Critical Thinking and Clinical Reasoning in Undergraduate Medical Course: A Mixed-Methods Study in a Medical College in Kolkata, West Bengal, India

Critical thinking is considered as the essential set of skills for medical practice, particularly during emergencies. However, there is lack of conceptual clarity around it and it was not explicitly included in the undergraduate medical curriculum in India. The present study has been planned to assess the critical thinking disposition and clinical reasoning skills among medical undergraduate students in a medical college in West Bengal, India. The perceived definition and attributes of critical thinking in medical education will be explored and the contexts where application of critical thinking skills may be crucial for medical practice will be identified. The content validity index, test-retest agreement; internal consistency and construct validity of the Critical Thinking Disposition Assessment Questionnaire (CTDAQ) will be assessed through step-by-step procedure. CTDAQ and the case-based objective-type questions for the clinical reasoning skills will be applied to around 200 medical undergraduate students. Their perception and experience on critical thinking in medical education will be assessed with structured open-ended questions. In-depth interviews with medical teachers of the second and third phases of undergraduate medical curriculum will be conducted to assess their perception and experiences on critical thinking. The quantitative analysis will be conducted with MS excel and R software using the relevant packages. The qualitative data will be transcribed and translated in English, close to the participants’ verbatim. The thematic analysis will be conducted with inductive coding and memoing. The study will be conducted maintaining ethical standards for epidemiological studies. The present study, one of the first a few studies in India, will help to meet the conceptual gap in understanding the attributes of critical thinking, its association with clinical reasoning and the contexts of preferred application in medical practice.


Introduction
Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. 1Although it is not a new concept in medical education, most of the published literature on critical thinking in the healthcare setting concerns nursing personnel. 1quiring critical thinking skills is crucial for the practice of medicine.Doctors are supposed to make effective decisions in both well-defined and ill-defined emergencies.The inability to make appropriate decisions in ill-defined emergencies may lead to untoward incidents and affect the reputation of the healthcare facility and career of the individual doctor. 2 When encountering an ill-defined emergency, one of the primary reasons for difficulties is the inability to think critically. 3 Healthcare is prone to diagnostic and management errors. 3Knowledge and cognitive processing skills are interrelated and interdependent, which in turn are associated with conceptual understanding and metacognition. 3These skills, commonly referred as clinical reasoning skills, help in problem-solving based on the principles during unfamiliar and novel scenarios. 3Strict adherence to standard operating procedures will help minimize errors in data collection and decision making in well-defined medical problems, but is not an effective strategy to stimulate critical thinking and creativity in undefined, resource-constrained settings. 3,4Around one-third of problems in healthcare settings worldwide result from diagnostic errors. 2 Training in clinical reasoning and critical thinking may provide a solution to this problem, at least in part.Critical thinking is not explicitly included within the ambits of core competency in medical curricula in most cases. 1,2,5Now, the time requires that teaching and learning critical thinking skills should be explicitly considered in the curriculum for medical undergraduates.However, critical thinking and its implications in undergraduate medical education suffer from a lack of conceptual clarity. 6,7There are certain questions that remain unresolved: what is meant by critical thinking to medical educators and students, where in the medical curriculum does it appear, when, and how can it be inculcated, particularly in resource-constrained setting? 6,7he Watson and Glaser Critical Thinking Appraisal and the California Critical Thinking Disposition Instrument are commonly used to assess critical thinking in different settings, primarily in Western culture. 8Several questionnaires were developed to assess critical thinking disposition among medical professionals in Asian cultures. 8,9Two of these are the 19-item Critical Thinking Disposition Assessment (CTDA) questionnaire in English and 27-item Yoon's Critical Thinking Disposition (YCTD) Instrument.As there is transcultural variation in the meanings of different constructs, the questionnaire to be used needs to be validated in the Indian setting. 8,9 this background, the present study is planned in a Medical College in Kolkata, West Bengal, India, with the following objectives: 1. To develop and validate a questionnaire to assess critical thinking disposition among undergraduate medical students 2. To assess the critical thinking disposition among medical undergraduates at different levels of the course 3. To assess the clinical reasoning skills among medical undergraduates at different levels of the course 4. To find out the correlation between critical thinking and clinical reasoning among medical undergraduate students 5. To explore the perceptions and experiences of undergraduate medical students regarding critical thinking in medical education 6.To explore the perceptions and experiences of medical teachers regarding critical thinking in medical practice and education

Study type and design
This will be a descriptive, cross-sectional study using mixed-methods approach.Mixed-methods research allows researchers the opportunity to gain a more meaningful understanding of the problems and answer questions that may have been partially answered had quantitative or qualitative data alone. 10,11e mixed-methods approach will help to triangulate different systematic measures through quantitative and qualitative approaches to provide a comprehensive scenario on critical thinking in medical education. 12Critical thinking disposition and clinical reasoning skills will be quantitatively measured.However, to enhance the critical thinking and clinical reasoning skills among undergraduate medical students, it is imperative to understand the perceptions and experiences about what is meant by critical thinking and what are its essential attributes, as well as where and how training on those skills be placed in the undergraduate medical curriculum.This will be explored using qualitative methods.
The collection of both quantitative and qualitative data will be conducted simultaneously.

Study setting
The study will be conducted at a Medical College at the outskirts of the Kolkata Metropolitan area in the district of North 24 Parganas of West Bengal, India.

Study duration
The total duration of the study will be ten months.First two months will be used for preparatory work including development and validation of tool.Next four months will be used for collection of data from study participants.The last four months will be utilized for data entry, analysis and report writing.

Study population
1.The tool will be validated among undergraduate medical students (for objective-1) 2. The students enrolled in the second and third phases of undergraduate medical course during the data collection period in the referred college (for objectives2-5) 3. The Medical Teachers of the referred college who are imparting teaching during the second and third phases of undergraduate medical course (for objective 6)

Sample size and sampling method
For step-by-step validation of the questionnaire, the required sample size was as per the guidelines on educational research. 13,14e convenience sampling method will be used to approach all students (~125 per year-batch) enrolled in the second and third phases of MBBS at the College of Medicine and Sagore Dutta Hospital, Kolkata.Assuming a 20% non-response rate, the approximate number of respondents will be 200.
Around 20-25 Medical Teachers, depending on data saturation, attached to various departments of the College of Medicine and Sagore Dutta Hospital, Kolkata, imparting teaching and training during the second and third phases of MBBS, will be included for in-depth interviews through purposive stratified sampling.
Tools & techniques 1.A self-administered questionnaire with both closed-and open-ended questions will be administered to the students.
2. Case vignettes with follow-up questions will be applied to the students 3. Interview Guide for Medical Teachers of the second and third phases 6,15 Method of data collection The first section of the questionnaire will contain an informed consent form.The students will respond to the next section only after providing their consent.The second section will consist of anonymous structured questions on the socio-demographic and individual characteristics of the students.
The third section will consist of questions on different domains of Critical Thinking Disposition (CTD) and a few openended questions. 8,9,16The open-ended questions will explore the perceptions and experiences of medical students regarding critical thinking skills in medical education.The validated questionnaire will be used to assess critical thinking among undergraduate medical students in different phases.
The fourth section will contain case vignettes with follow-up questions to assess clinical reasoning skills.With the involvement of subject material experts, a series of case vignettes will be prepared with a case scenario followed by some questions to assess the clinical reasoning skills from five broad clinical specialties (Internal Medicine, Community Medicine, General Surgery, Pediatrics and Gynecology & Obstetrics) of the undergraduate medical curriculum.These case vignettes with follow-up supply type objective questions will be applied to assess the clinical reasoning skills of the students in each selected subject.
Both the authors were trained in qualitative research techniques.After obtaining written informed consent, the first author will conduct in-depth interview with audio recording with medical teachers from the selected medical college in a place and time of mutual convenience, with the help of the interview guide.After collecting socio-demographic and individual information about the teacher, their perceptions and experiences of critical thinking skills in medical practice and education will be explored.They will be requested to identify the context in medical practice where critical thinking skills can play a crucial role. 6,15tcome variables 1. Critical Thinking Disposition: It will be measured using the domain-wise score and the total score.A higher score reflects a higher critical thinking disposition of the students.Students will be categorized based on quartile values: those with scores greater than the third quartile value will be considered to have a high critical thinking disposition, those within the third and first quartiles will be considered to have an average, and those below the first quartile will be considered to have low critical thinking disposition.
2. Clinical Reasoning Skills: It will be assessed using the total score obtained by the individual students from the case-based questions.A higher score reflects higher clinical reasoning skills.Students will be categorized based on quartile values: those with scores more than the third quartile value will be considered to have high clinical reasoning skills, those within the third and first quartiles will be considered to have average, and those below the first quartile will be considered to have low clinical reasoning skills.

Plan for data analysis
The Critical Thinking Disposition Assessment Questionnaire (CTDAQ) will be developed and tested for content validity with the help of experts from the field of Psychiatry, Psychology and Medical Education.Item-wise and total content validity indices will be calculated in MS Excel.It will first be applied to 25 first-year students twice, with a gap of three weeks to check test-retest agreement with weighted kappa statistics.It will then be applied to 150 MBBS students, other than the study population, to check internal consistency with Cronbach's alpha and construct validity through exploratory principal component analysis with varimax rotation. 13,14All analysis will be conducted using different packages (kappaGUI, cronbach and prcomp) of open-source 'R' 4.3.1 software. 17e data gathered through the questionnaire survey will be entered into an MS Excel spreadsheet and tested for consistency.The individual items of the questionnaire will be rated on a five-point Likert scale, ranging from 1 (strong disagreement) to 5 (strong agreement).The scores of all items under a specific domain will be added to obtain the domain-wise score.Domain-wise median (IQR) scores will be calculated for each phase and compared.Case-based questions will be marked according to the protocol designed by subject material experts.All the marks attained collectively in all case vignettes will be added to obtain total marks.The central tendency and dispersion will be expressed as the median and IQR of the marks.
Spearman correlation will be used to examine the relationship between the total scores of the critical thinking disposition assessment questionnaire and the total score from the test of clinical reasoning skills.
In-depth interviews will be transcribed from audio tape and field notes and then translated into English by the first author, close to verbatim within 48 hours of the interview.Participant confirmation will be ensured by Medical Teachers individually.The codes will be generated by two authors separately through inductive reasoning.They will be compared and contrasted, and discrepancies will be sorted out through discussion.Then, the codes will be collated with the help of memoing to generate categories and themes.The audit-trail of the analytic pathways will be maintained.

Sanhita Mukherjee
Rampurhat Government Medical College, Rampurhat, West Bengal, India APPROVED.Critical thinking is an essential cognitive skill for every individual but is a crucial component for healthcare professionals such as doctors.This helps the medical students to analyze the information critically and then apply that to the existing information.Critical thinking skill is considered a cornerstone for teaching and training medical students so as to maintain clinical competence and medical professionalism.This study nicely tries to assess the the critical thinking disposition and clinical reasoning skills among medical undergraduate students.This is an excellent attempt to develop and validate a questionnaire to assess critical thinking skill.I found a flawless method by which they are trying to develop the Critical Thinking Disposition Assessment Questionnaire (CTDAQ).Traditionally, higher education is thought to produce career thinkers equipped with the knowledge and intellectual abilities.However, there is a growing awareness that many students do not have expected professional abilities.Therefore, the higher education system needs development of these thinking abilities in curriculum.Specially in medical field to reach correct diagnosis one should not only depend on knowledge but also on this CRT in order to reduce the pain and harassment of the patient.CRT should be taught and assessed in undergraduate medical students in order to make them competent before they start their clinical practice.This study is a visionary effort toward this direction which is very rare in Indian medical schools.
Although CT is influenced by many educational and sociological parameters, curriculum is the most important parameter every student must deal with during academic studies.If a curriculum is based on CT skills, it directs learners toward disposition to CT.This study shows a crucial step towards inclusion of CRT in undergraduate medical curriculum in India.Perception of students on CRT will also help to understand student's point of view on it.Students of this era of social media and AI are more practical and tech savvy.The patients and their relatives are also open to the information domain.Previously in India ignorance of patient and patient party about medical science made the job of the clinicians easier.Nowadays in order to face well informed patient and to communicate with them CRT is essential.
Hence I approve this study.

Is the rationale for, and objectives of, the study clearly described? Yes
Is the study design appropriate for the research question?Yes Are sufficient details of the methods provided to allow replication by others?Yes

Are the datasets clearly presented in a useable and accessible format? Yes
Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Medical Education
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Ananya Mandal
Nil Ratan Sircar Medical College and Hospital, Kolkata, India I found this study proposal very intriguing.Moving head of rote learning that used to be the cornerstone of medical education critical thinking can allow students to be better prepared for their lives as doctors.This is however not constructively taught to the students.As the authors have mentioned an in depth look at the methodology of such training for medical undergraduates is essential.Their planning involves content validity index, test-retest agreement; internal consistency and construct validity of the Critical Thinking Disposition Assessment Questionnaire (CTDAQ).This will provide a scientifically backed method of development of the module that may help in future teaching.Also their suggestion of using case based scenarios for the student questionnaire seems appropriate for fulfilling their ultimate objective.
Another good part of their methodology is the use of in depth interviews of the medical teachers to assess their perception and experiences on critical thinking.The primary stakeholders of the system being the students and teachers, this seems to be vital.As such the plan for analysis doesn't warrant a comment as it is well thought out and detailed.Overall, the protocol seems to be well planned and thought out.The study has not been conducted yet so data is not available for review.As such study methodology appears to be complete and logical.

Comment: Approved
Is the rationale for, and objectives of, the study clearly described?Yes  I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
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Figure 1 .
Figure 1.Flowchart showing the activity planning for the study.

3 .
The perceptions and experiences of students and teachers on critical thinking skills in medical education and practice under a) Conceptual definition of critical thinking b) The essential attributes of critical thinking c) The importance of critical thinking skills in medical practice d) Contexts in medical practice, where the application of critical thinking skills may be crucial in terms of outcomes

Reviewer Report 15
May 2024 https://doi.org/10.5256/f1000research.160038.r271971© 2024 Mandal A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Is the rationale for, and objectives of, the study clearly described?PartlyIs the study design appropriate for the research question?PartlyAre sufficient details of the methods provided to allow replication by others?PartlyAre the datasets clearly presented in a useable and accessible format?Not applicableCompeting Interests: No competing interests were disclosed.Reviewer Expertise: I am professor of medical education for over 15 years.I have expertise in medical education, research methods, public health, and gastroenterology.I have over 120 published research in top journals and 5 textbooks.

the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests:
No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.King Saud University, Riyadh, Riyadh Province, Saudi Arabia Critical Thinking and Clinical Reasoning in Undergraduate Medical Course: A Mixed-Methods Study in a Medical College in Kolkata, West Bengal, India STUDY PROTOCOL Thank you for inviting me to review the above-titled manuscript.While the topic is intriguing, the manuscript is marred by a lack of focus, unclear research questions, and insufficient details.Who are the participants -include inclusion and exclusion criteria.7)Whichquestionnaire data?Is this a validated questionnaire from the literature, or will the authors create it?8)Statisticaltests to be used is missing.English editing is required for the whole manuscript.INTRODUCTION-1) Definition given is incomplete and not well addressed; please read the literature (first three lines).2) "well-defined and ill-defined emergencies" -Why? and what do you mean? 3) Is this only about an emergency?Emergency has been repeated but not in the title or the abstract.Is critical thinking in medicine limited to Emergencies?4) Define critical thinking, state its scope, and give examples.5)Figure-"In-depthinterviews".Why?Why not focus groups?You must explain and justify the purpose.Need to know where in the course and which subjects, what situations in small group learning students experience critical thinking.METHODS-1) What do you mean by mixed methods -explain what will be qualitative and what will be quantitative, regarding research design, methods used, data collected, data analysis, etc. 2) Add citations and references to methods.3) Study Population -Which tools? 3) What is the sample size and sample power?Explain the basis for your calculations, the equation to be used and give the exact number of sample sizes and sample types.4) Several parts were not clearly written Plamn for data analysis-Should be edited, organised and focused.Avoid contradictions-Earlier, the author mentioned applying for ethical approval, then here they say, "The study has obtained ethical approval."-which one should we believe?References -the authors should read and cite proper literature in Academic Medicine, Medical Education, Medical Teacher, BMC Medical Education, Teaching and Learning in Medicine, Journal of Surgical Education.Ref 16-too old Ref 17-Should be replaced Ref 18-Not a reference-Should be replaced https://doi.org/10.5256/f1000research.160038.r271966©2024 Azer S. ABSTRACT-1) Too many objectives.You must have a focus.2) State your research question.3)What did you use as a research method?What tools did you use? 4) We do not start methods by mentioning validity and reliability issues-We need to know what type of method was used to answer the research question and what tools were used.5)What is "test-retest agreement"?"construct validity"-mentioned twice but never explained how these will be considered.6)