In my previous article, I looked at the limits to critical thinking in EMS, noting a lack of training and insufficient knowledge as key issues. Proper training and guidance are not enough, however. In order to be an effective critical thinker, positive traits need to be identified and developed. These traits can also be applied to personal and professional practice as much as to critical thinking. For this article, I used the Foundation for Critical Thinking’s “Valuable Intellectual Traits,” as a guide, expanding and adapting the traits listed for EMS providers and professional practice.1
Humility is the foundational trait, grounding the practitioner’s understanding of the capabilities and limits of their knowledge and skills. Intellectually, it reminds us that we do not know everything. Others may have an answer to a question or the solution to the situation, and they may be far younger or have less overall experience than we do.
On a personal level, we should also acknowledge that we are imperfect and can make mistakes.2 This is especially true as EMS is largely an acute care setting as opposed to a routine task environment, responding to a new environment and a different situation every time. Adding irregular working schedules further compounds the risk of error. Cognitive errors can also be quite serious. Though data in the prehospital environment is limited, poor clinical judgment appears to be the more common source of error. Paramedics are more likely to misdiagnose or fail to recognize a life-threatening condition than to perform a skill incorrectly.3
Professionally, we must realize that, however specialized our role within the medical field, we are quite limited by our education and training. Compared to other medical professions, paramedic programs are brief, with the expectation that “real” learning will continue in the field following graduation. The biggest drawback of this rapid education is a lack of understanding of the true complexity of health care, the vast number of illnesses and injuries that exist, and respective treatment options. Significant gaps may also be present in a practitioner’s knowledge if certain patients are not regularly experienced in practice.
Humility remains a beneficial trait when we assume our role within the medical system. Paramedics specialize in the initial care and transportation of patients from a scene or hospital to a center for assessment or definitive care. We operate under very irregular circumstances with limited diagnostic tools, ad-hoc teams based on available resources, and may find ourselves with limited support for extended periods of time. Other healthcare professions have their own specialized clinical knowledge, different resources and diagnostic tools, treatment protocols and focus on long-term or definitive care. It is important to keep these different backgrounds and priorities in mind when interacting with other healthcare professionals. There is a role for paramedics to play in patient care and advocacy, but we must be careful not to overstep the limits of our experiences and knowledge in doing so. With humility, we can separate our ego from the equation and focus on the patient’s well-being.
Intellectual courage is the willingness to challenge any idea, especially those which are strongly supported or rejected. No idea or theory should be beyond questioning and should be challenged to ensure it stands up to scrutiny. Even foundational ideas such as the need for rapid response and rapid transport to the hospital must be challenged to determine their validity and merit. Having the courage to challenge deep-seated ideas ensures that only those determined to be constructive, effective and viable remain in the paramedic mindset. The courage to challenge long-held ideas such as the role of oxygen therapy is already leading to significant changes in protocols following evidence showing increased harm.4
In regular practice, paramedics must also be willing to assess whether their treatments are beneficial, unnecessary or possibly harmful. Practitioners should also have the courage to ask a question of their partner or other healthcare practitioners, to confirm the treatment plan to be followed or to better understand an idea. This courage could ensure that a treatment is not missed during more complex patient care or ensure that a procedure is withheld to protect the patient from the risk of needless complications.
Empathy is the ability to understand another’s thoughts, perspective, or situation by seeing things from their point of view. It is a vital element of critical thinking, allowing the thinker to take in other viewpoints and understand other perspectives. This is an important part of intellectual discourse, whether seeking to better understand another’s idea or trying to persuade them of the value of your own. If the latter, we must also remember that there were times in the past that we held beliefs that turned out to be incorrect, but stubbornly held on to those beliefs because they were more familiar or comfortable. The process of changing one’s mind can take time and requires patience and empathy.
Practically, we should extend this empathy to our patients, fellow practitioners and other healthcare professionals. It is important to see each patient’s situation as unique and worthy of an individual approach. However normalized emergency response may be for a paramedic, these situations are often exceptional and distressing for those directly affected by the emergency.
Fellow practitioners and other healthcare professionals are often judged harshly for making treatment decisions, often without an understanding of their background or the specific situation the practitioner faced. It is very easy to judge a situation when far removed from it, especially when possessing more knowledge or experience. Judgments are especially unfair when the final outcome is known. Empathizing with our fellow practitioners (and applying some humility) allows us to more accurately assess how we might have handled such a situation at a similar time in our career. This is especially crucial when interacting with junior practitioners, who have not had the chance to develop experience or expertise. Empathizing with colleagues allows us to be more supportive, congratulating them on successes and supporting them through challenges faced.
Autonomy entails the ability to freely ask questions, challenge beliefs, and adjust perceptions when met with new perspectives or evidence. Each member of the profession must be able to explore their thoughts and beliefs to better understand them and come to new knowledge or understanding.
In order to do so, the environment must be open to non-judgmental discussion. Questions must be asked respectfully and with the intent to learn, rather than to judge the individual’s actions or choices. In return, the answer should be similarly academic, seeking to expand the questioner’s understanding rather than judging them or the reason behind the question. The questioner can then freely change their mind or refute the information based on its merits.
Integrity in critical thinking requires that we test our current views with the same standards used on new or competing views. It is very easy to fall into the bias of personal experience and dismiss new ideas. Similarly, one can jump to new evidence too quickly without having properly tested it against current thinking.
Paramedics who have used a skill or treatment for an extended period may defend it despite evidence to the contrary or the introduction of a new, more effective treatment. Integrity is necessary to assess the effectiveness of each treatment, especially in the face of research to the contrary.
Critical thinking is not a skill acquired overnight. One must exercise it repeatedly, persevere through difficult situations and questions to arrive at solutions, and accept when the conclusion is a different answer than originally expected.
Similarly, paramedicine is a series of skills that requires persistence and perseverance. Time and patience are necessary to develop the necessary background understanding and hone the necessary practical and cognitive skills. Humility is an important trait for both the experienced and the newer practitioners, and empathy is beneficial for the experienced practitioner to recall how much time it takes to become proficient in skills.
Intellectual fairmindedness comes from considering each viewpoint and idea fairly. It does not mean that each viewpoint and opinion has equal merit, but all are worthy of consideration. It is important as practitioners to keep an open mind when it comes to ideas we experience in our profession. There are many different solutions to the situations we face, and we are not able to find the best one without fairly considering each idea. Applying some integrity, we can test each idea equally and determine its merits and shortcomings.
Optimism (Confidence in Reason)
The final trait, confidence in reason, was specific to critical thinking. Expanded to personal and professional practice, however, I think optimism is more apt. Intellectually, it is the idea that, through reason, others will come to similar conclusions or we will change our own minds when faced with a better idea or stronger evidence. With the right guidance, practitioners will develop their knowledge and approaches to situations to the betterment of their personal practice and patient care.
Practically and professionally, optimism allows us an approach or worldview where things will continue to improve. Daily frustrations can be mitigated by remembering that EMS is among the newest entities in medical care and a lot of the challenges currently faced are growing pains. As the role of EMS continues to develop and solidify, those growing pains will resolve as paramedics raise awareness of issues, add beneficial treatments and remove ineffective ones.
In addition to confidence, we must have an optimistic view of our fellow practitioners, trusting that our colleagues are also working to improve their personal and professional skills. We should be willing to share our insights with them and open our minds to the insights they have.
- The Critical Thinking Community. Valuable Intellectual Traits [Internet]. [cited 2020 Aug 30]. Available from: https://community.criticalthinking.org/libraryForEveryone.php.
- JEMS. Prevent Medical Errors in the Field with Cognitive Strategies. [Internet]. JEMS.com; December 2014 [cited 2020 Aug 30]. Available from: https://www.jems.com/2014/12/04/prevent-medical-errors-field-cognitive-s/.
- St. Pierre M, Hofinger G, Simon R. Crisis Management In Acute Care Settings. 3rd ed. Switzerland: Springer; 2016.13p.
- EMSAirway. We Love Oxygen. [Internet]. EMSAIrway.com; December 2019 [cited 2020 Aug 30]. Available from: https://www.emsairway.com/2019/12/27/we-love-oxygen/.