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Case Based Critical Thinking Questions For Preschoolers

Many more questions aiming on diagnosis

At the end of year 4, students of the MUV had had various lectures but hardly any actual experiences with therapies. This may explain why significantly more items concerned the diagnosis of psychiatric diseases than their therapies.

Among questions aiming on therapy, significantly more concerned pharmacotherapy than psychotherapy

Before Block 20, the seminars concerning therapies in the MUV Curriculum were almost exclusively pharmacological. After successful attendance of Block 20 most students who did not have any personal experience of psychotherapy only had little insight into how psychotherapy is developing on the long-term and what psychotherapy can really provide to the patient. Psychotherapy associations were still loaded with old stereotypes [13, 16]. This could explain why significantly more therapy questions addressed pharmacology than psychotherapy.

A huge majority of Step 1 questions

The students mainly offered Step 1 questions. It can be questioned, whether the lack of case-oriented questions was an indication for insufficient clinical thinking by the students. An essential explanation could be that students lacked adequate patient contact until the end of year four. Indeed, MUV students were allowed to begin their practical experience after year two and eight compulsory clerkship weeks were scheduled before the beginning of year five [17]. Thus, Austrian medical students gained consistent clinical experience only after year four, with rotations in year five and the newly introduced Clinical Practical Year in year six. A European comparison of medical universities’ curricula showed that students of other countries spent earlier more time with patients: Dutch, French and German medical students began with a nursing training in year one and had 40, 10 and 4 months, respectively, more clerkship experience than Austrian students before entering year five [18, 19, 20, 21]. French and Dutch universities are extremely centered on clinical thinking, with a total of 36 clerkship months in France and the weekly presence of patients from the first lectures on in Groningen [22]. Thus, it would be interesting to repeat a similar case-based exercise in these countries to explore if medical students at the same educational stage but with more practical experience are more likely to offer patient vignette items.

Students preferred to work with right facts and did not reject negatively worded questions

As negatively worded questions were usually banished from MCQ exams, it was interesting to observe that medical students did not reject them. In fact, negatively formulated questions are more likely to be misunderstood. Their understanding correlates to reading ability [23] and concentration. Although many guidelines [6, 24] clearly advised to avoid negative items, the students generated 27.5 % of negatively formulated questions. Also Pick N format-questions with several right answers were offered by the students, despite the recommendations for this exercise: They offered significantly less total answer possibilities but significantly more right answers to positively worded questions than to negatively worded questions. Those results supported the hypothesis that the students preferred handling right content while keeping wrong content to a minimum.

Several possible reasons can be contemplated. When students lack confidence with a theme and try to avoid unsuitable answer possibilities, it can be more difficult to find four wrong answers to a positively worded question instead of several right answers, which may be listed in a book. Furthermore, some students may fear to think up wrong facts to avoid learning wrong content. Indeed, among positively worded items, 26.6 % were offered with 3 or more right answers, which never happened for negatively worded items (Table 2).

Notably, “right answer possibilities” of negatively worded items’ stems as well as “wrong answer possibilities” of positively worded items’ stems are actually “wrong facts”. For example, the right answer of the item “Which of the following symptoms does NOT belong to ICD-10 criteria of depression?” (Item 177) is the only “wrong fact” of the 5 answer possibilities. Writing the 4 “wrong answers” of this question, which are actually the ICD-10 criteria for depression, can help the students learn these diagnostic criteria. On the contrary, the “right answers” to a positively worded item such as “Which vegetative symptoms are related to panic attacks?” (Item 121) are the true facts.

Finally, the students’ interest for right facts supports the theory that a positive approach, positive emotions and curiosity are favorable to learning processes. Indeed, asking for right content is a natural way of learning, already used by children from the very early age. The inborn curiosity — urge to explain the unexpected [25], need to resolve uncertainty [26] or urge to know more [27]— is shown by the amount of questions asked by children [28, 29]. The students’ way to ask for right contents appears very close to this original learning process.

The inputs of developmental psychology, cognitive psychology as well as of neurosciences underline this hypothesis. Bower presented influences of affect on cognitive processes: He showed a powerful effect of people’s mood on their free associations to neutral words and better learning abilities regarding incidents congruent with their mood [30]. Growing neurophysiological knowledge confirmed the close relation between concentration, learning and emotions — basic psychic functions necessitating the same brain structures. The amygdala, connected to major limbic structures (e.g. pre-frontal cortex, hippocampus, ventral striatum), plays a major role in affect regulation as well as in learning processes [15], and the hippocampus, essential to explicit learning, is highly influenced by stress, presenting one of the highest concentrations of glucocorticoid receptors in the brain [31]. Stress diminishes the synaptic plasticity within the hippocampus [32], plasticity which is necessary to long-term memory.

Neuroscientific research also underlined the interdependence of cognitive ability and affect regulation. Salas showed on a patient after an ischemic stroke event with prefrontal cortex damage that, due to executive impairment and increased emotional reactivity, cognitive resources could not allow self-modulation and reappraising of negative affects anymore [33].

Considering this interdependence, right contents might be related to a positive attitude and positive affects among the students. It could be interesting to further research on this relation as well as on the students’ motivations concerning the formulation of the questions.

The combination of those reasons probably explains why the students offered significantly more wrong answers to negatively worded items and more right answers to positively worded items, both resulting in the use of more right facts. All the students’ assessment questions and associated feedback were used to create a new database at the MUV trying to integrate more right facts in case-based learning exercises in the future.

The main limitation concerns the small sample size and the focus on only one curriculum element. Further studies with convenient sampling should include other medical fields and bridge the gap to learning outcome research.

Critical thinking in children: Are we teaching our kids to be dumb?

© 2008 - 2014, Gwen Dewar, Ph.D., all rights reserved

In his review of the research, Stephen Norris notes that critical thinking in children is uncommon:

“Most students do not score well on tests that measure ability to recognize assumptions, evaluate arguments, and appraise inferences" (Norris 1985).

Why is critical thinking so difficult? Some argue that humans aren’t designed for it.

According to this idea, evolution hasn’t equipped us for abstract, logical reasoning. Instead, natural selection has shaped the brain to solve specific, evolutionarily- relevant, problems-- like avoiding predators and identifying which people are breaking the rules (Tooby and Cosmides 1992).

Maybe these folks are right—I’m not going to argue that here. Instead, I want to make a different point:

We often train our kids to think in fallacious or illogical ways.

My evidence?

Consider these real-life examples of how TV, books, educational software, and even some teachers--discourage critical thinking in children.

How to discourage critical thinking in children: The case of Minnie Mouse

How about this a scene from Disney’s “Mickey Mouse Playhouse," a TV program for preschoolers.

Minnie Mouse--Mickey's feminissima pal--has a problem. She has been packaging and wrapping gifts, including a bow (just like the one on her head).

But Minnie forgot to label the packages she’s wrapped, and now she’s not sure which box contains the bow.

There are three possible boxes—small, medium-sized, and large.

Minnie asks: Which box might contain the bow?

Minnie holds out her hands to show us how big the bow is. She compares this with the size of the boxes. The bow seems too big for the smallest box. But it appears small enough to fit in the other two.

So...the answer is that the bow might be in either the medium-sized box or the big box. Right?


Minnie tells us that the bow MUST be in the medium-sized box.

Why does Minnie deny the logical possibility that the bow might be in the big box?

Presumably because the writers weren’t thinking straight and didn’t say what they meant.

Apparently, what they really wanted to ask was this:

“Which is the smallest box that the bow could fit in?"

But then again, there is the possibility that the bow could be in the smallest box. The bow seems too big for the smallest box. But what if Minnie had folded or wadded up the bow to make it fit?

So perhaps the writers should have posed this question:

“Which is the smallest box that the bow could fit in—assuming that Minnie didn’t scrunch up the bow?"

The point

Does this sound nit-picky or pedantic? Maybe it does to the writers of the Mickey Mouse show. But I’m really just asking for some common sense.

In the real world, people do scrunch and they really do sometimes package items in boxes that are a bit larger than needed. Why should we—the viewers—assume that they don’t?

The answer is that we shouldn’t. Not unless we know something about Minnie Mouse. Not unless we know what her unstated assumptions are.

And that’s the point. I don’t know what goes on in Minnie Mouse’s head, and I don’t suppose that my kids do, either. The writers of the Mickey Mouse show asked us to solve the problem based on information about the size of the bow and the size of the boxes.

Critical thinking means that we consider all the possibilities, not just the one that the Mouse thinks is most likely.

What happens when your child watches this sort of thing? It seems to me that the Mickey Mouse show is teaching something very different from critical thinking. It’s teaching kids conformist thinking. Don’t look at problems objectively or logically. Instead, figure out what the authorities want you to say.

You might wonder if young children really think this way. Aren't kids -- like the boy in the story of the Emperor's New Clothes -- supposed to speak their minds?

But experiments suggest that preschoolers are inhibited by the pronouncements of authoritative adults.

When grown-ups tell them how something works, kids don't question it. They act as if the adults have told them everything they need to know, and afterwards the children show less evidence of critical thinking (Bonawitz et al 2011; Buchsbaum et al 2011).

Not just Minnie Mouse: How formal educational experiences discourage critical thinking in children

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