Exploring the link of personality traits and tutors instruction on critical thinking disposition: a cross-sectional study among Chinese medical graduate students

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.

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