How important is metacognition

(thinking about thinking) in medical

teaching and learning?

FELIPE FREGNILUNES, 19 DE SEPTIEMBRE DE 2016

Is it possible that a medical student completes medical school with outstanding grades,
perhaps the first of the class, and still becomes an average physician? Yes. Physician
skills are multifactorial and complex and still there is no satisfactory map to truly
understand how to perfect them; however one important characteristic is important:
his/her analytical skills. The immediate follow-up question would be: how to train
physician critical thinking skills then?

There is a large amount of material to cover during medical school. From anatomy to
microbiology, immunology, embryology and so on. Four or six years (depending on
the system) are relatively short given so much it needs to be covered. But what does
it truly make the difference in someones learning during the medical school? Perhaps
anatomy? or immunology? No, it is not a single topic; but the process of thinking
medically. During medical school, physicians in training learn how to speak with
patients, learn how to process data coming from patients and how to make decisions
based on that. Of course, anatomy, immunology, physiology are important for such
thinking process; but the thinking process by itself is also extremely important.

How much effort and energy are spent in developing critical thinking skills in
physicians in training? Is there any formal course in decision making during medical
school? in cognitive processing? in thinking bias? The answer is likely not. There may
be some experimental courses in these disciplines in some medical schools, but this
is not part of what we think it is important for our physicians to be mastered. Someone
can argue that those skills may come naturally during learning of the traditional
medical topics. It is true that learning anatomy, physiology, cardiology and so on will
train thinking skills on these topics, however this is not enough if not made explicit.

In the book from Harvard professor David Perkins, Making Learning Whole: How
Seven Principles of Teaching Can Transform Education, the author gives a nice
example that just playing baseball will not maximize learning in how to play baseball.
True that playing baseball is as important as learning anatomy in these respective
fields. But they are not enough. It is important to analyze (and also learn how to
analyze) the thinking process.

What medical teachers can do more? They can use metacognition techniques. For
instance, be explicit and discuss importance of thinking process as a source of
cognitive errors and biases, use the power of questioning as a tool to probe thinking
about thinking, create environments that engage and promote discussions among
students that help then to analyze and understand thinking process. Students should
be constantly analyzing their thinking process and in fact understand the basic dual
thinking theory (the nobel prize Daniel Kahneman gives a great discussion on this
topic in his book Thinking Fast and Slow).

A medical student will likely learn that every patient is different; therefore,
biology/pharmacology/pathology knowledge is not enough to give all the answers. In
other words, scoring 100% in all the medical school exams will not be enough to
resolve the case of a future patient. On the contrary, it may give a false confidence of
enough expertise that may be harmful. The best physician is the one who understands
(and keeps mastering) his/her thinking process and then combine with
biology/medical knowledge to then make optimal decisions.