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Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing

Papp, Klara K. PhD; Huang, Grace C. MD; Lauzon Clabo, Laurie M. PhD, RN; Delva, Dianne MD; Fischer, Melissa MD, MEd; Konopasek, Lyuba MD; Schwartzstein, Richard M. MD; Gusic, Maryellen MD

doi: 10.1097/ACM.0000000000000220

Critical thinking is essential to a health professional’s competence to assess, diagnose, and care for patients. Defined as the ability to apply higher-order cognitive skills (conceptualization, analysis, evaluation) and the disposition to be deliberate about thinking (being open-minded or intellectually honest) that lead to action that is logical and appropriate, critical thinking represents a “meta-competency” that transcends other knowledge, skills, abilities, and behaviors required in health care professions. Despite its importance, the developmental stages of critical thinking have not been delineated for nurses and physicians. As part of a task force of educators who considered different developmental stage theories, the authors have iteratively refined and proposed milestones in critical thinking. The attributes associated with unreflective, beginning, practicing, advanced, accomplished, and challenged critical thinkers are conceived as independent of an individual’s level of training. Depending on circumstances and environmental factors, even the most experienced clinician may demonstrate attributes associated with a challenged thinker. The authors use the illustrative case of a patient with abdominal pain to demonstrate how critical thinking may manifest in learners at different stages of development, analyzing how the learner at each stage applies information obtained in the patient interaction to arrive at a differential diagnosis and plan for evaluation. The authors share important considerations and provide this work as a foundation for the development of effective approaches to teaching and promoting critical thinking and to establishing expectations for learners in this essential meta-competency.

Dr. Papp is professor and associate dean, Penn State College of Medicine, Hershey, Pennsylvania.

Dr. Huang is associate professor of medicine, Harvard Medical School, and director of assessment, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Dr. Lauzon Clabo is dean and professor, MGH Institute of Health Professions School of Nursing, Boston, Massachusetts.

Dr. Delva is chair and professor, Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.

Dr. Fischer is associate professor of medicine and associate dean for undergraduate medical education, University of Massachusetts Medical School, Worcester, Massachusetts.

Dr. Konopasek is associate professor of pediatrics (education), Weill Cornell Medical College, and designated institutional official, NewYork-Presbyterian Hospital, New York, New York.

Dr. Schwartzstein is Ellen and Melvin Gordon professor of medicine and medical education and faculty associate dean for medical education, Harvard Medical School, vice president for education, Beth Israel Deaconess Medical Center, and executive director, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Dr. Gusic is professor of pediatrics, Dolores and John Read professor of medical education, and executive associate dean for educational affairs, Indiana University School of Medicine, Indianapolis, Indiana.

Please see the end of this article for information about the authors.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Dr. Papp, Office of Medical Education MC H123, 500 University Dr., PO Box 850, Hershey, PA 17033-0850; telephone: (717) 531-0003 ext: 281249; fax: (717) 531-4786; e-mail:

© 2014 by the Association of American Medical Colleges