Running head: DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL

Dual-Process Theory and Diagnostic Error in Clinical Reasoning Matthew D. Moore University of Louisville

DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL REASONING Dual-Process Theory and Diagnostic Error in Clinical Reasoning Dual-process theory (DPT) describes two ways of information processing in which humans engage everyday. Its first system is intuitive and responds quickly to the environment.

Its second system is deliberate and requires active attention. Some researchers have investigated clinicians processes when making diagnoses and have found that each of the two systems of DPT plays an important role in clinical reasoning (CR). Others criticize the use of system 1 processing for its potentially biased responses, claiming that this system is highly responsible for diagnostic error. Some recent literature aims to dispel such criticisms regarding CR, claiming that errors arise from a number of problems that arent related solely to system 1. Many argue that the two systems are used in conjunction with one another, and that this way of processing information has the best outcome. This review aims to synthesize the literature on such debates and offer directions for further research. Additionally, I propose an adaptation to a current model of CR that illustrates one of the common clinical errors that can arise. Lets begin with a review of DPT. As described by Barrett et al. (2004), DPT involves automatic processing (system 1) and controlled processing (system 2). System 1 is the default mode of processing. Its primitive by nature and evolutionary inheritance, as its hallmark is a lack of conscious thought, and it exists in much of the Animal kingdom. Other names for it are nonconscious, non-analytic, implicit, and heuristic processing. System 1 processing is highly dependent on prior knowledgeschemas in long-term memoryto guide associative pathways. The associative aspect makes it much faster than system 2, which is hallmarked by slow and careful consideration. System 2 works entirely within the boundaries of working memory, which has a relatively low capacity for information handling and limited attentional resources. System 2 is also called conscious, analytic, explicit, and systematic processing. It can inhibit system 1

DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL REASONING processing if needed (such as when system 1 activates the wrong schema). This is system 2s main purpose in the clinical models examined in this review. Previous models of CR include the hypothetico-deductive model and the pattern

recognition model (Marcum, 2012). The hypothetico-deductive model was first articulated in the 1970s, stemming from research on medical problem solving. In this model clinicians formulate a few hypotheses and use them to obtain more evidence until a diagnosis is reached. This process is highly analytical, most consistent with system 2 processing. An alternative to this model is the pattern recognition model, which is most consistent with system 1 processing. In the pattern recognition model clinicians match the current case with ones encountered in the past. Advocates of this model value associative processings ability to view cases holistically, while critics say it trivializes the complex cognitive activities involved in CR (Marcum, 2012). Marcum criticized the linear trajectory of these models and other like them, because they dont feed back onto previous processes. He proposed a cyclical model for CR that integrates aspects of these previous models. Marcums (2012) illustrations of CR include four different phases: non-analytic processes, analytic processes, clinical decision, and metacognition (MC). Depending on its position in the sequence, MC either monitors the reasoning processes or validates or rejects a decision. Analytic processing includes traditional system 2 processes, as well as higher-order processes (see Evans type 3 processes and Stanovichs reflective mind). In Marcums first model (Fig. 1), non-analytic (i.e., system 1) processes are used to obtain the differential diagnosis. If a single pattern stands out that matches the case at hand, a clinical decision is made, followed by metacognition. In Marcums second model (Fig. 2), if a clinical decision cant be made after non-analytic processes (e.g., a single pattern doesnt stand out, there is inconclusive

DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL REASONING evidence, etc.), then analytic (i.e., system 2) processes are recruited. After analytic processing

comes MC, then a clinical decision, then MC again. When correct diagnoses are reached the two models cyclical nature allows for associations to grow stronger, which fosters clinical expertise. No feedback on correct processing can lead to having a lot of experience with very little expertise. Marcums models account for the development of expertise. An earlier study by Balla et al. (2009) supports Marcums model. Balla and colleagues conducted a one-year study in which they interviewed general practitioners in the United Kingdom. Practitioners were asked questions about their processing in cases theyd recently seen. Interviewers asked participants about what went through their minds (Balla et al., 2009) in those cases during a 20-minute semi-structured interview of open-ended questions. 35 practitioners participated and generated 72 cases to be analyzed. Two researchers reviewed manuscripts of the cases for trends supporting or rejecting DPT. They found much evidence supporting DPT, particularly for system 1 processing. In 79% of the cases a rapid judgment was made. In over half the cases heuristics were used, which is a function of system 1. Likewise, in nearly half the cases ruling out or differentially diagnosing was explicitly stated as the focus, while only a few cases stated ruling in possible conditions as the focus. This is consistent with the first step in Marcums models, a process of elimination using system 1. Consistent with system 2 processing, Balla and colleagues note that clinicians reframed problems and changed their immediate responses in one third of the cases. In Marcums second model this occurs when system 2 is recruited to settle discrepancies in system 1 processing. Balla et al. provide a model for the strategies they saw in the practitioners (Fig 3) similar to Marcums model. Neither of these models gives accounts for error, however, and the literature has a lot to say about it.

DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL REASONING Some of the criticisms of system 1 have already been discussed, but there are many

others. System 1 is often seen as a biased system, which in a clinical setting could mean favoring a familiar or common diagnosis albeit wrong. The consensus of the literature on diagnostic error is that errors are products mostly of cognitive bias, which is related to system 1 (Norman & Eva, 2010). Norman and Eva challenge this notion, finding that there isnt much evidence linking system 1 to diagnostic error. Their investigation begins with a review of error prevalence. An extensive review by Berner and Graber (2008; as cited by Norman & Eva, 2010) concludes that errors in fields such as radiology and pathology were usually less than 5%. An earlier study by Graber (2005; as cited by Norman & Eva, 2010) reviewed 100 cases of diagnostic error. Although nearly 75% of them involved some extent of cognitive error, less than half of those cognitive errors were related to what Graber calls Faulty Information Processing, which may relate to either processing system. The other three domains were Faulty Knowledge, Faulty Data Gathering, and Faulty Verification, none of which are solel y related to system 1. Graber found premature closure (i.e., stopping the consideration of other possibilities after reaching a diagnosis) to be the most common error. System 1 bias does play a role in premature closure, but its merely a correlate alongside other factors, such as incomplete history taking and failure to consider the correct diagnosis. While a mass of literature criticized the use of nonconscious processing, a few works find it to be powerful in making complex decisions. Dijksterhuis et al. (2006) call it the deliberationwithout-attention effect. They found that in making simple decisions based on fewer criteria conscious deliberation produces higher accuracy and greater decision satisfaction. More importantly they found that in making decisions based on more criteria unconscious deliberation produced higher accuracy and greater decision satisfaction. Considering overlap in diagnostic

DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL REASONING categories and abundance of existing conditions, clinical decision-making can be viewed as

highly complex with many criteria to juggle. Based on their findings, Dijksterhuis and colleagues might suggest clinicians to use less conscious deliberation than the hypothetico-deductive model or Marcums models prescribes. More importantly, their study emphasizes the importance and reliability that system 1 unconscious processing can have in the right situation. Croskerry (2009) compiled a number of possible cognitive failures that dont rest alone on system 1. He posits that sometimes system 2s performance monitoring over system 1 processing can fail. For example, cognitive overload can negatively affect system 2s ability to monitor system 1 (Gilbert et al., 2003; as cited by Croskerry, 2009). Fatigue and sleep deprivation can cause similar effects. This cognitive failure illustrates that, while system 1 can make an error in judgment, system 2 can be equally responsible for not inhibiting or correcting system 1s response. Like Norman and Eva, Croskerry also cites Berner and Grabers (2008) study, noting that overconfidence appears to be involved in many diagnostic errors. Overconfidence is mutually exclusive to neither processing system, favoring a de-emphasis of error attribution to system 1. This review leads to a few conclusions. First, there is a good deal of evidence suggesting that clinicians use both associative and deliberate processing in the diagnostic process. Each process has its own place in the CR process where it functions better than the other. For example, since so many clinicians try first to eliminate possible conditions, system 1 is best used to obtain a differential diagnosis. Its dependence on prior knowledge and independence of active attention accelerate the differential diagnostic process in CR. On the other hand, system 2 is best used to aid system 1 when a diagnosis cant be reached. Its conscious and rationale components allow it to direct attention to other foci in search of more evidence. Marcum applies these processes in

DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL REASONING his models. In regard to diagnostic error, there is a growing amount of evidence discordant with the notion that biased cognition from system 1 processing accounts for most diagnostic errors. Researchers have found a number of ways that cognitive errors arise that cant be attributed to system 1 alone. Most errors arise from an amalgamation of poor CR processes, such as faulty knowledge and premature closure. This isnt to say that system 1 is flawless. The potential for bias is always there, but system 1 bias appears to be less responsible for error than many critics currently hold it.

Marcums model of CR is particularly unique because of its cyclical nature and ability to feed back on prior processes. It accounts for the process of developing expertise, unlike any other model in this review. Still, this model needs more research to be determined a good tool for teaching rising clinicians. In the meantime, I propose two adaptations to Marcums second model from Figure 2, illustrating Grabers (2005) most commonly found error: premature closure. These adapted models are intended to demonstrate two ways this particular error might arise, either before analytic processing (Fig. 2a) or after analytic processing (Fig. 2b). In Fig. 2a, nonanalytic processes cant reach a diagnosis, signaling analytic processes to intervene. However, analytic processes dont intervene due to premature closure, and a decision is made by system 1 based on inconclusive evidence (noted as premature closure, type I). In Fig. 2b, a conflict arises between non-analytic processes and lower-order analytic processes. Higher-order analytical processes (i.e. type 3 or the reflective mind) arent allowed to resolve the conflict due to premature closure, and a decision is made by an automatic system 2 override (noted as premature closure, type II). In both adaptations, MC isnt allowed time to monitor operations or validate or reject the decision. These adaptations visually represent that while one system

DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL REASONING generates the incorrect diagnosis, other system failures and external stressors perpetuate the incorrect diagnosis. In such cases, error can be attributed to multiple systems, not just system 1. The direction of the research on CR looks promising. Evidence is building in support of models such as Marcums. With continued research these models may be concluded as reliable in accurately portraying clinicians processes. Such models can be very helpful in teaching CR and diagnosis, providing the framework for new clinicians to integrate their processing systems and foster expertise. The proposed adaptations to Marcums model may also be helpful in teaching how and where errors can occur, providing insight to new clinicians so that they can avoid such errors. There is no light way to say that clinicians make errors too. Diagnostic error could mean a clients death. Researchers of CR should take every step forward to come up with reliable ways to help clinicians avoid such errors.

DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL REASONING

Figure 1. Continuous cyclical or spiral model of nonanalytic processes, along with metacognition, for clinical reasoning and decision making. Adapted from An integrated model of clinical reasoning: dual process theory of cognition and metacognition, by J. A. Marcum, 2010, Journal of Evaluation in Clinical Practice, 18, p. 957. Copyright 2012 by Blackwell Publishing Ltd.

Figure 2. Continuous cyclical or spiral model of analytic and non-analytic processes, along with metacognition, for clinical reasoning and decision making. Adapted from An integrated model of clinical reasoning: dual-process theory of cognition and metacognition, by J. A. Marcum, 2010, Journal of Evaluation in Clinical Practice, 18, p. 957. Copyright 2012 by Blackwell Publishing Ltd.

Figure 2a. An adaptation of Marcums Fig. 2 illustrating premature closure, type I. Adapted from An integrated model of clinical reasoning: dual-process theory of cognition and metacognition, by J. A. Marcum, 2010, Journal of Evaluation in Clinical Practice, 18, p. 957. Copyright 2012 by Blackwell Publishing Ltd.

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Figure 2b. An adaptation of Marcums Fig. 2 illustrating premature closure, type II. Adapted from An integrated model of clinical reasoning: dual -process theory of cognition and metacognition, by J. A. Marcum, 2010, Journal of Evaluation in Clinical Practice, 18, p. 957. Copyright 2012 by Blackwell Publishing Ltd.

Figure 3. Model for reflection on clinical practice. Adapted from A model for reflection for good clinical practice, by J. I. Balla, C. Heneghan, P. Glasziou, M. Thompson, and M. E. Balla, 2009, Journal of Evaluation in Clinical Practice, 15, p. 967. Copyright 2009 by Blackwell Publishing Ltd.j

DUAL-PROCESS THEORY AND DIAGNOSTIC ERROR IN CLINICAL REASONING References Balla, J. I., Heneghan, C., Glasziou, P., Thompson, M., & Balla, M. E. (2009). A model for

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reflection for good clinical practice. Journal of Evaluation in Clinical Practice, 15, 964969. doi:10.1111/j.1365-2753.2009.01243.x Barrett, L. F., Tugade, M. M., & Engle, R. W. (2004). Individual Differences in Working Memory Capacity and Dual-Process Theories of the Mind. Psycho Bull., 130(4), 553573. Croskerry, P. (2009). Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv in Health Sci Educ, 14, 27-35. doi:10.1007/s10459-009-9182-2 Dijksterhuis, A., Bos, M. W., Nordgren, L. F., & van Baaren, R. B. (2006). On Making the Right Choice: The Deliberation-Without-Attention Effect. Science, 311, 1005-1007. doi: 10.1126/science.1121629 Marcum, J. A. (2012). An integrated model of clinical reasoning: dual-process theory of cognition and metacognition. Journal of Evaluation in Clinical Practice, 18, 954-961. doi:10.1111/j.1365-2753.2012.01900.x Norman, G. R., & Eva, K. W. (2010). Diagnostic error and clinical reasoning. Medical Education 2010, 44, 94-100. doi:10.1111/j.1365-2923.2009.03507.x