellion, academic research may begin to slowly fade away.

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• Published: 07 January 2022

Clinical trials: design, endpoints and interpretation of outcomes

• Megan Othus   ORCID: orcid.org/0000-0001-8176-6371 1 ,
• Mei-Jie Zhang 2 &
• Robert Peter Gale 3  

Bone Marrow Transplantation volume  57 ,  pages 338–342 ( 2022 ) Cite this article

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Series Editors Introduction

The ability to properly analyze results of clinical trials, especially randomized controlled trials (RCT), is a needed skill for every physician. This is especially so for those involved in haematopoietic cell transplants. Although seemingly straightforward, correct interpretation of clinical trials data is in reality complex and not for the fainthearted. When a RCT reports intervention A is safer and more effective than intervention B do we simply accept the authours’ conclusion or is more detective work needed. The answer: call in Inspector Clouseau! In this article Prof. Megan Othus and us discuss complexities in clinical trials interpretation including the challenge of false-positive error control, endpoints, power and sample size estimates (more often guesses), how to analyze competing events such as graft- versus -host disease (GvHD) and relapse, what to do when a study has > 1 primary endpoint, analyses of multi-arm trials, how to interpret analyses other than the primary endpoint and what do data from non-inferiority trials tell us. Lastly, we consider, the evil which will not die (the statistical Rasputin): reporting survival outcomes by response. We hope this article will be of practical use to clinicians facing the challenge of correctly interpreting clinical trials data. The good news: only one relatively simple equation. And remember, we can be reached 24/7 on Twitter #BMTStats. Our operators are standing by. Robert Peter Gale MD, PhD, DSc(hc), FACP, FRCP, FRCPI(hon), LHD, DPS Mei-Jie Zhang PhD

Introduction

There are those who reason well, but they are greatly outnumbered by those who reason badly Galileo Galilei

Clinical trials, especially randomized controlled trials, are typically designed to facilitate straightforward interpretation [ 1 ]. However, despite randomization, a formal protocol document and clinical trials registries such as clinicaltrials.gov, it remains challenging to appropriately evaluate reports of clinical trials. Herein, we review several issues regarding critical interpretation of clinical trial results.

False-positive errors

The first topic to discuss is false-positive errors, also called α (alpha) errors. Many potentially convoluted choices are made in the design and presentation of clinical trials data to the end of trying to “control” or hold the false-positive error rate below a specified threshold. Every statistical analysis reporting a p value (or confidence interval, though we will focus on p values for simplicity) and which interprets this value as “significant” (at or below some threshold, often p  < 0.05) or “without evidence of significance” or “not significant” (above this threshold) is potentially subject to an incorrect conclusion (summarized in Table  1 ).

When reporting a p value we can only comment on whether it is “statistically significant” or not. We do not know whether this conclusion is correct or not. But by thoughtful construction of the test and calculations used to derive the p value we can quantify the probability of error. Over many years conventions in clinical research (partly driven by regulatory agency standards which themselves might be driven by legislation) have converged on some typical error rates in clinical trials. In most trials the false-negative error rate is typically selected to be 10–20% resulting in a power of 80–90%. False positive error rates in phase-3 trials are typically controlled to be <5% [ 2 , 3 , 4 , 5 , 6 ] or even <2.5% [ 7 ]. Randomized phase-2 trials often “relax” the false-positive rate to 10–20% [ 8 , 9 , 10 ].

Any one analysis or test has an associated false-positive rate. If more than one test is done, each test has its own rate and we can quantify the overall false-positive rate (the rate of having ≥1 test with a false-positive conclusion). The overall false-positive rate is related to numbers of tests done and false-positive rate of each test. If each test uses the same false positive rate ( α ), we can write the overall false positive rate as:

If we take the common α  = 5% (0.05) then with two tests the overall false positive rate is 9.75%, with 10 tests, 40%, with 20 tests, 64% and with 50 tests, 92%. In an analysis reporting many p values each interpreted individually as significant or not the probability of a false-positive conclusion quickly becomes high. This is why false-positive error control is a major concern in clinical trials design.

If a trial has only one primary endpoint and only one analysis of that endpoint is done the alpha level for that one test will match the overall false positive rate for the trial. However, many clinical trials pre-specify ≥1 endpoints and/or ≥1 analyses. Moreover, often a variety of manipulations are used to control for the false-positive rate across analyses. False-positive errors are further discussed below as different topics intersect with error control in clinical trials.

Endpoints are measures which can be observed or calculated for each subject on a trial. Often these measures are combined together mathematically in various ways to estimate a statistic. All statistics have associated measures of uncertainty. The combination of the statistic and the measure of uncertainty can be used to calculate confidence intervals and p values which we typically use to interpret clinical trials results. There are many possible endpoints but those commonly used in clinical trials of haematopoietic cell transplants are summarized in Table  2 .

Censoring is what distinguishes time-to-event from quantitative endpoints. Quantitative endpoints should be measurable or observed on every subject in a clinical trial whereas time-to-event endpoints may not. For example, if a clinical trial collects data on subjects for 5 years after study-entry and a subject does not die during that interval the trial will not observe the time-to-death for that subject. We know this subject lived ≥5 years and this can be used to evaluate and estimate survival up to 5 years. After 5 years the subject cannot contribute data for estimating or quantifying survival and they are termed censored. Different statistical analyses are needed for time-to-event versus quantitative data to account for censoring.

Regression analyses are an important element of randomized trials analyses even when the primary analysis is not based on regression models. Regression models provide estimates of effect sizes (e.g., odds ratios or hazard ratios), which are important when interpreting the results of trials. In addition, regression analyses allow for adjustments for co-variates not used in randomization stratification. Although randomization is likely to balance most factors across arms it does not guarantee balance without stratification. Regression analyses can allow for more precise estimation of effect sizes when there is an imbalance in a prognostic co-variate across arms.

Power, sample size, and endpoints

In a clinical trial protocol the sample size should have the associated power reported (typically 80–90%). For categorical and quantitative co-variates power is directly related to numbers of subjects enrolled onto the trial. For time-to-event endpoints power is driven by the number of “events” (e.g., for survival, the event is death; for time-to-relap se the event is relapse). Numbers of events are driven by the rate at which they occur, the interval subjects were accrued and how long each subject was observed since study-entry. Typically, clinical trials with time-to-event endpoints specify analyses will be done after a specified number of events are observed. When developing a protocol best efforts are made at making reasonable assumptions (guesses is often a more accurate descriptor) at how soon the event(s) under consideration will be observed. But if the assumptions are wrong for any reason the timing calculated in the protocol will be incorrect and analyses may be done sooner or later than pre-specified. The issues with post-hoc or retrospective power calculations have been well-described elsewhere, but in short, such calculations are not appropriate and should rareley (potentially never) be performed [ 11 ].

Competing events

When a subject can experience >1 event (say relapse and death) and the clinical trial is only interested in the time to one of those events, say time-to-relap se, the other event is called a “competing event.” For most time-to-event endpoints like relapse, death before relapse is a competing event. For example, in a time-to-relapse analysis if a subject dies without relapse we cannot assume they would never have relapsed had they not died. But the subject is also not just censored at time of death as one would do in a survival endpoint analysis because there may be a non-random relationship between death and relapse. For example, there exists a correlation between severity of G v HD and relapse risk (reviewed in Horowitz et al. [ 12 ]). To account for this possibility different analyses are needed to analyze such time-to-event endpoints. The Kaplan–Meier method should not be used [ 13 ]. Instead cumulative incidence rates should be estimated [ 14 , 15 , 16 , 17 ]. Log-rank tests should not be used but rather alternative tests which account for competing risks [ 18 , 19 , 20 , 21 , 22 ].

Multiple primary endpoints

It is increasingly common for clinical trials to specify >1 primary endpoint [ 3 , 4 ]. Why? Clinical trials are expensive and time-consuming and it can be disappointing to complete a trial and conclude there was no benefit in the investigational cohort because the wrong endpoint was specified. To mitigate this concern multiple primary endpoints can be specified before the study begins. However, as we discuss above, testing >1 endpoint “inflates” or increases the overall false-positive rate above the false positive ( α ) rate for each test.

There are several strategies to evaluate >1 endpoint. In order to interpret a trial as “positive” if ≥1 endpoint is significant, the α should be “split” (allocated) across endpoints. The split can be done evenly; for example for a trial with overall α of 5% and two primary endpoints, each could be tested with an α of 2.5% [ 3 ]. However, the split need not be even. For example, a trial could allocate 4% of the α to the 1st endpoint and use the formula (1-0.04)*(1 − α 2 ) = 1 − α = 0.95 to calculate that α 2  = 0.0104 and allocate 1.04% to a 2nd endpoint. Again this must be done before the trial starts. The gain from using this formula versus a simple split of 4 and 1% is small enough such that many trials simply use the simple split [ 4 ]. Alpha can also be split between cohorts or sub-cohorts [ 23 ]. For example, 4% alpha could be allocated to a survival analysis of amongst all subjects in a trial, with the remaining alpha allocated to a biomarker-positive cohort, say a cohort which has a FLT3 mutation in a trial of midostaurin. The “remaining alpha” could be set at 1% but because the biomarker-positive cohort is included in the analysis of the full trial population, the results of the analyses are not independent. Because the analyses are not independent we can test the biomarker-positive cohort at an α level >1% and still control the overall α level at 5%. The correlation depends on the proportion of all events observed in the biomarker-positive cohort. Formulae for this calculation can be implemented in statistical programmes [ 24 ].

An alternative to this α splitting is a fixed-sequence approach. The sequence of tests is pre-specified and each endpoint is tested at the same α level . Testing continues along the sequence until there is a test with a p value >  α , at which point testing stops and no further endpoints in the sequence should be evaluated. Sometimes these tests are described as “carrying forward” the alpha after a significant test. All of the α is “spent” at the first test with p value >  α [ 25 ].

A combination of α splitting and fixed sequence testing can also be done. As numbers of endpoints increases the numbers of ways to allocate the α across endpoints also increases. The specific α allocation can vary between trials.

It is uncommon in transplant studies to have >1 primary endpoint or to require all primary endpoints to be significant in a trial to declare success [ 26 ]. For example, for a design to require a significant association with complete remission and also with survival. The false-positive rate is not inflated in this design because there is only one way to have a positive trial, i.e., in a trial requiring all endpoints to be significantly associated with intervention, each endpoint can be tested at the same α level. Because these designs have increased false-negative error rates compared with designs with a one primary endpoint they have less power and require larger samples.

A single composite endpoint including multiple potential “events” is not uncommon across transplant studies. For example, the endpoint G v HD-relapse-free-survival (GRFS) measures the time until the first event: G v HD, relapse or death. GRFS and similar composite endpoints weight the contributory events equally. If equal weighting of these endpoints is not appropriate, alternative statistics can be used to compare arms in a trial including the win ratio [ 27 ] which evaluates composite endpoints in a fixed hierarchy between matched pairs of subjects and tallies in how many pairs the experimental therapy dies first. If neither subject in the pair dies the second event is compared and so forth. Confidence intervals and p values can be calculated for the win ratio like other statistics. Win ratios can be calculated for individual events and composite lists of events and compared to understand the role each event has in the composite win ratio (see Fig. 2 of Pocock et al. [ 27 ], for an example). We note that acute G v HD alone or as a component of a composite endpoint is problematic because of the lack of definitive diagnostic criteria with substantial inter-observer discordances. Consequently, a clinical trial with acute G v HD as the primary endpoint (either alone or within a composite endpoint) is only definitive when a masked (blinded) randomized design is used.

Multi-arm clinical trials

Multi-arm clinical trials are an efficient way to conduct >1 investigation/evaluation within a protocol. Multi-arm trials can have increased false-positive error rates like trials with >1 primary endpoint because of multiple comparisons. Strategies like those discussed above can be used to control the false-positive rate (e.g. , α splitting; fixed-sequence tests). Some multi-arm trials choose not to control α and use the same α for each comparison. When all comparisons in a multi-arm trial are reported in one report it is straightforward to count numbers of comparisons and calculate the overall false-positive rate [ 28 ]. However, it is unfortunately common for multi-arm trials to report each comparison in separate publications [ 29 , 30 ]. As such, readers need to be aware of the general design when reading and interpreting results of only one comparison within a multi-arm trial.

When comparing two or more interventions added to a backbone, sometimes placebo if there is no standard-of-care , factorial designs can be used to evaluate potential synergy or interactions between the interventions. For example, a multi-arm study of two therapies designated X and Y added to a backbone designated B could have four arms: X + B, Y + B, X + Y + B, and B [ 31 ]. This design allows quantification of the “interaction” between X and Y, namely, are the therapies better or worse together or do they have individual benefits which are additive? [ 32 , 33 ]. These designs are uniquely able to evaluate multiple therapies in this way but can quickly become large and expensive. Some factorial designs assume X and Y are “independent” in the sense that any benefit of X can be evaluated ignoring whether a subject received Y or not. Analyses will then pool data across arms to evaluate X and Y separately. For example, to evaluate X, X + B and X + Y + B are combined and compared with B and Y + B. If the assumption of independence is true this design can lead to a substantial decrease in sample size compared with running separate trials of B + X and B + Y. But if there is a positive or negative synergy or interaction between X and Y results of the trial may be uninterpretable. As such, this trial design assumes no synergy and/or interaction, typically an unproved hypothesis. There will also be too little power to separately evaluate the cohorts because the sample size was selected assuming the cohorts could be pooled [ 34 ].

All the other analyses reported with a clinical trial

Clinical trials typically report analyses other than the pre-specified primary objective or endpoint. Such analyses are often labeled secondary, exploratory, subgroup, or translational analyses. Because of the increased probability of a false-positive conclusion discussed above all secondary objectives and analyses in a clinical trial should interpreted as non-definitive or hypothesis generating. When many “secondary” analyses are provided after the primary endpoint of a trial is not met, the results of any “significant” findings should be viewed with strong skepticism or outright ignored.

Sub-group analyses are common in clinical trials data reporting. Because the power of a comparison is related to the sample size, sub-group comparisons have less power than comparisons of the entire population. Lack of significance ( p value >  α ) in a sub-group does not mean there is no association in the sub-group. It can be a false-negative result because the sample size is too small or for many other reasons [ 35 ]. Interpretation of p values is challenging in general, especially in the context of evaluating multiple subgroups [ 35 ]. In these analyses, reviewing point-estimates and confidence intervals should be the focus. Interpretation of confidence intervals is also challenging; Greenland et al. [ 35 ] provide guidance. As noted above, retrospective or post-hoc power analyses are never appropriate for a subgroup or any analysis [ 11 ]. Sub-group analyses can only be used to assess if there appears to be significant heterogeneity across sub-groups compared with the entire trial population [ 36 , 37 , 38 ]. Forest plots are a way to visualize this. If there appears to be heterogeneity (some subgroups have a benefit and others, not), a definitive evaluation of such a sub-group effect requires validation in a new trial.

Sub-group analyses which are not pre-specified should be viewed skeptically or ignored. If someone evaluates 100 different non-pre-specified subgroups each with an α of 5% we would expect five of these to have a p value < 0.05 even when there is no difference in any of the sub-groups analyzed. This feature of statistical significance testing means that if enough tests are conducted, a significant p value is very likely to be found. Analyses conducted until finding a result with a significant p value are sometimes described as “fishing expeditions.” As noted above, subgroup analyses typically lack power which leads many significant subgroup results to be false-positive results. These issues are why so much emphasis is put on pre-specifying subgroup and other secondary analyses in clinical trials.

Non-inferiority

Randomized clinical trials evaluating whether one therapy is better than another nearly always analyze results using the intent-to-treat (ITT) principle. Subjects are analyzed in their assigned/randomized cohort regardless of the intervention they received. ITT analyses are considered “conservative” in that subjects receiving the alternative (non-assigned) intervention skew or “bias” towards showing no difference between the cohorts. In this instance an ITT analysis may result in the incorrect conclusion an intervention is ineffective, a false-negative. When the primary objective of a trial is to evaluate non-inferiority, an ITT analysis skews the data towards potentially showing non-inferiority. Because of this it is typical in non-inferiority trials to use an as-treated analysis as the primary analysis [ 39 , 40 ].

A critical element of a non-inferiority design is the non-inferiority margin the design will exclude. There are no specific rules on what threshold would warrant a conclusion of “non-inferiority,” though some regulatory agencies have provided guidance in some situations, and margins vary widely across endpoints, patient populations, and trials [ 39 , 40 , 41 , 42 , 43 , 44 ]. Any interpretation of a non-inferiority trial requires the reader to evaluate whether they find the non-inferiority margin selected convincing and of clinical import.

The interpretation of non-inferiority trials (and most clinical trials) is further complicated when endpoints are measured beyond the intervention period, which is (nearly) always the case with a survival endpoint. After the intervention period, there is typically less information on how patients are being treated and followed, and later therapies or interventions are often not randomly or equally allocated across arms. For example, when patients were randomized between lenalidomide and placebo for post-transplant maintenance therapy for multiple myeloma, therapy after failure varies by randomized arm. In many ways, clinical trial analyses with longer-term endpoints should be reviewed as essentially observational database analyses, with the associated caveats in analysis and interpretation [ 1 ].

Survival by response

Difficult as it is to believe, analyses comparing survival of responders versus non-responders remains common despite wide-spread knowledge such analyses are subject to diverse biases [ 45 ]. A critical bias is that a subject must live long enough to respond. This is referred to as guarantee-time or immortal-time bias. Statistical remedies of these bias are described [ 46 ].

This is an education-orientated review of design and correct interpretation of clinical trials data. We discuss issues including multiple endpoints and subgroup analyses. Many of the issues discussed are relevant to the correct interpretation of data from clinical trials of haematopoietic cell transplants.

Zheng C, Dai R, Gale R, Zhang M. Causal inference in randomized clinical trials. Bone Marrow Transpl. 2019;55:4–8.

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Acknowledgements

MO acknowledges support from the National Cancer Institute (NCI) grant U10CA180819. MJZ acknowledges support from the National Institutes of Health (NCI, NHLBI) and Health Resources and Services Administration (HRSA). RPG acknowledges support from the National Institute of Health Research (NIHR) Biomedical Research Centre funding scheme.

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Othus, M., Zhang, MJ. & Gale, R.P. Clinical trials: design, endpoints and interpretation of outcomes. Bone Marrow Transplant 57 , 338–342 (2022). https://doi.org/10.1038/s41409-021-01542-0

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The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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Clinical trials: A significant part of cancer care

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Editor's note: May is National Cancer Research Month.

By Mayo Clinic staff

A cancer diagnosis is an emotional experience. Learning that you have cancer can create feelings of hopelessness, fear and sadness. This is especially true if your cancer is advanced or available treatments are unable to stop or slow its growth.

"Often, when patients are diagnosed with cancer , they feel hopeless and scared. Clinical trials are one way patients can be proactive. They can make a choice in how their care is going to be," says Matthew Block, M.D., Ph.D. , a Mayo Clinic medical oncologist.

Cancer clinical trials help physician-scientists test new and better ways to control and treat cancer. During a clinical trial, participants receive specific interventions, and researchers determine if those interventions are safe and effective. Interventions studied in clinical trials might be new cancer drugs or new combinations of drugs, new medical procedures, new surgical techniques or devices, new ways to use existing treatments, and lifestyle or behavior changes.

Clinical trials provide access to potential treatments under investigation, giving options to people who otherwise may face limited choices. "Clinical trials open the door to a new hope that maybe we can fight their cancer back and give them a better quality of life," says Geoffrey Johnson, M.D., Ph.D. , a Mayo Clinic radiologist, nuclear medicine specialist and co-chair of the Mayo Clinic Comprehensive Cancer Center Experimental and Novel Therapeutics Disease Group.

You will receive cancer treatment if you participate in a clinical trial. "I think one common misperception about clinical trials is that if you enter a clinical trial, you may not get treatment (receive a placebo). And that's actually very much not true. Most clinical trials are looking at one treatment compared to another treatment," says Judy C. Boughey, M.D. , a Mayo Clinic surgical oncologist, chair of Breast and Melanoma Surgical Oncology at Mayo Clinic in Rochester, Minnesota, and chair of the Mayo Clinic Comprehensive Cancer Center Breast Cancer Disease Group.

"I think one common misperception about clinical trials is that if you enter a clinical trial, you may not get treatment (receive a placebo). And that's actually very much not true. Most clinical trials are looking at one treatment compared to another treatment." Judy C. Boughey, M.D.

Watch this video to hear the experiences of people who have participated in cancer clinical trials and to hear Drs. Block, Johnson and Boughey discuss the importance of clinical trials in cancer care:

Clinical trials are a significant part of cancer care at Mayo Clinic Comprehensive Cancer Center. Cancer care teams work together across specialties to make sure the right clinical trials are available to serve the needs of people with cancer who come to Mayo Clinic.

"We are very particular in how we select the clinical trials that we have available for patients," says Dr. Boughey. "We want to have the best trials available for our patients. Some of the clinical trials are evaluating drugs — we are so excited about those drugs, but we can't prescribe those drugs for patients without having that trial. And so we will actually fight to try to get that trial open here to have it available as an opportunity for our patients."

If you choose to participate in a clinical trial, you will continue to receive cancer care. "For most patients that we evaluate, there's always the standard of care treatment option for those patients. And then, in many situations, there's also a clinical trial that the patient can participate in," says Dr. Boughey.

People who participate in clinical trials help make new and better cancer care available for future patients. The treatments available for cancer patients today exist because of the clinical trial participants of yesterday. "We couldn't advance medicine if it wasn't for people volunteering for trials. And the promise from our side is to say we're not going to put patients on trials or offer trials for them to consider unless we think there's a good chance that they'll get a benefit or that society at large will get a benefit," says Dr. Johnson.

"We couldn't advance medicine if it wasn't for people volunteering for trials. And the promise from our side is to say we're not going to put patients on trials or offer trials for them to consider unless we think there's a good chance that they'll get a benefit or that society at large will get a benefit." Geoffrey Johnson, M.D., Ph.D.

Participating in a clinical trial may give you access to cutting-edge treatment, improve your quality of life and extend your time with loved ones.

"It's definitely worth reaching out to your healthcare provider and asking, 'What clinical trials could I be a potential candidate for?'" says Dr. Boughey. "And remember, you can ask this of your surgical oncologist, your medical oncologist, your radiation oncologist, or any of the physicians you're seeing because there are trials in all disciplines. There are also ongoing trials that require the collection of tissue or the donation of blood. They can also be important in trying to help future generations as we continue to work to end cancer."

Participating in a clinical trial is an important decision with potential risks and benefits. Explore these FAQ about cancer clinical trials, and ask your care team if a clinical trial might be right for you.

Learn more about cancer clinical trials and find a clinical trial at Mayo Clinic.

Join the Cancer Support Group on Mayo Clinic Connect , an online community moderated by Mayo Clinic for patients and caregivers.

Read these articles about people who have participated in clinical trials at Mayo Clinic:

• A silent tumor, precancerous polyps and the power of genetic screening
• Mayo Clinic’s DNA study reveals BRCA1 mutations in 3 sisters, prompts life-changing decisions

Read more articles about Mayo Clinic cancer research made possible by people participating in clinical trials.

Related Posts

Drs. Terry Burns and Alfredo Quiñones-Hinojosa discuss brain tumors called gliomas and the hope being offered by new technology and clinical trials.

Dr. Sujay Vora is studying a new approach to glioblastoma treatment that is improving health outcomes and quality of life for elderly people like Richard Casper.

Dr. S. John Weroha discusses new treatments and research that are helping more people survive ovarian cancer.

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Critical Thinking: A Simple Guide and Why It’s Important

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Critical Thinking: A Simple Guide and Why It’s Important was originally published on Ivy Exec .

Strong critical thinking skills are crucial for career success, regardless of educational background. It embodies the ability to engage in astute and effective decision-making, lending invaluable dimensions to professional growth.

At its essence, critical thinking is the ability to analyze, evaluate, and synthesize information in a logical and reasoned manner. It’s not merely about accumulating knowledge but harnessing it effectively to make informed decisions and solve complex problems. In the dynamic landscape of modern careers, honing this skill is paramount.

The Impact of Critical Thinking on Your Career

☑ problem-solving mastery.

Visualize critical thinking as the Sherlock Holmes of your career journey. It facilitates swift problem resolution akin to a detective unraveling a mystery. By methodically analyzing situations and deconstructing complexities, critical thinkers emerge as adept problem solvers, rendering them invaluable assets in the workplace.

☑ Refined Decision-Making

Navigating dilemmas in your career path resembles traversing uncertain terrain. Critical thinking acts as a dependable GPS, steering you toward informed decisions. It involves weighing options, evaluating potential outcomes, and confidently choosing the most favorable path forward.

☑ Enhanced Teamwork Dynamics

Within collaborative settings, critical thinkers stand out as proactive contributors. They engage in scrutinizing ideas, proposing enhancements, and fostering meaningful contributions. Consequently, the team evolves into a dynamic hub of ideas, with the critical thinker recognized as the architect behind its success.

☑ Communication Prowess

Effective communication is the cornerstone of professional interactions. Critical thinking enriches communication skills, enabling the clear and logical articulation of ideas. Whether in emails, presentations, or casual conversations, individuals adept in critical thinking exude clarity, earning appreciation for their ability to convey thoughts seamlessly.

☑ Adaptability and Resilience

Perceptive individuals adept in critical thinking display resilience in the face of unforeseen challenges. Instead of succumbing to panic, they assess situations, recalibrate their approaches, and persist in moving forward despite adversity.

☑ Fostering Innovation

Innovation is the lifeblood of progressive organizations, and critical thinking serves as its catalyst. Proficient critical thinkers possess the ability to identify overlooked opportunities, propose inventive solutions, and streamline processes, thereby positioning their organizations at the forefront of innovation.

☑ Confidence Amplification

Critical thinkers exude confidence derived from honing their analytical skills. This self-assurance radiates during job interviews, presentations, and daily interactions, catching the attention of superiors and propelling career advancement.

So, how can one cultivate and harness this invaluable skill?

✅ developing curiosity and inquisitiveness:.

Embrace a curious mindset by questioning the status quo and exploring topics beyond your immediate scope. Cultivate an inquisitive approach to everyday situations. Encourage a habit of asking “why” and “how” to deepen understanding. Curiosity fuels the desire to seek information and alternative perspectives.

✅ Practice Reflection and Self-Awareness:

Engage in reflective thinking by assessing your thoughts, actions, and decisions. Regularly introspect to understand your biases, assumptions, and cognitive processes. Cultivate self-awareness to recognize personal prejudices or cognitive biases that might influence your thinking. This allows for a more objective analysis of situations.

✅ Strengthening Analytical Skills:

Practice breaking down complex problems into manageable components. Analyze each part systematically to understand the whole picture. Develop skills in data analysis, statistics, and logical reasoning. This includes understanding correlation versus causation, interpreting graphs, and evaluating statistical significance.

✅ Engaging in Active Listening and Observation:

Actively listen to diverse viewpoints without immediately forming judgments. Allow others to express their ideas fully before responding. Observe situations attentively, noticing details that others might overlook. This habit enhances your ability to analyze problems more comprehensively.

✅ Encouraging Intellectual Humility and Open-Mindedness:

Foster intellectual humility by acknowledging that you don’t know everything. Be open to learning from others, regardless of their position or expertise. Cultivate open-mindedness by actively seeking out perspectives different from your own. Engage in discussions with people holding diverse opinions to broaden your understanding.

✅ Practicing Problem-Solving and Decision-Making:

Engage in regular problem-solving exercises that challenge you to think creatively and analytically. This can include puzzles, riddles, or real-world scenarios. When making decisions, consciously evaluate available information, consider various alternatives, and anticipate potential outcomes before reaching a conclusion.

✅ Continuous Learning and Exposure to Varied Content:

Read extensively across diverse subjects and formats, exposing yourself to different viewpoints, cultures, and ways of thinking. Engage in courses, workshops, or seminars that stimulate critical thinking skills. Seek out opportunities for learning that challenge your existing beliefs.

✅ Engage in Constructive Disagreement and Debate:

Encourage healthy debates and discussions where differing opinions are respectfully debated.

This practice fosters the ability to defend your viewpoints logically while also being open to changing your perspective based on valid arguments. Embrace disagreement as an opportunity to learn rather than a conflict to win. Engaging in constructive debate sharpens your ability to evaluate and counter-arguments effectively.

✅ Utilize Problem-Based Learning and Real-World Applications:

Engage in problem-based learning activities that simulate real-world challenges. Work on projects or scenarios that require critical thinking skills to develop practical problem-solving approaches. Apply critical thinking in real-life situations whenever possible.

This could involve analyzing news articles, evaluating product reviews, or dissecting marketing strategies to understand their underlying rationale.

In conclusion, critical thinking is the linchpin of a successful career journey. It empowers individuals to navigate complexities, make informed decisions, and innovate in their respective domains. Embracing and honing this skill isn’t just an advantage; it’s a necessity in a world where adaptability and sound judgment reign supreme.

So, as you traverse your career path, remember that the ability to think critically is not just an asset but the differentiator that propels you toward excellence.

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School Boards Are at a Critical Juncture. Here’s What DU Is Doing About It.

Joy hamilton.

Publications and Research Writing Manager

The Morgridge College of Education is collaborating with Colorado school boards to address school closures, mental health and teacher retention.

Colorado’s school boards grapple with a range of issues, from fluctuating enrollment and changes in state funding to concerns about school safety and persistent teacher shortages. In recent years, the COVID-19 pandemic and heightened political attention have thrust school boards into even more turbulent waters.   

“ Effective school boards serve as strong advocates for their community ,” says Lolita Tabron , associate professor in Morgridge College of Education (MCE).  As representatives of their community, they are well positioned to catalyze widespread democratic engagement to address the needs of their local school community, Tabron added.

That’s why Provost Mary Clark,  Dean Knight-Manuel  and  Emeritus Chancellor Dan Ritiche   gathered a year ago to address a question frequently on their minds: How might MCE support the important work of Colorado school boards?

“ That led to loads of research to learn more about school board’s needs and issues our Colorado school boards are facing, ” says Starla Sieveke-Pearson , clinical assistant professor in  educational leadership and policy studies

So, Pearson, Tabron and  Doris Candelarie, clinical associate professor in educational leadership and policy studies,  set out to lend MCE’s research and networking prowess to leaders who serve Colorado’s 800,000+ students impacted by school boards. Made up of democratically elected, unpaid members who are mandated to execute state policy and law, school boards play a crucial role in educational governance, says Pearson.

The result was a year’s worth of research leading up to the University of Denver’s inaugural School Board Symposium , in which school board directors from 29 districts — some waking before sunrise to travel from Gunnison, La Junta and the Roaring Fork Valley — gathered on DU’s campus for day of discussion, networking and, ultimately, action to address K-12’s most pressing challenges.

School closures, mental health crisis and teacher shortages

MCE’s research started with gathering input from school board members across the country and in Colorado to determine hot topics facing school boards. Four themes emerged that served as the symposium’s focus: 1) superintendent relationships, 2) shifting enrollment and school closures, 3) youth mental health and 4) teacher shortages, recruitment and retention.     

In preparation for the event, Doctoral students in MCE's educational leadership and policy program—who are experienced practitioners within K-12 schools—prepared literature briefs with faculty containing research on the symposium’s themes.  This provided participants with cutting-edge information to inform decision-making.

Panel speakers represented a diverse range of experiences. Jeffco Public Schools superintendent Tracy Dorland, for instance, shared the difficult process of closing 21 out of 180 schools and encouraged school board members to lead with courage, heart and honesty.

“It's just extremely challenging work with lots of emotion,” Dorland told participants.

Declining birth rates, rising housing costs and suburban flight are all factors impacting school closures, which has recently been complicated by an influx of migrant students.

“ It’s not just data—it’s data and stories. What are the lived experiences of people in these communities?” added Dr. Carrie Olson, former teacher and current president of the Denver school board during the panel.

Bringing together academic and practitioner perspectives

From the onset, DU faculty intentionally merged academic and on-the-ground practitioner expertise in an effort to support school boards that are often siloed and create an atmosphere conducive to community building and collaboration.      “It was empowering to be in community with so many leaders engaging in conversations on pressing topics that are impacting our students, teachers and communities,” says Katilyn Daniel, a PhD student who created fact sheets for the symposiu m. 

The symposium’s atmosphere was intimate, with panelists speaking on problems keeping them up at night. For some, the youth mental health crisis causes many sleepless nights.

“I think about the children who had experienced the trauma in the last five years that hasn't been collected,” said Jillian Blueford, clinical assistant professor in the department of counseling psychology.

Blueford presented data that 1 in 13 students in Colorado will lose a parent or sibling by the age of 18, a statistic that she knows well, having lost her mom at a young age. 

“The systems and the policies and lack of resources and lack of mental professionals we have in schools is causing more trauma for students,” she adds.

As part of the symposium, MCE faculty documented various mental health initiatives to support education, prevention and intervention in an effort to help directors accomplish milestones in supporting youth in crisis.  

“These conversations were a reminder that with partnerships, collective action and commitment, our school communities can increase mental health care access for all students. No one has to do this work alone,” says Daniel.

Creating a roadmap for the future

“ Coming together to grapple with these hot topics collectively will be immensely impactful, ” says Tabron.   

Organizers say the symposium is something between an “inaugural event and a maiden voyage,” indicating MCE’s long-term commitment to supporting school boards in the years to come as they navigate an educational system constantly in flux.

“It is my hope that the Morgridge College of Education can be a partner for school boards today and well into the future, as we are well aware of the invaluable impact of school board members in representing the voices of the families and communities that you serve,” Dean Michelle Knight-Manuel told the 51 attendees during opening remarks for the event.    

In addition to research presentations and discussions, MCE used the symposium to identify what additional needs school board directors have that DU might support in the future.   

“We see ourselves as a bridge, a connector,” says Tabron, “to not only just the research but also to an extraordinary community of colleagues. We want them to know they're not alone and that we're there to support them.”   

For more information on the symposium and literature briefs on the four themes, visit the event website .  

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