Expanding Critical Thinking in EMS Beyond Clinical Thinking

Paramedics huddled around
Photo/Adam Mason

When thinking about a topic, the first step is to define relevant terms to avoid misconceptions. The definition of critical thinking is “a persistent effort to examine any belief or supposed form of knowledge in the light of the evidence that supports it and the further conclusions to which it tends.”1 The key word in this definition is “any,” revealing a short-sightedness in our perception of critical thinking.

Currently, attempts to improve critical thinking skills largely focus on our ability to think through a patient’s medical concern, a process I have termed clinical thinking. This is a small, but significant nuance, and one I failed to note in my first article. In this article, I hope to expand on what I mean by clinical thinking and why the world of EMS thought is much larger than we believe it is.

What is Clinical Thinking?

Clinical thinking encompasses the cognitive skills paramedics use as they manage a patient. Faced with a chief complaint, the paramedic must complete appropriate assessments, create a differential diagnosis, and develop an appropriate treatment plan. Clinical thinking is present throughout, as the paramedic selects relevant assessments to conduct and compiles the objective and subjective information generated to create a differential diagnosis.

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From there, the paramedic must create an appropriate treatment plan and prioritize the care needed. The process then repeats as necessary based on the effects of treatments or changes in the patient’s condition until transfer of care at the hospital.

Effective clinical thinking, as I argued in my previous article, is dependent on a strong foundation of knowledge and the development and correct application of thinking skills. A paramedic must be able to sort through the list of available therapies to select only those appropriate to the situation. Equally important, the paramedic must withhold potentially detrimental treatments.

As the paramedic’s scope of practice increases, there must be a proportional increase in the level of foundational knowledge and clinical thinking skills. Given that this is the main role of a paramedic, it is not surprising that most articles catering to paramedics focus on developing clinical knowledge or clinical thinking skills.

How Can We Apply Critical Thinking Beyond Clinical Thinking?

Focusing critical thinking on clinical matters neglects other important fields. As Joe Y.F Lau notes, critical thinking “is a domain-general skill.”2 The earlier definition supports this stance. Expanding thinking in EMS beyond the clinical generates questions that practitioners should consider to guide their own personal practice and understanding of paramedicine.

With a more general approach to critical thinking, we can examine the fundamental questions of paramedicine. We can define the role of a paramedic and what part they play in the health care system. By defining and understanding this role more clearly, we can advocate for the expansion of knowledge or practice within this role without stretching paramedics beyond their intended purpose.

An evolving field of thought in the practice of medicine is effective communication. Looking beyond the question of whether the medical care the patient received was appropriate, we can begin to ask whether we were able to effectively communicate our findings and priorities with our partner, other healthcare providers and our patients.

We can also ask whether an objective, clinical approach is necessary for patient care and what role empathy and personal judgment have in our practice. Two examples in this field include Anthony Correia’s exceptional article calling for practitioners to see the patient beyond the medical condition and Justin Porter’s article introducing the concept of patient-centered care.

We can also examine interpersonal dynamics in paramedicine. What is an ideal paramedic practitioner? When must a paramedic be a leader and when do they function better as followers? What form of leader is more appropriate for a particular situation? Is a more authoritarian role necessary or is a collaborative leader more effective? Given that EMS requires life-long learning to keep current with developments, should more experienced members be expected to guide newer practitioners? Should newer members also be expected to update older practitioners with evolving approaches and treatments?

Ethics and morality can also be examined. Paramedics should question their understanding of beliefs with regards to right and wrong. Does a paramedic’s personal ethics have a role to play in their clinical practice? Can they refuse to perform a skill or administer a medication they personally disagree with? If they refuse, should they be obligated to hand over care to another practitioner who is willing to provide said care if the patient requests it? What if the patient is unable to make their own decisions?

How Do We Develop Critical Thinking Beyond Clinical Thinking?

Clinical thinking is easier to develop because paramedics are provided a foundation of knowledge through their schooling and then challenged with various scenarios. Following graduation, articles, podcasts and school materials then enhance or reinforce their clinical knowledge and help to develop their thinking. Developing domain-general critical thinking is more challenging because there may not be any foundational knowledge to guide further thinking. For many paramedic programs, there is insufficient time to focus on other elements such as philosophy, ethics or leadership dynamics.

It thus falls to practitioners to identify questions and begin to look for information to guide them towards an answer. Observing other approaches and reflecting on their strengths and weaknesses may be the first step. Reaching out to a mentor or asking a partner for their ideas may help guide thoughts on the topic in question. Research may be required to expand one’s knowledge on the topic. From there, practice may be needed to determine how best to apply new knowledge or insights.

It is important to note that answers to many of these questions may change to reflect different situations and many of these questions are sufficiently open-ended to allow for multiple solutions. A practitioner’s personal beliefs or background will influence their thoughts; each practitioner must develop their own answers based on their perspective.

Why Should We Expand Clinical Thinking to Critical Thinking?

The philosopher David Hume spoke of custom as the main guide of human life.3 We often behave (or think) in the way we do because we have done so in the past, without reflecting on whether the behavior or thought can be justified by fact or reason. In general, this serves as an effective way to operate, trusting that if it worked in the past, it should be equally effective in future situations.

However, this approach can also imprint stale thoughts or anchor poor practice. For an evolving industry such as paramedicine, complacency of thought or mindset is problematic. We can use critical thinking to, as Dan Ariely says, “inventory the imprints and anchors in our own life. Even if they once were completely reasonable, are they still reasonable? Once the old choices are reconsidered, we can open ourselves to new decisions.”4 Our field is much broader than the clinical problem presented to us when a patient calls 911. Our thinking should be, too.


1. The Critical Thinking Community. Defining Critical Thinking [Internet]. [cited 2021 Mar 3]. Available from: https://www.criticalthinking.org/pages/index-of-articles/defining-critical-thinking/766.

2. Lau, J. An Introduction to Critical Thinking and Creativity: Think More, Think Better. 1st ed. Hoboken: Wiley; 2011. 272 p.

3. Hume, D., Selby-Bigge L.A. An Enquiry Concerning Human Understanding. [Internet] Project Gutenberg. 2011 Feb [cited 2021 Mar 3]. Available from: https://www.gutenberg.org/files/9662/9662-h/9662-h.htm

4. Ariely, D. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: Harper Collins; 2008. 280 p.

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