Critical Thinking-A Systematic Review On Critical Thinking in Medical Education

Int J Adolesc Med Health 2016; aop
Review
Zenobia C.Y. Chan*
A systematic review on critical thinking in medical

education
DOI 10.1515/ijamh-2015-0117
Received December 4, 2015; accepted February 13, 2016
Introduction
Abstract
No one would deny that the major role of a clinician is to

heal the sick. However, as patients come from all walks
of life and have different views about what is wrong with
them, clinicians often face the challenge of providing
patients with the best treatment through making appropriate judgements and solving problems. Critical thinking
is defined as the ability/process of raising discriminating
questions in an attempt to search for better ideas, a deeper
understanding and better solutions (1). Undoubtedly, it is
important for future physicians to have the ability to think
critically when they are tackling challenging issues in
medical routine practice, such as deciding treatment plans,
making diagnoses, putting concepts into real-life practice
and avoiding mistakes (24). Such skills are developed
through a series of active learning processes and practice
(5). Critical thinking should be one of the clinical components of a medical school education to enable students to
use their basic and applied knowledge in the sciences and
medicine to formulate better questions, and to make better
diagnoses and treatment plans (3, 69).
Despite the importance of critical thinking in medical
education (10), most discussions have focused on students
perspectives of their courses or on their education in difficult subjects (1115). Studies of how soft skills like critical thinking have been enhanced by medical education are
limited. Because of this gap in our knowledge, the aim of
this article is to explore the development and assessment
of critical thinking in medical education. Specifically, an
attempt will be made to reorganise the existing knowledge
on the topic and to raise the awareness of the academic
sector of the importance of critical thinking in medical education, thereby stimulating more endeavours devoted to
exploring the role of critical thinking in medical education.
Background: Critical thinking is the ability to raise discriminating questions in an attempt to search for better
ideas, a deeper understanding and better solutions relating to a given issue.
Objective: This systematic review provides a summary of
efforts that have been made to enhance and assess critical
thinking in medical education.
Design: Nine databases [Ovid MEDLINE(R), AMED, Academic Search Premier, ERIC, CINAHL, Web of Science,
JSTOR, SCOPUS and PsycINFO] were searched to identify
journal articles published from the start of each database
to October 2012.
Results: A total of 41 articles published from 1981 to 2012
were categorised into two main themes: (i) evaluation of
current education on critical thinking and (ii) development of new strategies about critical thinking. Under each
theme, the teaching strategies, assessment tools, uses of
multimedia and stakeholders were analysed.
Discussion: While a majority of studies developed teaching strategies and multimedia tools, a further examination
of their quality and variety could yield some insights. The
articles on assessment placed a greater focus on learning
outcomes than on learning processes. It is expected that
more research will be conducted on teacher development
and students voices.
Keywords: critical thinking; learning outcomes; medication education; teacher development.
*Corresponding author: Zenobia C.Y. Chan, School of Nursing,

The Hong Kong Polytechnic University, Hong Kong,
Phone: +852 2766 6426, Fax: +852 2364 9663,
E-mail: zenobia.chan@polyu.edu.hk
Design
The systematic review is a transparent way to gather,
critically evaluate and interpret all of the relevant primary
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2Chan: Critical thinking in medical education

research that is available (16). Systematic reviews contrast
with traditional reviews, in that in a systematic review
previous work is not merely described but also systematically identified, assessed for quality and synthesised
(p. 1) (17). Amidst disconnected and dichotomous perspectives about a phenomenon under study, a systematic
review extends knowledge of that phenomenon (18, 19).
Search strategy
A computer-assisted literature search was conducted. The
search was performed from October 2012 to January 2013
to identify reports on journal articles exploring the role
of critical thinking in medical education. The method of
the systematic review was based mainly on the PRISMA
(20). A combination of keywords was used to search for
relevant studies from the following nine databases: Ovid
MEDLINE(R), AMED, Academic Search Premier, ERIC,
CINAHL, Web of Science, JSTOR, SCOPUS and PsycINFO.
The above databases were searched using the following
search strategies with minor modifications for variation
in the requirements of searching: (critical think* or
critical-think*), (curricul* or lecture* or teach* or learn*
or program* or educat* or class* or undergraduate* or
student*) and medic*. The search encompassed studies
that appeared from the earliest date of publication of the
journals included in the database. (Refer to Table S1 in the
supplementary material for details.)
Eligibility criteria
This systematic review included original articles published in English that report research on critical thinking
in medical education at the undergraduate level, such as
in preclinical studies and clerkships, narrowly interrupted
here as education provided to train students who will be
future registered physicians practising Western medicine.
Moreover, studies were selected only if they contained a
section that explicitly describe the procedures for collecting
data. Letters, short communications, reviews, or description of interventions that did not include a formal evaluation were excluded. The studies were assessed for inclusion
according to the predetermined criteria for inclusion.
the author looked into the discrepancy and made the final
judgment by revisiting the contents of those studies. Eventually, a total of 5689 titles were identified by the search
strategy. After removing exact duplications, 5369 articles
remained. These articles underwent title screening and
abstract screening to further exclude close duplications,
non-research papers and irrelevant research. A total of
795 articles remained for retrieval. Articles that did not
mention the discipline of the study in the abstract, which
were therefore difficult to identify in terms of type or
research focus, were subjected to full text screening. After
full text screening, 41 articles were assessed for eligibility
(Table 1). (Refer to Figure S1 in the supplementary material for details.)
Assessment of reliability
The author, a research assistant and a doctoral student
read and assessed 41 articles independently. The reliability in the judgment between the three was achieved by
discussions and voting among us to prevent any personal
bias in reaching a consensus. The credibility of the studies
was checked in terms of whether relevant measures were
mentioned. All studies that met the criteria for inclusion
underwent a quality assessment.
Data extraction and synthesis

After the articles were screened, data were extracted
from the 41 studies using basic data extracting methods,
including focusing on such headings as research objective, data collection method, participant numbers and
characteristics, recruitment method, findings and measures to ensure credibility. Thematic synthesis (61) was
adopted for this systematic review, which involved thoroughly reading through the findings to identify important
and recurrent patterns, then encoding the patterns with
theme labels for synthesis (62).
Results
Overview of the characteristics of the studies
Study selection
Publication year
The research assistant and a doctoral student conducted

the search for the relevant studies separately first. Then,
A total of 41 studies met the criteria for inclusion. One

article was published before 1990 (37), two in 19901994
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de Leng etal. (2009),

The Netherlands (35)
Elizondo-Montemayor
etal. (2007), Mexico (36)
DAntoni etal. (2010),

USA (34)
Curet and Mennin (2003),

USA (33)
Mixed, exam scores, self reflection

writing
Quantitative, questionnaire, Medical

College Admission Test (MCAT)
scores
Quantitative, Health Sciences
Reasoning Test, Mind Map

Assessment Rubric
Mixed, number of discussion
threads, content analysis of

discussion
Qualitative, national meeting
Quantitative, questionnaire
Birgegrd and Lidquist

(1998), Sweden (31)
Chamberlain etal.
(2012), USA (32)
Quantitative, critical thinking ratios

of tutorial transcripts, questionnaire
Quantitative, evaluation form
Quantitative, Short Inventory of
Approaches to Learning (SIAL) scores

Quantitative, exam scores,

questionnaire
Basu Roy and McMahon

(2012), USA (30)
Antepohl etal. (2003),

Sweden (29)
Abraham etal. (2006),

India (25)
Ahmed and Van (2010),
Egypt (26)
Alur etal. (2002),
Singapore (27)
Alweshahi etal. (2007),
Oman (28)
Quantitative, exam scores,

questionnaire

India (23)
India (24)
Abdelmoneim (2003),
Saudi Arabia (21)
India (22)
Research method, data collection
Author (year), country
Table 1:Summary of reviewed studies.
120 faculty members and deans of

medical schools
8 fifth- and sixth-year medical students
131 first-year medical students
147 first- and second-year medical

students and 91 tutors
Statistical study: 849 students

Qualitative study: 514 students
Crossover study: 28 students and four
tutors
Survey study: 165 students and 18 tutors
186 first-clinical year students
446 medical graduates
84 final year medical students
382 fourth-year forensic medicine

students
112 medical teaching websites
223 first-year physiology students
30 first-year physiology refresher

students
51 sixth-year primary health care

students
Sample recruitment
E-learning was successful in
establishing dialogues among

students and experts
9 national outcomes and minimum
requirements were identified
50% of the sites promoted critical

thinking explicitly
Communication domain was
more important in ideal bedside

teaching than demographics
The graduates felt well prepared
in critical thinking from
undergraduate study
Participants preferred video-based
cases. The use of videos may
reduce deep thinking
Significant changes of problem-
solving and critical thinking in PBL
Case presentation improved
students critical thinking and

exam scores
Long-term tutors were rated
higher than short-term tutors in

developing critical thinking
There is no significant difference
in scores
Seminars scored the lowest in
enhancing critical thinking

Post-Clinically Oriented Physiology
Teaching (COPT) scores were the
highest
No assessment ranked highest for
all items
Students did better in Post-COPT
exam and stated that COPT was
useful
COPT seemed to affect students
learning approaches
Peer critique was useful
Results/findings
Development of assessment
approach: 9 outcomes
Development of teaching
approach: E-learning
Evaluation of mind mapping
Evaluation of PBL tutors
approach: case presentation
Evaluation of PBL approach
Evaluation of video-based cases
Evaluation of problem-based
learning (PBL) curriculum
Evaluation of bedside teachers
Evaluation of SIAL; Development

of teaching approach: COPT
approach: peer critique
Evaluation of various websites
Evaluation of various assessment

tools
approach: COPT
Evaluation of various academic

instructions
approach: COPT
Data synthesis
Chan: Critical thinking in medical education3
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Qualitative, QSR NUD*IST

from content analysis
Kamin etal. (2003),

USA(40)
Kamin etal. (2001),

USA(41)
Kim etal. (2002),
USA(42)
Quantitative, exam results, Watson-

Glaser Critical Thinking Appraisal
(WGCTA)
Mala-Maung etal.
(2011), Malaysia (48)
Manzoor etal. (2012),
Pakistan (49)
Miller etal. (1993),
USA(50)
Quantitative, California Critical

Thinking Skills Test (CCTST) scores
Qualitative, discussions, openended questionnaire
Loy etal. (2004),

USA(46)
Quantitative, science tests,
matriculation examination, learningfrom-text tasks
Lumlertgul etal. (2009),

Thailand (47)
Lindblom-Ylnne etal.
(1999), Finland (45)
63 third- and fourth-year medical

students
196 first-year medical students
708 medical students
26 second-year medical ethics and

clinical thinking students
62 third-year obstetrics and gynaecology

clerkship students
174 second-year endocrinology and

reproduction students, 17 faculty
moderators
109 medical freshmen
Mixed, questionnaires, focus group

discussion
10 third-year paediatrics clerkship

students
30 third-year family medical students,
2faculty moderators

students
123 clinical immunology and serology

students
19 doctors
163 final-year orthopaedics students
119 third-year students and 22 medical

faculty members
Sample recruitment
Quantitative, test scores
Quantitative, critical thinking
examination, student attendance,

course evaluation
from content analysis
Hoag etal. (2005),

USA(39)
Kumta etal. (2003),
Hong Kong (43)

Lieberman etal. (2000),
USA (44)
Qualitative, observation of clinical

instruction
Graffam (2008), USA (38)
Quantitative, Flanders system of

interaction analysis of discussion
Foster (1981), USA (37)
Table 1(continued)
Case-based scenario in movies
could facilitate learning on

professionalism
Appreciation of PBL was positively
related with higher-order thinking
Role-play was well accepted and
enhanced critical thinking
The exam results could partially
reflect students critical thinking
abilities
Students with virtual modality
with digital video case had the

highest critical thinking ratios
Critical thinking ratios could
evaluate case modality

Disparate interactions caused
little differences in enhancing

students critical thinking
Web-based tutorials enhance end-
of-module test scores
Structured student debates
promoted critical thinking and

informatics skills
The three types of scores could
predict the medical course grades,

pace of studying and the deepest
level of learning
Workshop attendants scored
higher on the CCTST
Aptitude and previous knowledge

contribute majorly in students
outcomes
Instructors may frame their
questions to enhance learning

outcomes
Case studies did not improve
critical thinking significantly
Results/findings
Evaluation of learning
environment (e.g. PBL)
approach: role-play
Evaluation of assessment tool
approach: critical questioning
workshop
approach: cinemeducation project
approach: web-based tutorial
approach: Structured student
debates
Evaluation of various assessment
tools
approach: virtual modality with
digital video case
Development of assessment
approach: critical thinking ratio
Evaluation of disparate
interactions
Evaluation of case studies
Evaluation of clinical instruction
Evaluation of small group

interaction
Data synthesis
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Plack etal. (2010),

USA(52)
Rehman etal. (2012),
Pakistan (53)
Wee etal. (2011),

Singapore (60)
Mixed, modified questionnaire,

interview
Mixed, content analysis of learning

goals, statistical analysis
Qualitative, open-ended
questionnaire, group discussion
Torok etal. (2009),

USA(58)
Torre etal. (2007),
USA(59)
Quantitative, online forum,

questionnaire, exam scores
Qualitative, electronic discussion
board, essays
Quantitative, Student Assessment of
Learning Gains scores, exam results,
questionnaire
Quantitative, exam results,
questionnaire
Quantitative, WGCTA, clinical test
scores
Quantitative, WGCTA, grade-point
averages
Quantitative, evaluation form
Taradi and Taradi (2004),

Croatia (57)
Saalu etal. (2010),

Nigeria (54)
Scott etal. (1998),
USA(1)
Scott and Markert
(1994), USA (55)
Shafi etal. (2010),
Pakistan (56)
Ortiz etal. (2011),

Puerto Rico (51)
Table 1(continued)
240 medical students, 34 nursing

students, 355 patients
134 third-year medical students
290 third-year clerkship students
220 second-year physiology students
92 first- and second-year medical

students
99 second-year medical students, 20
faculty members
82 first- and third-year medical students
76 third-year medical students
92 physiology students
70 paediatrics clerkship students

students
Sample recruitment
High-fidelity simulator was an
effective tool to strengthen the
learning outcomes
Virtual action learning improved
reflection
The lab skills course supported
students to achieve high scores in
practical examinations
PBL enabled students critical and
reflective thinking
Tests of critical thinking may not
predict clinical evaluation
WGCTA score was moderately
predictive of GPA
Integrated learning was well
received by the participants in
developing countries
Online forum was successful in
developing critical thinking in
physiology
Students main goal was the
acquisition of clinical skills
Concept mapping facilitated
critical thinking and knowledge
integration
Neighbourhood Health Screening
program was beneficial across
various domains
Results/findings
approach: Neighbourhood Health
Screening program
Evaluation of students learning

goals
approach: concept mapping
approach: online forum
approach: PBL
Evaluation of students
performance
Evaluation of students
performance
approach: integrated learning
approach: virtual action learning
approach: lab skills course
approach: high-fidelity simulator
Data synthesis
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(50, 55), and three in 19951999 (1, 31, 45). Twelve articles
were published in 20002004 (21, 24, 27, 29, 33, 4044, 46,
57), and another 12 in 20102012 (26, 30, 32, 34, 48, 49, 51
54, 56, 60). Eleven articles were published in 20052009
(22, 23, 25, 28, 35, 36, 38, 39, 47, 58, 59).
Source of studies
A majority of the studies (n=18) were conducted in the
USA (1, 30, 3234, 3742, 44, 46, 50, 52, 55, 58, 59), 14 in
Asia (2125, 27, 28, 43, 4749, 53, 56, 60), five in Europe (29,
31, 35, 45, 57), and two in Africa (26, 54). In addition to
18 studies from the USA, two studies were carried out in
North America (36, 51).
Samples
As this systematic review focused on undergraduate
medical education, most studies described interventions
amongst students (1, 2126, 28, 4660). The remainder
involved graduates (29), faculty members and tutors (30,
33, 36, 37, 42, 44, 56), doctors (38), and patients (60). One
study used teaching websites as the focus of research (27).
Design of studies
Most articles (n=30) employed only quantitative studies,
such as a Likert scale questionnaire and a comparison
of assessment scores (1, 2131, 33, 34, 37, 39, 40, 42, 43,
45, 46, 4851, 5357). The remaining articles were qualitative studies (n=6) (36, 38, 41, 47, 52, 59) and mixed
methods research (n=5) (32, 35, 44, 58, 60). The research
approaches included essays, discussions, direct observations and interviews.
Integration of findings by themes

A more comprehensive thematisation of the reviewed
studies was conducted. The findings were synthesised
under two main themes: (i) evaluation of current education on critical thinking and (ii) development of new
strategies about critical thinking. One article (25) was
categorised under both themes. Under each theme, the
teaching strategies, assessment tools, uses of multimedia
and stakeholders were analysed (Table 2).
Evaluation of current education on critical thinking

Under this theme, there were 20 articles evaluating various
elements of current medical education. These articles are
related to teaching strategies (n=6) (21, 29, 31, 34, 39, 48),
the accuracy of assessment tools (n=6) (1, 23, 25, 45, 50,
55), the uses of multimedia (n=2) (27, 30), and stakeholders (n=6) (28, 33, 37, 38, 42, 58).
Teaching strategies
Six quantitative studies measured the effectiveness and
students perspectives of the entire curriculum (21) or of
specific teaching strategies, such as problem-based learning (PBL) (29, 31, 48), mind map (34), and case-based
instruction (39). The sample population of the studies
consisted of students, except in the case of one study
(29), in which the participants were graduates. However,
as A
ntepohl et al., who conducted that study, asked the
invited graduates about their opinion of the undergraduate programme, that study was included in this systematic
review (29). A
bdelmoneim evaluated the teaching methods
of a public health care course and found that practical
sessions were more efficient than seminars in improving
Table 2:Distribution of reviewed studies according to the themes.

Theme
Example
No. of studies/references
Evaluation of current education on critical thinking
Teaching strategy
Seminar, problem-based learning, mind map, case study
Assessment tool
Watson-Glaser Critical Thinking Appraisal, admission test
Multimedia
Teaching website, video-based case
Stakeholder
Teacher: bedside teacher, clinical instructor
Student: learning goal
Development of new strategies about critical thinking
Teaching strategy
Active/peer learning: peer critique, structured student debate
Professional learning: lab skill course, integrated learning
Assessment tool
Critical thinking ratio
Multimedia
Virtual modality, web-based tutorial, online forum
20
6 (21, 29, 31, 34, 39, 48)
6 (1, 23, 25, 45, 50, 55)
2 (27, 30)
5 (28, 33, 37, 38, 42)
1 (58)
22
11 (22, 2426, 32, 44, 49, 51, 54, 59, 60)
3 (46, 53, 56)
2 (36, 41)
6 (35, 40, 43, 47, 52, 57)
One article (25) was categorised under both themes.
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critical thinking (21). Regarding specific teaching strategies, PBL was appreciated for its effectiveness in enhancing critical thinking (29, 31, 48), but the effectiveness of
mind map (34) and case-based instruction (39) was not
obvious.
Assessment tools
Six quantitative articles discussed the tools used to assess
students critical thinking. Four examined the correlation
between critical thinking abilities and examination scores
(1, 45, 50, 55). One article measured students preference
towards various assessment strategies (23), and one evaluated the reliability of an assessment tool (25). All of the
studies recruited students as the sample. The most commonly adopted assessment tool was the Watson-Glaser
Critical Thinking Appraisal (WGCTA), which was used
to compare critical thinking abilities with students performance (1, 50, 55). Four articles also referred to exam
scores, including school course exams (50), clerkship
evaluations (1), grade-point averages (55), and admission
exams (45). The other strategies were essays incorporating critical thinking questions (23), the Short Inventory of
Approaches to Learning (SIAL) (25), and Learning-fromText (LFT) tasks (45).
Uses of multimedia
Two quantitative studies focused on the use of multimedia to promote critical thinking. One was about teaching
websites (27) and the other was about video-based cases
(30). Alur etal., evaluated whether the selected websites
met the criteria of enhancing critical thinking (27). Basu
Roy and McMahon invited students and tutors to measure
students performance by using video-based cases in PBL
(30). Both studies indicated that the use of these tools was
unsatisfactory in enhancing critical thinking.
Stakeholders
Six articles related to stakeholders of medical education:
five related to teachers (28, 33, 37, 38, 42) and one related
to students (58). Most were quantitative studies, except
that conducted by Graffam (38), who used a qualitative
approach. With regard to the studies about teachers, two
investigated the performance of PBL tutors (33, 42), two
investigated the performance of clinical instructors and
bedside teachers (28, 38), and one investigated the performance of faculty members in general (37). These articles
focused on the quality and quantity of teacher-student
communication. Three articles stated that the cognitive
level of the teachers and their constructiveness in dealing
with clinical questions affected the students ability to

think critically (28, 37, 38). With regard to the quantity of
communication, while Curet and Mennin (33) mentioned
that the duration of instruction influenced the development of critical thinking among the students. Kim et al.
(42) disagreed with the argument that the number of comments and feedback posted on the web could significantly
promote critical thinking. The only article on the learning goals of students during their clerkship found that
improving critical thinking was a common goal during the
first half year of the clerkship (58).
Development of new strategies on critical thinking
In addition to evaluations of the current state of medical
education, there were studies reporting the development
of new strategies to promote or assess critical thinking.
Twenty-two articles were found under this theme: 14 articles about teaching strategies (22, 2426, 32, 44, 46, 49, 51,
53, 54, 56, 59, 60), two about the creation of assessment
tools (36, 41), and six about the uses of multimedia (35,
40, 43, 47, 52, 57). No studies on developing the sources of
stakeholders were found.
Teaching strategies
Fourteen articles related to the development of new teaching approaches, of which 11 promoted active or peer
learning to adopt critical thinking (22, 2426, 32, 44, 49,
51, 54, 59, 60), and three reported on the use of professional courses or workshops to nurture critical thinking
(46, 53, 56). Most articles were quantitative studies (22,
2426, 46, 49, 51, 53, 54, 56), one was qualitative (59), and
the remaining three adopted mixed approaches (32, 44,
60). Regarding 11 articles about active or peer learning,
seven suggested employing various types of speeches or
discussions in class, such as peer critiques, debates and
case presentations (22, 2426, 32, 44, 54), three promoted
the application of critical thinking in society, such as
service learning or high-fidelity simulations (49, 51, 60),
and one encouraged the use of a concept map (59). With
regard to three articles that reported on the use of professional courses or workshops to nurture critical thinking,
Loy etal., developed critical questioning workshops (46),
Rehman etal., implemented a lab skills course (53), and
Shafi etal., promoted integrated learning (56).
Assessment tools
Two qualitative articles developed new guides for assessing
critical thinking abilities (36, 41). These studies explored the
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respective views of faculty members, deans and students.
Kamin etal., created a new assessment instrument: the critical thinking ratio (41). Elizondo-Montemayor etal., reported
nine major outcomes of medical graduates, in which critical thinking and research was one of the outcomes (36).
Uses of multimedia
Six studies developed new ways of using multimedia in
enhancing critical thinking (35, 40, 43, 47, 52, 57). Three
employed quantitative research (40, 43, 57), two adopted
qualitative research (47, 52), one used a mixed approach
(35). All of the studies recruited students as the sample.
A majority (n=4) explored the application of e-learning,
such as online discussion forums (35, 52, 57) and webbased tutorials (43). The other two articles suggested
using videos to enhance students critical thinking abilities, such as digital video cases (40) and movies (47).
Discussion
This article systematically reviewed 41 primary empirical studies on enhancing or assessing critical thinking
in medical education. It summarised the evaluation and
development of teaching strategies, assessment tools, the
use of multimedia and the performance of stakeholders.
As medical education is intended to train students in critical thinking for their future career needs, understanding
the role that critical thinking plays in medical education
would help to improve the quality of the education provided to future practitioners of Western medicine and
hence have a significant practical impact (6368). The
following section will compare the current state [from
theme (i)] and new development [from theme (ii)] of
teaching strategies, assessment tools, the use of multimedia and stakeholders, in order to show the trends in critical thinking in medical education and provide relevant
suggestions.
Evaluation and development of teaching

strategies to enhance critical thinking
The evaluation and development of teaching strategies
were the major research interests in medical education on
critical thinking, with 20 out of 41 articles falling under
this category. Among 20 articles, 14 reported new strategies and six compared the effectiveness of existing strategies. While more scholars created innovative strategies
to strengthen the ability of students to think critically, the

formats of some strategies were similar to those of others,
such as peer critiques (26) and debates (44). This result
generally showed that the commonly investigated strategies had reached a mature state of development. It also
implied that it would be more difficult to explore new
teaching strategies that use different formats. Therefore,
future research is expected to be conducted on enhancing the quality on these commonly investigated strategies,
such as the integration of various strategies with different
formats [e.g. peer critiques (26) and a critical questioning
workshop (46)] or similar formats [e.g. case presentations
(32) and PBL (54)]. When the quantity of new teaching
strategies is increasing, it is hoped that more studies will
focus on further enhancing the quality of these strategies.
Evaluation and development of assessment

tools to evaluate critical thinking
Eight articles examined how competence in critical thinking can be assessed. In contrast to the articles on teaching
strategies, there were more articles evaluating the existing
tools than on developing new tools. These articles depicted
how critical thinking is interpreted in medical education.
Most did not challenge the previously recognised definitions but simply adopted the well-established assessment
tools, WGCTA for instance, to compare whether course
exams or clinical assessments were relevant indicators
of the critical thinking ability of students (1, 50, 55). More
research, especially qualitative research, exploring the
different contextual interpretations of critical thinking
should therefore be conducted.
In addition, most of these articles focused on the
assessment of learning outcomes instead of the learning
process. The study by Elizondo-Montemayor et al., on
outcome-based education was typical (36). Five studies
emphasised exams, tests, coursework and clerkship evaluation scores (1, 23, 45, 50, 55). Only two were related to
the learning process of students, namely a comparison
of deep and surface learning approaches (25) and group
process issues (41). This research trend has directed the
development of medical education on critical thinking to
outcome-based approaches. Although assessing outcomes
is more convenient than assessing learning processes,
critical thinking is more about the thinking process. While
students may employ different ways of thinking to come
up with correct answers in tests or exams, assessing the
learning processes of students would be a more thorough
way of investigating their frameworks of thinking and
reveal their strengths and weaknesses.
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Evaluation and development of multimedia

to enhance critical thinking
Eight articles addressed the use of multimedia to enhance
critical thinking. Similar to studies of teaching strategies,
more articles (n=6) reported the development of new uses
of multimedia than evaluated existing ones. Although
more articles aimed to explore new uses of multimedia,
most formats on the use of multimedia were similar. Three
articles mentioned online discussions (35, 52, 57) and
three mentioned video-based learning (30, 40, 47). As the
meaning of multimedia is to combine two or more forms of
content, more combinations of media to enhance critical
thinking are welcome. For example, educators may make
use of audio or still images to nurture clinical reasoning
and diagnosis skills, or adopt animation to promote and
interpret health concepts.
Evaluation and development of stakeholders

to enhance critical thinking
Six articles evaluated stakeholders of medical education
(such as bedside teachers, PBL tutors and students) and
no article was about the development of new stakeholders
to enhance critical thinking. While mixed results relating
to the effect of the quantity of the teachers instructions on
the critical thinking abilities of students were found (33,
42), the quality of these instructions was closely related
to the enhancement of critical thinking (28, 37, 38). Therefore, rather than focus solely on improving the critical
thinking abilities of students, those of the teachers also
need to be further sharpened. What teacher development
strategies should be adopted to strengthen the critical
thinking competence of teachers and the ways to nurture
this competence in class needs further exploration. That
there was only one article on the perspectives of students
is also notable (58). More research on their voices on critical thinking should be conducted. Lastly, although it is
hard to imagine how new stakeholders were developed
and no article was found on this subject, new sources of
stakeholders could be explored. For instance, learning
from philosophy teachers may nurture students to think
logically and critically.
Limitations of the review

In this systematic review, only the results of previously
published articles were used. The limitations of this
study hence result from the fact that this study is an
interpretation of other researchers interpretations. It was

hardly to ensure that the studies actually measured the
same construct due to the definitions of critical thinking
might be a slightly different among these included studies
for review. The selected studies had different research
designs and outcome measures, and the majority of the
samples were recruited from a particular context or location; thus, the results that were obtained may not represent the situation prevailing among medical students in
general. The exclusion of articles in languages other than
English may limit the understanding of medical education in certain contexts. This may have an impact on the
conclusions drawn from this study. Finally, most of the
studies included in this systematic review are quantitative in nature, and only a few studies are qualitative in
nature. This may have reduced the comprehensiveness of
the results.
Conclusion
According to the reviewed articles, there is a strong trend
towards developing new teaching strategies and uses for
multimedia. However, the quality and variety of these
approaches have to be improved. The assessments of critical thinking explored the extent of learning outcomes, but
how critical thinking can be assessed during learning processes has not been well addressed. Further research in this
area should focus on teacher development, students voices
and new sources of stakeholders in medical education.
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Int J Adolesc Med Health 2016; aop

A systematic review on critical thinking in medical

No one would deny that the major role of a clinician is to

*Corresponding author: Zenobia C.Y. Chan, School of Nursing,

2Chan: Critical thinking in medical education

Data extraction and synthesis

The research assistant and a doctoral student conducted

A total of 41 studies met the criteria for inclusion. One

de Leng etal. (2009),

etal. (2007), Mexico (36)

DAntoni etal. (2010),

Curet and Mennin (2003),

Mixed, exam scores, self reflection

Quantitative, questionnaire, Medical

Reasoning Test, Mind Map

threads, content analysis of

Birgegrd and Lidquist

Quantitative, critical thinking ratios

Quantitative, evaluation form

Quantitative, Short Inventory of

Approaches to Learning (SIAL) scores

Quantitative, exam scores,

Basu Roy and McMahon

Antepohl etal. (2003),

Abraham etal. (2006),

Quantitative, exam scores,

Abraham etal. (2005),

Research method, data collection

Author (year), country

Table 1:Summary of reviewed studies.

120 faculty members and deans of

8 fifth- and sixth-year medical students

131 first-year medical students

147 first- and second-year medical

Statistical study: 849 students

Crossover study: 28 students and four

446 medical graduates

84 final year medical students

382 fourth-year forensic medicine

223 first-year physiology students

30 first-year physiology refresher

51 sixth-year primary health care

E-learning was successful in

establishing dialogues among

50% of the sites promoted critical

more important in ideal bedside

students critical thinking and

higher than short-term tutors in

Seminars scored the lowest in

enhancing critical thinking

Evaluation of mind mapping

Evaluation of PBL tutors

Evaluation of PBL approach

Evaluation of video-based cases

Evaluation of bedside teachers

Evaluation of SIAL; Development

Evaluation of various assessment

Evaluation of various academic

Chan: Critical thinking in medical education3

Qualitative, QSR NUD*IST

Quantitative, critical thinking ratios

Kamin etal. (2003),