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Abstract
Objectives This study aimed to investigate the associations between critical thinking (CT) disposition and personal characteristics and tutors’ guidance among medical graduate students, which may provide a theoretical basis for cultivating CT.
Design A cross-sectional study was conducted.
Setting This study was conducted in Sichuan and Chongqing from November to December 2021.
Participants A total of 1488 graduate students from clinical medical schools were included in this study.
Data analysis The distribution of the study participants’ underlying characteristics and CT was described and tested. The Spearman rank correlation coefficient was used to evaluate the correlation between each factor and the CT score. The independent risk factors for CT were assessed using a logistic regression model.
Results The average total CT score was 81.79±11.42 points, and the proportion of CT (score ≥72 points) was 78.9% (1174/1488). Female sex (OR 1.405, 95% CI 1.042 to 1.895), curiosity (OR 1.847, 95% CI 1.459 to 2.338), completion of scientific research design with reference (OR 1.779, 95% CI 1.460 to 2.167), asking ‘why’ (OR 1.942, 95% CI 1.508 to 2.501) and team members’ logical thinking ability (OR 1.373, 95% CI 1.122 to 1.681) were positively associated with CT while exhaustion and burn-out (OR 0.721, 95% CI 0.526 to 0.989), inattention (OR 0.572, 95% CI 0.431 to 0.759), Following others’ opinions in decision-making (OR 0.425, 95% CI 0.337 to 0.534) and no allow of doubt to tutors (OR 0.674, 95% CI 0.561 to 0.809) had negative associations with the formation of CT disposition in the fully adjusted model.
Conclusions Factors associated with motivation and internal drive are more important in the educational practice of cultivating CT. Educators should change the reward mechanism from result-oriented to motivation-maintaining to cultivate students’ CT awareness.
- risk factors
- schools
- public health
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
Our study focused on postgraduate medical students, and the sample size was relatively large.
Previous research on critical thinking has focused primarily on Europe, the USA and Japan. Hence, researching critical thinking in Chinese populations is a valuable addition to this area.
Given the traditional limitations of cross-sectional studies, the findings of this study cannot be used as direct evidence of a causal relationship between potential influences and outcomes. Nevertheless, they can provide clues to reveal causal relationships.
Introduction
Critical thinking (CT) is reasoned, reflective thinking that decides what to believe or do. The emphasis is on reasonableness, reflection and decision-making.1 CT is even more important in the medical field, where a lack of CT can lead to delayed or missed diagnoses, incorrect cognition and mismanagement. The centrality of CT is reflected in the competency framework of health professions and is a core skill of healthcare professionals.2–6 Six crucial skills have been proposed to operationalise the definition of CT: interpretation, analysis, evaluation, inference, explanation and self-regulation. Specifically, interpretation involves comprehending the significance of information and conveying it effectively to others. Analysis requires piecing together fragmented data to decipher their intended purpose. Inference entails identifying and leveraging relevant information to formulate logical conclusions or hypotheses. Evaluation necessitates assessing the trustworthiness of a statement or information. Explanation aims to clarify shared information to ensure its comprehensibility to others. Finally, self-regulation pertains to regulating one’s thoughts, behaviours and emotions.7–9
The role of CT in assisting medical students in navigating complex health scenarios and resolving clinical issues through sound decision-making is paramount. Extensive research has established positive correlations between CT and clinical proficiency,10 11 academic excellence12 and research capabilities.13 Consequently, the Institute for International Medical Education has emphasised ‘CT and research’ as one of the seven crucial competencies that medical graduates must possess, as outlined in the Global Minimum Essential Requirements.14 Similarly, the Ministry of Education in the People’s Republic of China has underscored the importance of ‘scientific attitude, innovation and CT’ as essential requirements for Chinese medical graduates.15
Research on CT in medical students has been carried out to varying degrees in Western countries and many Asian countries.16 17 Some scholars have pointed out that Western methods, including CT and clinical reasoning, are used in thinking skills education worldwide. However, there are significant differences between Chinese and Western culture, especially educational culture while cultural differences affect ways of thinking17 18; therefore, previous research may not be able to reflect the actual situation of Chinese students and teaching methods may not apply to them. Most Western students tend to possess assimilating learning styles, enabling them to excel in student-centred learning environments. Conversely, Eastern students often exhibit accommodating learning styles that align more with teacher-centred instruction.19 The discipline-based curriculum in China may not adequately foster the development of CT dispositions among Chinese medical students. This curriculum typically comprises isolated phases (theory, clerkship and internship), limited faculty–student interaction and a knowledge-focused evaluation system.20
Previous research has suggested that a range of personal characteristics, including gender, major, blended learning methods, increased self-study hours, heightened self-efficacy in learning and performance, exposure to supportive environments and active participation in research activities, contribute to varying degrees of CT dispositions and skills.21–24 A study conducted in Vietnam revealed that age, gender, ethnicity, educational level, health status, nursing experience, tenure at the current hospital, familiarity with ‘CT’ and job position all influence CT ability.25 Furthermore, teacher support is paramount to learners’ mental and psychological development. This support encompasses educators’ empathy, compassion, commitment, reliability and warmth towards their students.26 According to Tardy’s social support paradigm,27 teacher support is defined as providing informational, instrumental, emotional or appraisal assistance to students, irrespective of their learning setting. Supportive teachers prioritise fostering personal relationships with their students and offering aid, assistance and guidance to those in need.28 Practical teacher assistance can make students feel comfortable and inspired, motivating them to invest more effort in their studies, engage more actively in educational pursuits and achieve superior educational outcomes.29
Current CT research on mainland Chinese medical students focuses on the impact of undergraduates’ experiences and classroom instruction. However, for postgraduates, their tutors play a more critical role in education and cultivation. According to Wosinski’s study,30 tutors should be trained to effectively guide the teamwork of undergraduate nursing students during the problem-based learning (PBL) process to achieve their goals. There is no analysis of the influencing factors of CT focused on medical postgraduates.
Therefore, assessing the tutor’s effect on postgraduates’ CT disposition. This study investigated the associations between CT disposition and personal characteristics and tutors’ guidance among medical graduate students, which may provide a theoretical basis for cultivating CT.
Methods
Study design and participants
Study design
This was a cross-sectional observational study. The project team sent 1525 electronic questionnaire links to WeChat groups of full-time medical graduate students in higher medical institutions in Sichuan and Chongqing between November and December 2021. After removing incomplete and duplicate questionnaires, a total of 1488 valid questionnaires were returned for an effective rate of 97.57%.
Sampling procedure
We employed a random sampling method to select medical graduate students carefully and used PASS V.15.0 software to calculate the sample size for different analyses and outcome scenarios. In the estimation of the sample size with the proportion of CT disposition as the primary outcome, we considered p=0.5, adopted the two-sided Z value under the significance level of a=0.05, and the sample size was the largest when the sampling error was 3%, which was 1067. Moreover, estimating of sample size with the correlation coefficient as the primary outcome, we considered r=0.1 according to the results from the prestudy, and the test power was 0.9; thus, we obtained n=1048. The sample size should be at least 1334 considering a 20% non-response rate.
The inclusion criteria were as follows: (1) full-time medical graduate students (clinical medicine, medicine technology, integrative Chinese and Western medicine, medical laboratory, nursing and so on) in higher medical institutions in Sichuan and Chongqing and (2) after reading the introduction to the research, participants voluntarily agreed to participate and electronically signed the study’s informed consent form. The exclusion criterion was a refusal to participate in the study.
Procedure and data collection
The electronic questionnaire we used consisted of a condensed version of the Critical Thinking Measurement Scale, which was used to evaluate participants’ scores on CT disposition and a Potential Influencing Factors Questionnaire, which investigated participants’ underlying information, personal factors and education-related factors. To increase the response rate, we told the students how long it might take to fill out this questionnaire when we sent the questionnaire link to WeChat groups. Moreover, our participants all had master’s degrees or above whose understanding ability and compliance were better. We also sent reminders to all invited participants three times, and the survey lasted approximately 1 month.
Critical Thinking Measurement Scale
We used the Chinese version of the short-form critical thinking disposition inventory (SF-CTDI-CV), which is based on the CTDI-CV reported by Huang.31 The CTDI-CV includes seven subscales, namely Truth Seeking, Open-mindedness, Analyticity, Systematicity, Critical Thinking Self-confidence, Inquisitiveness and Cognitive Maturity, which have good reliability and validity (0.90 for the overall Cronbach’s alpha and 0.89 for the overall Content Validity Index).32 Huang removed ineffective questions based on the CTDI-CV and obtained a simplified scale with 18 items of three factors, which increased the proportion of total explained variation and had better reliability and validity than the original version. Huang selected items according to important indicators in factor analysis, including factor loading and communality. Specifically, Huang removed items whose factor loading was less than 0.4 or whose commonality was less than 0.3. Each item of the SF-CTDI-CV has six options (Likert scale) from 1 to 6 (1 means complete agreement and 6 means disagree entirely); the higher the score is, the stronger the CT tendency.31 The Kaiser-Meyer-Olkin (KMO) value for SF-CTDI-CV is 0.90 while the p value of Bartlett’s test is less than 0.05, indicating that this short-form inventory has ideal structural validity. A total score of 72 or more indicates a CT disposition, and all participants were divided into two groups according to whether they possessed essential characteristics of thinking.
Potential Influencing Factors Questionnaire
The Potential Influencing Factors Questionnaire was based on previous research and interviews. The interviewees including senior education practitioners and invited medical postgraduate students, focused on their experiences and feelings regarding medical education in China. We compiled an interview outline and invited a total of 22 professionals, including 9 doctoral candidates, 5 doctoral supervisors, 2 counsellors and 6 young backbone teachers, to participate in the interviews. The interview schedule is flexible, but to ensure efficiency, we controlled the interview duration for each participant to within 40 min. After the interviews, we used professional NVivo V.11.0 software to analyse the collected interview data thoroughly.
The Potential Influencing Factors Questionnaire consists of 10 questions in the essential information section, 35 questions in the influencing factors section and 3 flexible questions, for 48 valid entries. The essential information section includes gender, age, secondary education background, higher education major, level of education, type of degree, full-time work experience, type of household registration, the highest level of parental education and whether the respondent was from an only child family. The influencing factors section can be grouped into two main areas: ‘personal factors’ and ‘educational factors’, with personal factors including the individual characteristics section. The educational factors include the practice and training, tutor and team, and educational environment section. This study defines every potential factor as an ordinal variable, with greater rank, depth and frequency of the corresponding factors. For reliability, Cronbach’s alpha=0.795 indicates that the questionnaire’s reliability is good enough for investigation. The content validity of the questionnaire was tested to determine whether the content met the objectives and requirements of the study. Most of the items of the influencing factors questionnaire were selected from previous literature, and the content validity was good. The KMO values and p values for the Bartlett’s test of sphericity for every aspect indicate that the structural validity of the questionnaire is good (see more details in online supplemental table S1).
Supplemental material
In the questionnaire design process, we first formed a preliminary framework concerning previous qualitative and quantitative research. Then we conducted interviews with educators, doctoral supervisors and representatives of medical postgraduate students according to the initial framework to understand their work experience in the practice of medical postgraduate education in China. Then, the questionnaire was supplemented according to the frequently mentioned items in the interviews. Finally, a questionnaire focusing on whether personal and educational pathways influence the formation of CT disposition was developed, as well as the key points of CT cultivation.
Data collection and organisation
The project team designed the electronic questionnaire based on the Influencing Factors Questionnaire and Critical Thinking Measurement Scale. Excel 2019 collated the raw data exported from the electronic questionnaire platform. Using the electronic questionnaire platform, answer completion settings rule out the possibility of logical anomalies. Samples with missing answers on the Critical Thinking Inventory were eliminated. Participants who were missing other information were asked to fill in as much as possible through the telephone number they had left. Those who were unable to do so were eliminated. Each factor in the influencing factors section was assigned a value in steps of 1 from lowest to highest (eg, the four categorical variables were assigned values of 1, 2, 3, and 4; 1 for never and 4 for always).
Students and public involvement
Former students were involved in the preparatory phase of this study. They reviewed the informed consent form and provided feedback.
Statistical analysis
The data were analysed by using SPSS V.24.0 software. The distribution of the study participants’ underlying characteristics and CT were described and tested. Continuous variables are described as the mean±SD, and t-tests or one-way analysis of variance (ANOVA) were used for hypothesis tests. Categorical variables are expressed as composition ratios and χ2 tests are used for hypothesis tests. Correlation analysis: The Spearman rank correlation coefficient was used to evaluate the correlation between each factor and the CT score. Difference analysis: Trend ANOVA was used to test whether there was a trend change in CT scores at different levels of each potential influencing factor. A t-test was used to compare the differences in the levels of influencing factors between different CT trait groups. Factors with differences between groups were included in a multivariate unconditional logistic regression model. We fitted several multivariate logistic regression models to evaluate potential confounding variables. By comparing the χ2 value, the −2-likelihood ratio, the Akaike information criterion, and the practical meanings of this study’s interesting factors, the final model in which X variables could explain most of the Y variables (CT scores) was chosen. The above tests were performed at 0.05, and a p<0.05 was considered statistically significant.
Results
Essential characteristics
A total of 1488 medical graduate students were included in this study, with an average age of 26.63±3.72 years. Most of the participants had a science background in high school (96.84%), a higher education major in clinical medicine (78.43%) and had never participated in full-time work (71.91%). Most of the participants were female (65.93%), lived in urban areas (61.69%), had parents with junior school education or below (39.18%), were not the only child in the family (51.48%), scientific graduate students (51.61%) and had a master’s degree (55.51%). Among all the research subjects, the average total CT score was 81.79±11.42 points, and the proportion of CT (score ≥72 points) was 78.9% (1174/1488). The essential characteristics of the included subjects are shown in table 1.
Participants’ essential characteristics and the distribution of critical thinking dispositions
Distribution of CT disposition
Table 1 demonstrates the distribution of CT disposition among the study participants. For the essential CT scores, participants with urban residence, higher parental education, only-child families, a science background before admission, science-based graduates, longer full-time employment and higher education levels had significantly greater CT scores (p<0.05). According to the CT questionnaire used in this project, subjects with a score more excellent than 72 points were considered to have an apparent CT disposition. The results showed that among our participants, women (80.80% vs 75.10%), science students (79.50% vs 61.70%) and PhD students (81.60% vs 76.80%) had a more significant proportion of CT disposition (p<0.05).
CT scores are linearly correlated with impact factor scores
Table 2 shows the correlation between each factor and the CT scores. The Spearman correlation coefficients suggested that most terms related to personal factors were correlated with CT scores (p<0.001). Sense of achievement (r=0.324), curiosity (r=0.480) and following others’ opinions in decision-making (r=−0.292) were strongly correlated with CT scores. Regarding educational factors, all factors in the practice and training section, all factors in the tutor and team section, and most factors in the educational environment impacted CT scores (p<0.001). Factors in the tutor and team section were more strongly related to CT scores, such as teaching students according to their aptitude (r=0.247) and tutors asking heuristic questions (r=0.242). Only no allow of doubt to tutors hurt the CT scores (r=−0.179, p<0.001).
The correlation between the potential influencing factors and the score of critical thinking
Factors influencing CT disposition
Univariate analysis
The influencing factors associated with CT disposition are presented in table 3. Univariate analysis revealed that in terms of personal factors, a sense of achievement, curiosity and interpersonal skills were all possible facilitators of CT disposition (p<0.05), and the group with CT disposition had higher average scores. In contrast, fatigue and burn-out, inattention and following others’ opinions in decision-making were possible hindering factors. Regarding educational factors, most factors in the ‘practice and training’ section, all factors in the ‘tutor and team’ section, and some factors in the ‘educational environment’ section were impact factors on CT disposition. In the practice and traning section, academic performance (p<0.001), number of intensively reading (p<0.001), paper writing (p=0.001), participation in academic conferences (p=0.009), completion of scientific research design with reference (p<0.001), time for extracurricular reading (p=0.006), summarisation and reflection (p<0.001), asking ‘why’ (p<0.001) and knowledge of critical thinking (p<0.001) were all positively related to CT disposition. For the tutor and team section, participants with CT disposition had higher scores for the following factors (p<0.01): tutors sharing thinking methods, communicating learning and life with tutors, tutors asking heuristic questions, encouragement of using ‘possible’ and ‘potential’, advocation of logical thinking training and lifelong learning, teaching students according to their aptitude and team members’ logical thinking skills. No allow to doubt tutors hurt CT disposition (p<0.001). The use of multifunctional classrooms (p<0.001) and having active classes (TBL class, flipped class, p=0.006) in the educational environment section were also correlated with CT disposition.
Impact factors
Multivariate logistics regression analyses
Multivariate logistics regression analysis demonstrated that female (OR 1.405, 95% CI 1.042 to 1.895), curiosity (OR 1.847, 95% CI 1.459 to 2.338), completion of scientific research design with reference (OR 1.779, 95% CI 1.460 to 2.167), asking ‘why’ (OR 1.942, 95% CI 1.508 to 2.501) and team members’ logical thinking ability (OR 1.373, 95% CI 1.122 to 1.681) were the promoting factors for the development of CT disposition after adjusting for other confounding factors. However, exhaustion and burn-out (OR 0.721, 95% CI 0.526 to 0.989), inattention (OR 0.572, 95% CI 0.431 to 0.759) and following others’ opinions in decision-making (OR 0.425, 95% CI 0.337 to 0.534) and no allow of doubt to tutors (OR 0.674, 95% CI 0.561 to 0.809) may be hindering factors for the formation of CT disposition in the fully adjusted model (table 4, adjusted R2=0.323).
Multifactor regression model
Discussion
This cross-sectional study explored the factors influencing the CT disposition of Chinese medical graduate students in terms of both personal and educational factors. A total of 78.9% of the participants in this study had positive CT dispositions (score ≥72, 1174/1488), and women were 40.5% more likely than men to have CT dispositions (OR 1.405, 95% CI 1.042 to 1.895). Multivariate logistics regression analysis revealed that among personal factors, curiosity was the promoting factor while exhaustion and burn-out, inattention and following others’ opinions in decision-making may be the hindering factors. For educational factors, completing the scientific research design with reference, asking ‘why’ and the high logical thinking ability of team members were associated with CT disposition. However, no allow of doubt to tutors may hinder the disposition of CT.
According to our demographic information, our study revealed a greater prevalence of CT disposition among women, aligning with Zhai’s findings.22 Several factors may contribute to this observed gender disparity. A systematic review established that men tend to engage more with objects while women prefer interpersonal interactions.33 Women are more inclined to engage in dialogue and foster their understanding through collaborative learning, often exhibiting a more receptive mindset. Second, a study using fractional anisotropy measures derived from diffusion tensor imaging in 425 participants, including 118 males, revealed that divergent thinking in females correlates positively with fractional anisotropy in the corpus callosum and the right superior longitudinal fasciculus.34 Conversely, it correlates with fractional anisotropy in the right tapetum in males. Zhang et al’s34 research sheds light on the sex-specific structural connectivity within and between hemispheres that underpins divergent thinking. These gender differences in creativity may reflect the inherent diversity between males and females in society. However, Faramarzi and Khafri35 reported contrasting results. They concluded that although the results differed between the sexes, the likely cause was females’ higher education level rather than a difference due to gender. Several studies concur that self-esteem is a principal determinant of CT.22 35 Barkhordary et al,36 in their study of 170 third-year and fourth-year nursing students in Yazd, identified a significant link between CT and self-esteem. Pilevarzadeh et al further demonstrated that students with higher self-esteem exhibit more robust CT skills.37 Self-esteem is defined as ‘an individual’s overall subjective emotional assessment of their worth’.38 Bleidorn et al39 conducted a groundbreaking large-scale, cross-cultural study with an internet sample of 985 937 participants, examining gender and age differences in self-esteem across 48 nations. They discovered significant gender differences, with males consistently reporting higher self-esteem levels than females, which may influence their responses to negative feedback to some degree.
In the section on personal factors, the results of this study on personal internal and external environmental factors such as curiosity, burn-out and inattention are consistent with previous studies.40–45 The relationship between these internal and external environmental factors and cognitive capacity has been described in cognitive load theory,46 particularly the role of ‘working memory’, the capacity to process information. Specifically, researchers47 reported on a consensus on CT teaching, assessment and faculty development compiled by a high-level team recommended by 32 medical schools across the USA. Learners’ personal attributes, characteristics, perspectives and behaviours are critical components of their motivation to prepare for and engage in deeper learning and laborious clinical reasoning. Distractions and interruptions, on the other hand, can reduce attention to important issues, affecting learners’ ability to engage in clinical reasoning and their CT skills.48 Making decisions based on the opinions of others in this study may reflect the participants’ interdependent view of self, which was identified by Futami et al49 as a negative factor for CT dispositions.
Regarding the educational factors, learning methods and research group membership characteristics were more strongly associated with CT disposition than learning frequency and learning form. Completing the scientific research design with reference and asking ‘why’ are learning methods that promote the formation of CT for medical graduate students. Research50 suggests that CT requires a persistent effort to test any belief or supposed form of knowledge according to the evidence supporting it and the further conclusions it tends to help. Completing scientific research design with reference is the specific manifestation of evidence-based reasoning in the scientific research field, which may be why it affects the formation process of CT. Furthermore, similar to our research, much research has explored the crucial role that questioning or problem-based thinking plays in CT.47 51–53 Our research also suggested that the teaching style of the group supervisor and the logical thinking ability of other group members also impacted CT dispositions. Although no previous research has explored the role-specific behaviours of subject mentors and peers in CT disposition from a quantitative perspective, Futami et al49 reported higher CT scores for subjects who had connections with research experts, suggesting a positive influence of research mentors on CT. Self-esteem positively affects CT, and overbearing instructors may undermine students’ self-esteem and, thus, their CT disposition. Moreover, several authors47 53 54 have argued that professors’ encouragement of students to express uncertainty, to question and assess the quality of knowledge learnt, and to improve team members’ logical thinking skills are all positively associated with CT, consistent with our findings.
The CT scores in our study were lower than those in several Western countries among medical students,55 56 possibly because of differences in educational culture and methods. In China, medical education comprises three stages: primary medical education, clinical education and internships. Primary medical education introduces students to the medical world. The delivery of traditional courses used to be prescribed and even dull simply because teachers were accustomed to a conventional teaching style and were afraid of making changes to course delivery.57 The strategies to develop reflective and CT in nursing students in eight countries indicated that reflexive CT was found in most curricula, although with diverse denominations. The principal learning strategies used were PBL, group dynamics, reflective reading, clinical practice and simulation laboratories. The evaluation methods are the knowledge test, case analysis and practical exam.58
The importance of early clinical exposure is universally acknowledged, particularly in developing countries where its value is profoundly esteemed. For instance, the South African Health Professions Council has spearheaded educational reforms for medical professionals, enabling first-year medical students to participate in healthcare visits. These visits aim to enrich the comprehension of future professional environments and foster a more profound passion for medicine.59 Notably, most students perceived these visits as invaluable learning experiences, leaving them better prepared for medical practice. Similarly, Chinese medical colleges offer comparable programmes spanning 1–2 weeks. A Peking University study using questionnaires and reports revealed that all students benefited from these activities, gaining perceptual knowledge of clinical work. Remarkably, 61.5% of students reported that their early clinical exposure had significantly assisted them.60
Interestingly, there was a more significant proportion of PhD students with a CT disposition in our study. This may be because doctoral research is more in-depth and complex, requiring students to engage in more detailed, rigorous and innovative thinking based on their existing knowledge. During the research process, doctoral students must constantly question, analyse, evaluate and reconstruct knowledge, which undoubtedly exercises and enhances their CT abilities.61 However, this does not imply that master’s students possess lower CT skills than doctoral students. The master’s programme also emphasises cultivating CT, although possibly differing in depth and breadth. Both stages have unique development paths and manifestations in terms of CT. Regardless of the stage, graduate students should focus on developing their CT skills to address challenges in academic research and life.
Our research revealed that factors influencing CT motivation appear to be more closely linked to CT tendencies in personal and educational components. Miele and Wigfield50 suggested that the factors affecting students’ critical analytical thinking motivation can be divided into two aspects: quantity and quality, the quantitative relationship between motivation and CT, that is, whether students have sufficient motivation to make high-level spiritual efforts. This is reflected in our study regarding curiosity, burn-out, distraction, an interdependent self-view and influence by research team members. The qualitative relationship is the willingness of students to engage in CT, which corresponds to the desire to ask ‘why’ and to refer to existing evidence to complete a research design in this study. This suggests that internal motivation may play an essential role in CT and that educators should focus more on maintaining students’ motivation and building awareness than on the frequency of rigid external research training and curriculum formats. Students are actively promoted and encouraged to apply CT in practice. At the same time, the existing overly outcome-oriented reward mechanism is changed, and assessment criteria are enriched, for example, by including ‘whether you ask interesting questions’ as one of the criteria for classroom assessment to motivate people to become more proactive learners. Recently, medical education has garnered considerable attention and traditionally assumes that medical students are inherently motivated by their dedication to specialised training and a highly focused profession. However, motivation plays a crucial role in determining the quality of learning and ultimate success. Its absence may provide a plausible explanation for why teachers occasionally encounter medical students who appear discouraged, have lost interest or abandon their studies, feeling a sense of powerlessness or resignation.62
To foster CT among medical students, educational reform should encompass several key aspects: (1) Encouraging active learning and exploration: Teachers must urge students to engage actively in the learning process, providing resources and guidance to kindle their intellectual curiosity. This will empower students to seek out challenges, pose inquiries and address them through a critical lens.63 (2) Implementing heuristic learning and case studies: Educators should incorporate case studies, enabling students to hone their CT, discriminatory skills and decision-making abilities by analysing authentic or hypothetical scenarios.64 65 (3) Stressing the mastery of professional knowledge: It is imperative to ensure that students grasp the fundamental theories and principles of the medical field, along with proficiency in practical medical skills.66 (4) Nurturing teamwork skills: Group discussions, collaborative projects and similar activities should be used to cultivate teamwork among medical students. This teaches them to listen attentively, manage team dynamics, and allocate resources effectively, enhancing their CT and problem-solving capabilities.67 (5) Providing clinical practical experience: Early exposure to clinical practice is crucial in developing students’ analytical and problem-solving skills through firsthand observation and participation in real-life case management.68 (6) Shifting teachers’ roles: Educators must evolve into mentors and role models for CT, leading by example and inspiring students through their practices and teachings.69 Collectively, these recommendations for educational reform will empower medical students to address intricate issues they may encounter in their future medical careers, ultimately increasing the quality and safety of healthcare services.
It is worth noting that our questionnaire incorporated many potential entries with high reliability. It mostly also showed differences between the two groups with or without CT disposition in univariate analysis but were not ultimately presented in the regression models. These factors are meaningful for the development of CT but taking into account the simplicity and informativeness of the model, other entries in the model may have represented them. Our model explained more of the variance in CT than regression models from previous studies.49 70 71
Strengths and limitations
This study has particular strengths. First, the questionnaire for this study was scientific and practice based. The findings of previous studies on personal and educational factors were extensively referenced, and in-depth interviews were also conducted. Second, our study focused on postgraduate medical students and the sample size was relatively large. Postgraduate medical students are the key group for CT development, and the findings obtained among postgraduate medical students are more relevant and better reflect the thinking characteristics of postgraduate medical students. Research from China has considerably enriched the worldwide sample of CT influencing factors. It has been suggested that cultural context strongly influences CT,72 but previous research on CT has mostly focused on Europe, the USA and Japan. Therefore, researching CT in Chinese populations is a valuable addition to this area. In addition, this study is the first to quantitatively explore the impact of tutor and team on CT disposition. For Chinese postgraduates, tutors and their scientific research teams are the people who have the most contact during their studies. In our previous interviews, educators, tutors and postgraduates all recognised the vital role of tutors in postgraduate education, especially in the cultivation of thinking. Based on interviews and literature extraction, we summarise the specific influence of tutors and teams and present them as numerical indicators to refine the influence of tutors on educational factors to make them more comprehensive and exact.
There are several limitations to our study. First, given the traditional constraints of cross-sectional studies, the findings of this study cannot be used as direct evidence of a causal relationship between potential influences and outcomes. Still, they can provide clues to reveal causal relationships. Second, some influencing factors, such as participation in project submissions, participation in CT courses, attempts at innovation and entrepreneurship, and exchange abroad may need to be revised when measured due to limited educational resources. The lack of opportunity for most students to participate in the projects mentioned above, even if they had the will to do so, may help obscure the correlation between CT and these factors. Our regression models did not include other factors of the same type with higher coverage, such as article writing. This suggests that specific formal factors do not significantly influence CT disposition and that bias may not affect the overall results. In addition, we did not use the CTDI-CV scale. Given the busy workload of postgraduate medical students and the fact that online surveys are challenging to monitor and quality control, to avoid as much as possible the impact of too many questions on the quality of the study and to increase the recall rate, we used a condensed version of the Critical Thinking Scale, which has a greater total explained variance than the CTDI-CV scale and has good reliability and validity.
Conclusions
In conclusion, this study provides a comprehensive scientific assessment of the factors influencing the CT disposition of Chinese medical postgraduates in terms of personal and educational factors. Being curious, completing the scientific research design with reference, asking ‘why’, and having high logical thinking ability among team members were positively associated with CT. Exhaustion and burn-out, inattention, following others’ opinions in decision-making and not allowing to doubt tutors were negatively associated with CT scores. These findings suggest that we pay more attention to factors related to motivation and internal drive in our educational practice, shift from an outcome-focused reward mechanism and focus on motivation maintenance to build students’ CT awareness.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The research team collected data after obtaining their consent and signatures on the study’s informed consent form. The Ethics Committee of West China Hospital (tertiary), Sichuan University, approved the study in 2021 (Ethics No. 980).
Acknowledgments
The authors want to acknowledge the medical students who participated in this study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
LW and WC contributed equally.
Contributors LW and WC were involved in designing the study, reviewing the literature, designing the protocol, developing the questionnaire, collecting the data, performing the statistical analysis and preparing the manuscript. TH and W-BH were involved in searching and collecting the data. YW was involved in interpreting the data and critically reviewed the manuscript. YW is responsible for the overall content as the guarantor. All the authors have read and approved the final manuscript.
Funding This study was supported by the Sichuan University Postgraduate Education Reform project (GSSCU2021038).
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.