Dual Process Model

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Dual Process Model

Saori Wendy Yosioka, MLIS AHIP (Marshall B. Ketchum University, Fullerton, CA)

1. Articles
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3. Books
4. Weblinks
5. Presentations (slides)
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Articles

1. J EvalClinPract. 2012 Oct;18(5):954-61. doi: 10.1111/j.1365-2753.2012.01900.x.

An integrated model of clinical reasoning: dual-process theory of cognition and

metacognition.

Marcum JA.

Department of Philosophy, Baylor University, Waco, TX, USA.

RATIONALE AND AIM: Clinical reasoning is an important component for providingquality medical care. The aim of the present paper is to develop a model ofclinical reasoning that integrates both the non-analytic and analytic processesof cognition, along with metacognition.

METHOD: The dual-process theory of cognition (system 1 non-analytic and system 2 analytic processes) and the metacognition theory are used to develop anintegrated model of clinical reasoning.

RESULTS: In the proposed model, clinical reasoning begins with system 1 processesin which the clinician assesses a patient's presenting symptoms, as well as otherclinical evidence, to arrive at a differential diagnosis. Additional clinicalevidence, if necessary, is acquired and analysed utilizing system 2 processes to assess the differential diagnosis, until a clinical decision is made diagnosingthe patient's illness and then how best to proceed therapeutically. Importantly, the outcome of these processes feeds back, in terms of metacognition's monitoringfunction, either to reinforce or to alter cognitive processes, which, in turn,enhances synergistically the clinician's ability to reason quickly and accuratelyin future consultations.

CONCLUSIONS: The proposed integrated model has distinct advantages over othermodels proposed in the literature for explicating clinical reasoning. Moreover,it has important implications for addressing the paradoxical relationship betweenexperience and expertise, as well as for designing a curriculum to teach clinicalreasoning skills.

PMID: 22994991 [PubMed - indexed for MEDLINE]

2. BMC Med Inform DecisMak. 2012 Sep 3;12:94. doi: 10.1186/1472-6947-12-94.

Dual processing model of medical decision-making.

Djulbegovic B, Hozo I, Beckstead J, Tsalatsanis A, Pauker SG.

Center for Evidence-based Medicine and Health Outcomes Research, Tampa, FL, USA.

BACKGROUND: Dual processing theory of human cognition postulates that reasoningand decision-making can be described as a function of both an intuitive,experiential, affective system (system I) and/or an analytical, deliberative(system II) processing system. To date no formal descriptive model of medicaldecision-making based on dual processing theory has been developed. Here wepostulate such a model and apply it to a common clinical situation: whethertreatment should be administered to the patient who may or may not have adisease.

METHODS: We developed a mathematical model in which we linked a recently proposeddescriptive psychological model of cognition with the threshold model of medical decision-making and show how this approach can be used to better understanddecision-making at the bedside and explain the widespread variation in treatmentsobserved in clinical practice.

RESULTS: We show that physician's beliefs about whether to treat at higher(lower) probability levels compared to the prescriptive therapeutic thresholdsobtained via system II processing is moderated by system I and the ratio ofbenefit and harms as evaluated by both system I and II. Under some conditions,the system I decision maker's threshold may dramatically drop below the expected utility threshold derived by system II. This can explain the overtreatment often seen in the contemporary practice. The opposite can also occur as in thesituations where empirical evidence is considered unreliable, or when cognitiveprocesses of decision-makers are biased through recent experience: the threshold will increase relative to the normative threshold value derived via system IIusing expected utility threshold. This inclination for the higher diagnosticcertainty may, in turn, explain undertreatment that is also documented in thecurrent medical practice.

CONCLUSIONS: We have developed the first dual processing model of medicaldecision-making that has potential to enrich the current medical decision-making field, which is still to the large extent dominated by expected utility theory.The model also provides a platform for reconciling two groups of competing dualprocessing theories (parallel competitive with default-interventionalisttheories).

PMCID: PMC3471048

PMID: 22943520 [PubMed - indexed for MEDLINE]

3. Front Psychol. 2012;3:384. doi: 10.3389/fpsyg.2012.00384. Epub 2012 Oct 9.

Unreliable gut feelings can lead to correct decisions: the somatic marker

hypothesis in non-linear decision chains.

Bedia MG, Di Paolo E.

Department of Computer Science, University of Zaragoza Zaragoza, Spain.

Dual-process approaches of decision-making examine the interaction betweenaffective/intuitive and deliberative processes underlying value judgment. Fromthis perspective, decisions are supported by a combination of relatively explicitcapabilities for abstract reasoning and relatively implicit evolveddomain-general as well as learned domain-specific affective responses. One suchapproach, the somatic markers hypothesis (SMH), expresses these implicitprocesses as a system of evolved primary emotions supplemented by associationsbetween affect and experience that accrue over lifetime, or somatic markers. Inthis view, somatic markers are useful only if their local capability to predictthe value of an action is above a baseline equal to the predictive capability of the combined rational and primary emotional subsystems. We argue thatdecision-making has often been conceived of as a linear process: the effect ofdecision sequences is additive, local utility is cumulative, and there is nostrong environmental feedback. This widespread assumption can have consequencesfor answering questions regarding the relative weight between the systems andtheir interaction within a cognitive architecture. We introduce a mathematicalformalization of the SMH and study it in situations of dynamic, non-linear

decision chains using a discrete-time stochastic model. We find, contrary toexpectations, that decision-making events can interact non-additively with theenvironment in apparently paradoxical ways. We find that in non-lethalsituations, primary emotions are represented globally over and above their local

weight, showing a tendency for overcautiousness in situated decision chains. Wealso show that because they tend to counteract this trend, poorly attuned somaticmarkers that by themselves do not locally enhance decision-making, can stillproduce an overall positive effect. This result has developmental and

evolutionary implications since, by promoting exploratory behavior, somaticmarkers would seem to be beneficial even at early stages when experientialattunement is poor. Although the model is formulated in terms of the SMH, theimplications apply to dual systems theories in general since it makes minimalassumptions about the nature of the processes involved.

PMCID: PMC3466990

PMID: 23087655 [PubMed]

4. Int J Gen Med. 2012;5:873-4. doi: 10.2147/IJGM.S36859. Epub 2012 Oct 17.

System 3 diagnostic process: the lateral approach.

Shimizu T, Tokuda Y.

Rollins School of Public Health, Emory University, Atlanta, GA, USA.

The process of obtaining diagnosis is described as a dual-process model,including the intuitive process, and the analytical process. The similaritybetween the two systems is that they both infer a diagnosis from patient-derived information. Here we present another process by which to elicit the diagnosis:asking direct questions of the patient themselves, such as "What do you think is the cause?" or "What do you suspect is wrong?" This simple method would enable usto elicit pivotal information for diagnosis. Asking patients direct questionsallows them to think about the cause of their own problem and suggest their owndiagnosis. This method of reasoning is completely different from the twoabove-mentioned systems and may represent a third approach. We highlight thisthird process as an important strategy, thereby using this third effective methodof inquiry to facilitate quick and effective diagnosis in conjunction with former

two systems.

PMCID: PMC3479944

PMID: 23109811 [PubMed]

5. Med Educ Online. 2011 Mar 14;16. doi: 10.3402/meo.v16i0.5890.

An analysis of clinical reasoning through a recent and comprehensive approach:the dual-process theory.

Pelaccia T, Tardif J, Triby E, Charlin B.

Prehospital Emergency Care Service (SAMU 67)-Centre for Emergency Care Teaching

(CESU 67), Strasbourg University Hospital, Strasbourg, France.

CONTEXT: Clinical reasoning plays a major role in the ability of doctors to make diagnoses and decisions. It is considered as the physician's most criticalcompetence, and has been widely studied by physicians, educationalists,psychologists and sociologists. Since the 1970s, many theories about clinicalreasoning in medicine have been put forward.

PURPOSE: This paper aims at exploring a comprehensive approach: the "dual-processtheory", a model developed by cognitive psychologists over the last few years.

DISCUSSION: After 40 years of sometimes contradictory studies on clinicalreasoning, the dual-process theory gives us many answers on how doctors thinkwhile making diagnoses and decisions. It highlights the importance of physicians'intuition and the high level of interaction between analytical and non-analyticalprocesses. However, it has not received much attention in the medical educationliterature. The implications of dual-process models of reasoning in terms ofmedical education will be discussed.

PMCID: PMC3060310

PMID: 21430797 [PubMed - indexed for MEDLINE]

6. Med Educ. 2010 Jan;44(1):94-100. doi: 10.1111/j.1365-2923.2009.03507.x.

Diagnostic error and clinical reasoning.

Norman GR, Eva KW.

Department of Clinical Epidemiology and Biostatistics, McMaster University,

Hamilton, Ontario, Canada.

Comment in

Med Educ. 2010 Jan;44(1):15-6.

CONTEXT: There is a growing literature on diagnostic errors. The consensus ofthis literature is that most errors are cognitive and result from the applicationof one or more cognitive biases. Such biased reasoning is usually associated with'System 1' (non-analytic, pattern recognition) thinking.

METHODS: We review this literature and bring in evidence from two other fields:research on clinical reasoning, and research in psychology on 'dual-process'models of thinking. We then synthesise the evidence from these fields exploringpossible causes of error and potential solutions.

RESULTS: We identify that, in fact, there is very little evidence to associatediagnostic errors with System 1 (non-analytical) reasoning. By contrast, studies of dual processing show that experts are as likely to commit errors when they areattempting to be systematic and analytical. We then examine the effectiveness of various approaches to reducing errors. We point out that educational strategiesaimed at explaining cognitive biases are unlikely to succeed because of limitedtransfer. Conversely, there is an accumulation of evidence that interventionsdirected at specifically encouraging both analytical and non-analytical reasoninghave been shown to result in small, but consistent, improvements in accuracy.

CONCLUSIONS: Diagnostic errors are not simply a consequence of cognitive biasesor over-reliance on one kind of thinking. They result from multiple causes andare associated with both analytical and non-analytical reasoning. Limitedevidence suggests that strategies directed at encouraging both kinds of reasoningwill lead to limited gains in accuracy.

PMID: 20078760 [PubMed - indexed for MEDLINE]

7. Frankish K. Dual-Process and Dual-System Theories of Reasoning. Philosophy Compass. 2010;5(10):914-926.

Dual-process theories hold that there are two distinct processing modes available for many cognitive tasks: one (type 1) that is fast, automatic and non-conscious, and another (type 2) that is slow, controlled and conscious. Typically, cognitive biases are attributed to type 1 processes, which are held to be heuristic or associative, and logical responses to type 2 processes, which are characterised as rule-based or analytical. Dual-system theories go further and assign these two types of process to two separate reasoning systems, System 1 and System 2 – a view sometimes described as ‘the two minds hypothesis’. It is often claimed that System 2 is uniquely human and the source of our capacity for abstract and hypothetical thinking. This study is an introduction to dual-process and dual-system theories. It looks at some precursors, surveys key work in the fields of learning, reasoning, social cognition and decision making, and identifies some recent trends and philosophical applications.

8.Adv Health SciEduc Theory Pract. 2009 Sep;14Suppl 1:37-49. doi:10.1007/s10459-009-9179-x. Epub 2009 Aug 11.

Dual processing and diagnostic errors.

Norman G.

Department of Clinical Epidemiology and Biostatistics, McMaster University, ON,

Canada.

In this paper, I review evidence from two theories in psychology relevant todiagnosis and diagnostic errors. "Dual Process" theories of thinking, frequently mentioned with respect to diagnostic error, propose that categorization decisionscan be made with either a fast, unconscious, contextual process called System 1or a slow, analytical, conscious, and conceptual process, called System 2.Exemplar theories of categorization propose that many category decisions ineveryday life are made by unconscious matching to a particular example in memory,and these remain available and retrievable individually. I then review studies ofclinical reasoning based on these theories, and show that the two processes areequally effective; System 1, despite its reliance in idiosyncratic, individualexperience, is no more prone to cognitive bias or diagnostic error than System 2.Further, I review evidence that instructions directed at encouraging theclinician to explicitly use both strategies can lead to consistent reduction inerror rates.

PMID: 19669921 [PubMed - indexed for MEDLINE]

9. Adv Health SciEduc Theory Pract. 2009 Sep;14Suppl 1:27-35. doi:10.1007/s10459-009-9182-2. Epub 2009 Aug 11.

Clinical cognition and diagnostic error: applications of a dual process model of reasoning.

Croskerry P.

Department of Emergency Medicine, Dalhousie University, NS, Canada.

Both systemic and individual factors contribute to missed or delayed diagnoses.Among the multiple factors that impact clinical performance of the individual,the caliber of cognition is perhaps the most relevant and deserves our attention and understanding. In the last few decades, cognitive psychologists have gainedsubstantial insights into the processes that underlie cognition, and a new,universal model of reasoning and decision making has emerged, Dual ProcessTheory. The theory has immediate application to medical decision making andprovides an overall schema for understanding the variety of theoreticalapproaches that have been taken in the past. The model has important practicalapplications for decision making across the multiple domains of healthcare, andmay be used as a template for teaching decision theory, as well as a platform forfuture research. Importantly, specific operating characteristics of the modelexplain how diagnostic failure occurs.

PMID: 19669918 [PubMed - indexed for MEDLINE]

10. Acad Med. 2009 Aug;84(8):1022-8. doi: 10.1097/ACM.0b013e3181ace703.

A universal model of diagnostic reasoning.

Croskerry P.

Department of Emergency Medicine, Faculty of Medicine and Division of Medical

Education, Dalhousie University, Halifax, Nova Scotia, Canada.

Clinical judgment is a critical aspect of physician performance in medicine. Itis essential in the formulation of a diagnosis and key to the effective and safe management of patients. Yet, the overall diagnostic error rate remainsunacceptably high. In more than four decades of research, a variety of approacheshave been taken, but a consensus approach toward diagnostic decision making hasnot emerged. In the last 20 years, important gains have been made inpsychological research on human judgment. Dual-process theory has emerged as the predominant approach, positing two systems of decision making, System 1(heuristic, intuitive) and System 2 (systematic, analytical). The author proposesa schematic model that uses the theory to develop a universal approach towardclinical decision making. Properties of the model explain many of the observedcharacteristics of physicians' performance. Yet the author cautions that not all medical reasoning and decision making falls neatly into one or the other of themodel's systems, even though they provide a basic framework incorporating therecognized diverse approaches. He also emphasizes the complexity of decisionmaking in actual clinical situations and the urgent need for more research tohelp clinicians gain additional insight and understanding regarding theirdecision making.

PMID: 19638766 [PubMed - indexed for MEDLINE]

11. Ann N Y Acad Sci. 2008 Apr;1128:53-62. doi: 10.1196/annals.1399.007.

Multiple systems in decision making.

Sanfey AG, Chang LJ.

Department of Psychology, University of Arizona, 1503 E. University Boulevard,

Tucson AZ 85721, USA.

Neuroeconomics seeks to gain a greater understanding of decision making bycombining theoretical and methodological principles from the fields ofpsychology, economics, and neuroscience. Initial studies using thismultidisciplinary approach have found evidence suggesting that the brain may beemploying multiple levels of processing when making decisions, and this notion isconsistent with dual-processing theories that have received extensive theoreticalconsideration in the field of cognitive psychology, with these theories arguingfor the dissociation between automatic and controlled components of processing.While behavioral studies provide compelling support for the distinction betweenautomatic and controlled processing in judgment and decision making, less isknown if these components have a corresponding neural substrate, with someresearchers arguing that there is no evidence suggesting a distinct neural basis.This chapter will discuss the behavioral evidence supporting the dissociationbetween automatic and controlled processing in decision making and review recent literature suggesting potential neural systems that may underlie these processes.

PMID: 18469214 [PubMed - indexed for MEDLINE]

12. Implement Sci. 2006 May 25;1:12.

Implementation science: a role for parallel dual processing models of reasoning?

Sladek RM, Phillips PA, Bond MJ.

Flinders University, Adelaide, South Australia.

BACKGROUND: A better theoretical base for understanding professional behavior change is needed to support evidence-based changes in medical practice.Traditionally strategies to encourage changes in clinical practices have beenguided empirically, without explicit consideration of underlying theoreticalrationales for such strategies. This paper considers a theoretical framework for reasoning from within psychology for identifying individual differences incognitive processing between doctors that could moderate the decision toincorporate new evidence into their clinical decision-making.

DISCUSSION: Parallel dual processing models of reasoning posit two cognitivemodes of information processing that are in constant operation as humans reason. One mode has been described as experiential, fast and heuristic; the other asrational, conscious and rule based. Within such models, the uptake of newresearch evidence can be represented by the latter mode; it is reflective,explicit and intentional. On the other hand, well practiced clinical judgmentscan be positioned in the experiential mode, being automatic, reflexive and swift.Research suggests that individual differences between people in both cognitivecapacity (e.g., intelligence) and cognitive processing (e.g., thinking styles)influence how both reasoning modes interact. This being so, it is proposed thatthese same differences between doctors may moderate the uptake of new researchevidence. Such dispositional characteristics have largely been ignored inresearch investigating effective strategies in implementing research evidence.Whilst medical decision-making occurs in a complex social environment withmultiple influences and decision makers, it remains true that an individualdoctor's judgment still retains a key position in terms of diagnostic andtreatment decisions for individual patients. This paper argues therefore, thatindividual differences between doctors in terms of reasoning are importantconsiderations in any discussion relating to changing clinical practice.