1
Dual Process Model
Saori Wendy Yosioka, MLIS AHIP (Marshall B. Ketchum University, Fullerton, CA)
1. Articles 2. Blog Posts 3. Books 4. Weblinks 5. Presentations (slides) 6. Thesis 7. Video
Articles
1. J Eval Clin Pract. 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. [email protected]
RATIONALE AND AIM: Clinical reasoning is an important component for providing quality medical care. The aim of the present paper is to develop a model of clinical reasoning that integrates both the non- analytic and analytic processes of 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 an integrated model of clinical reasoning.
RESULTS: In the proposed model, clinical reasoning begins with system 1 processes in which the clinician assesses a patient's presenting symptoms, as well as other clinical evidence, to arrive at a differential diagnosis. Additional clinical evidence, if necessary, is acquired and analysed utilizing system 2 processes to assess the differential diagnosis, until a clinical decision is made diagnosing the patient's illness and then how best to proceed therapeutically. Importantly, the outcome of these processes feeds back, in terms of metacognition's monitoring function, either to reinforce or to alter cognitive processes, which, in turn, enhances synergistically the clinician's ability to reason quickly and accurately in future consultations.
CONCLUSIONS: The proposed integrated model has distinct advantages over other models proposed in the literature for explicating clinical reasoning. Moreover, it has important implications for addressing the paradoxical relationship between experience and expertise, as well as for designing a curriculum to teach clinical reasoning skills.
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 2
PMID: 22994991 [PubMed - indexed for MEDLINE]
2. BMC Med Inform Decis Mak. 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. [email protected]
BACKGROUND: Dual processing theory of human cognition postulates that reasoning and 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 medical decision-making based on dual processing theory has been developed. Here we postulate such a model and apply it to a common clinical situation: whether treatment should be administered to the patient who may or may not have a disease.
METHODS: We developed a mathematical model in which we linked a recently proposed descriptive psychological model of cognition with the threshold model of medical decision-making and show how this approach can be used to better understand decision-making at the bedside and explain the widespread variation in treatments observed in clinical practice.
RESULTS: We show that physician's beliefs about whether to treat at higher (lower) probability levels compared to the prescriptive therapeutic thresholds obtained via system II processing is moderated by system I and the ratio of benefit 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 the situations where empirical evidence is considered unreliable, or when cognitive processes of decision-makers are biased through recent experience: the threshold will increase relative to the normative threshold value derived via system II using expected utility threshold. This inclination for the higher diagnostic certainty may, in turn, explain undertreatment that is also documented in the current medical practice.
CONCLUSIONS: We have developed the first dual processing model of medical decision-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 dual processing theories (parallel competitive with default-interventionalist theories).
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.
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 3
Bedia MG, Di Paolo E.
Department of Computer Science, University of Zaragoza Zaragoza, Spain.
Dual-process approaches of decision-making examine the interaction between affective/intuitive and deliberative processes underlying value judgment. From this perspective, decisions are supported by a combination of relatively explicit capabilities for abstract reasoning and relatively implicit evolved domain-general as well as learned domain-specific affective responses. One such approach, the somatic markers hypothesis (SMH), expresses these implicit processes as a system of evolved primary emotions supplemented by associations between affect and experience that accrue over lifetime, or somatic markers. In this view, somatic markers are useful only if their local capability to predict the value of an action is above a baseline equal to the predictive capability of the combined rational and primary emotional subsystems. We argue that decision-making has often been conceived of as a linear process: the effect of decision sequences is additive, local utility is cumulative, and there is no strong environmental feedback. This widespread assumption can have consequences for answering questions regarding the relative weight between the systems and their interaction within a cognitive architecture. We introduce a mathematical formalization of the SMH and study it in situations of dynamic, non-linear decision chains using a discrete-time stochastic model. We find, contrary to expectations, that decision- making events can interact non-additively with the environment in apparently paradoxical ways. We find that in non-lethal situations, primary emotions are represented globally over and above their local weight, showing a tendency for overcautiousness in situated decision chains. We also show that because they tend to counteract this trend, poorly attuned somatic markers that by themselves do not locally enhance decision-making, can still produce an overall positive effect. This result has developmental and evolutionary implications since, by promoting exploratory behavior, somatic markers would seem to be beneficial even at early stages when experiential attunement is poor. Although the model is formulated in terms of the SMH, the implications apply to dual systems theories in general since it makes minimal assumptions 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 similarity between 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 us to elicit pivotal information for diagnosis. Asking patients direct questions allows them to think about the cause of their own problem and suggest their own diagnosis. This method of reasoning is completely different from the two above-
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 4 mentioned systems and may represent a third approach. We highlight this third process as an important strategy, thereby using this third effective method of 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. [email protected]
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 critical competence, and has been widely studied by physicians, educationalists, psychologists and sociologists. Since the 1970s, many theories about clinical reasoning in medicine have been put forward.
PURPOSE: This paper aims at exploring a comprehensive approach: the "dual-process theory", a model developed by cognitive psychologists over the last few years.
DISCUSSION: After 40 years of sometimes contradictory studies on clinical reasoning, the dual-process theory gives us many answers on how doctors think while making diagnoses and decisions. It highlights the importance of physicians' intuition and the high level of interaction between analytical and non- analytical processes. However, it has not received much attention in the medical education literature. The implications of dual-process models of reasoning in terms of medical 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. [email protected]
Comment in Med Educ. 2010 Jan;44(1):15-6.
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 5
CONTEXT: There is a growing literature on diagnostic errors. The consensus of this literature is that most errors are cognitive and result from the application of 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 exploring possible causes of error and potential solutions.
RESULTS: We identify that, in fact, there is very little evidence to associate diagnostic errors with System 1 (non-analytical) reasoning. By contrast, studies of dual processing show that experts are as likely to commit errors when they are attempting to be systematic and analytical. We then examine the effectiveness of various approaches to reducing errors. We point out that educational strategies aimed at explaining cognitive biases are unlikely to succeed because of limited transfer. Conversely, there is an accumulation of evidence that interventions directed at specifically encouraging both analytical and non-analytical reasoning have been shown to result in small, but consistent, improvements in accuracy.
CONCLUSIONS: Diagnostic errors are not simply a consequence of cognitive biases or over-reliance on one kind of thinking. They result from multiple causes and are associated with both analytical and non- analytical reasoning. Limited evidence suggests that strategies directed at encouraging both kinds of reasoning will 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 Sci Educ Theory Pract. 2009 Sep;14 Suppl 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,
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 6
Canada. [email protected]
In this paper, I review evidence from two theories in psychology relevant to diagnosis and diagnostic errors. "Dual Process" theories of thinking, frequently mentioned with respect to diagnostic error, propose that categorization decisions can be made with either a fast, unconscious, contextual process called System 1 or a slow, analytical, conscious, and conceptual process, called System 2. Exemplar theories of categorization propose that many category decisions in everyday life are made by unconscious matching to a particular example in memory, and these remain available and retrievable individually. I then review studies of clinical reasoning based on these theories, and show that the two processes are equally effective; System 1, despite its reliance in idiosyncratic, individual experience, is no more prone to cognitive bias or diagnostic error than System 2. Further, I review evidence that instructions directed at encouraging the clinician to explicitly use both strategies can lead to consistent reduction in error rates.
PMID: 19669921 [PubMed - indexed for MEDLINE]
9. Adv Health Sci Educ Theory Pract. 2009 Sep;14 Suppl 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. [email protected]
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 gained substantial insights into the processes that underlie cognition, and a new, universal model of reasoning and decision making has emerged, Dual Process Theory. The theory has immediate application to medical decision making and provides an overall schema for understanding the variety of theoretical approaches that have been taken in the past. The model has important practical applications for decision making across the multiple domains of healthcare, and may be used as a template for teaching decision theory, as well as a platform for future research. Importantly, specific operating characteristics of the model explain 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
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 7
Education, Dalhousie University, Halifax, Nova Scotia, Canada. [email protected]
Clinical judgment is a critical aspect of physician performance in medicine. It is essential in the formulation of a diagnosis and key to the effective and safe management of patients. Yet, the overall diagnostic error rate remains unacceptably high. In more than four decades of research, a variety of approaches have been taken, but a consensus approach toward diagnostic decision making has not emerged. In the last 20 years, important gains have been made in psychological 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 proposes a schematic model that uses the theory to develop a universal approach toward clinical decision making. Properties of the model explain many of the observed characteristics of physicians' performance. Yet the author cautions that not all medical reasoning and decision making falls neatly into one or the other of the model's systems, even though they provide a basic framework incorporating the recognized diverse approaches. He also emphasizes the complexity of decision making in actual clinical situations and the urgent need for more research to help clinicians gain additional insight and understanding regarding their decision 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. [email protected]
Neuroeconomics seeks to gain a greater understanding of decision making by combining theoretical and methodological principles from the fields of psychology, economics, and neuroscience. Initial studies using this multidisciplinary approach have found evidence suggesting that the brain may be employing multiple levels of processing when making decisions, and this notion is consistent with dual-processing theories that have received extensive theoretical consideration in the field of cognitive psychology, with these theories arguing for the dissociation between automatic and controlled components of processing. While behavioral studies provide compelling support for the distinction between automatic and controlled processing in judgment and decision making, less is known if these components have a corresponding neural substrate, with some researchers arguing that there is no evidence suggesting a distinct neural basis. This chapter will discuss the behavioral evidence supporting the dissociation between 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.
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 8
Implementation science: a role for parallel dual processing models of reasoning?
Sladek RM, Phillips PA, Bond MJ.
Flinders University, Adelaide, South Australia. [email protected]
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 been guided empirically, without explicit consideration of underlying theoretical rationales for such strategies. This paper considers a theoretical framework for reasoning from within psychology for identifying individual differences in cognitive processing between doctors that could moderate the decision to incorporate new evidence into their clinical decision-making.
DISCUSSION: Parallel dual processing models of reasoning posit two cognitive modes of information processing that are in constant operation as humans reason. One mode has been described as experiential, fast and heuristic; the other as rational, conscious and rule based. Within such models, the uptake of new research evidence can be represented by the latter mode; it is reflective, explicit and intentional. On the other hand, well practiced clinical judgments can be positioned in the experiential mode, being automatic, reflexive and swift. Research suggests that individual differences between people in both cognitive capacity (e.g., intelligence) and cognitive processing (e.g., thinking styles) influence how both reasoning modes interact. This being so, it is proposed that these same differences between doctors may moderate the uptake of new research evidence. Such dispositional characteristics have largely been ignored in research investigating effective strategies in implementing research evidence. Whilst medical decision-making occurs in a complex social environment with multiple influences and decision makers, it remains true that an individual doctor's judgment still retains a key position in terms of diagnostic and treatment decisions for individual patients. This paper argues therefore, that individual differences between doctors in terms of reasoning are important considerations in any discussion relating to changing clinical practice.
SUMMARY: It is imperative that change strategies in healthcare consider relevant theoretical frameworks from other disciplines such as psychology. Generic dual processing models of reasoning are proposed as potentially useful in identifying factors within doctors that may moderate their individual uptake of evidence into clinical decision-making. Such factors can then inform strategies to change practice.
PMCID: PMC1523359 PMID: 16725023 [PubMed]
13. Nurs Health Sci. 2006 Mar;8(1):57-65.
Diagnostic practise in nursing: a critical review of the literature.
Lee J, Chan AC, Phillips DR.
School of Science and Technology, The Open University of Hong Kong, Homantin, Kowloon, Hong Kong. [email protected]
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 9
The purpose of this article is to critically review and synthesize the literature related to the general concepts and the process of diagnosing the client's condition, and the possible variables which influence diagnostic practise in nursing. It is suggested that statistical theories are capable of capturing the diagnostic process and offer an effective means to predict diagnostic decisions. Studies underpinned by information-processing theory argue that diagnosing a patient's condition follows a hypothetico- deductive model that consists of specific stages. Those who hold a phenomenological perspective remark that there is yet another form of diagnostic practise: intuitive reasoning, which plays an important role in diagnosing the patient's clinical condition. Other related studies suggest that diagnostic practise is contingent on some personal, psychosocial, and structural variables. Regrettably, these studies offer no conclusive explanation to delineate diagnostic practise in nursing. Based on the literature reviewed, a conceptual framework is suggested to help articulate the underlying structures and processes of diagnostic practise in nursing.
PMID: 16451430 [PubMed - indexed for MEDLINE]
14. Psychon Bull Rev. 2004 Dec;11(6):988-1010.
An evaluation of dual-process theories of reasoning.
Osman M.
Department of Psychology, University College London, London, England. [email protected]
Current theories propose that reasoning comprises two underlying systems (Evans & Over, 1996; Sloman, 1996; Stanovich & West, 2000). The systems are identified as having functionally distinct roles, differ according to the type of information encoded, vary according to the level of expressible knowledge, and result in different responses. This article evaluates the arguments and the evidence from a select number of key tasks that have been supportive of dual-reasoning theorists' proposals. The review contrasts the dualist approach with a single-system framework that conjectures that different types of reasoning arise through the graded properties of the representations that are utilized while reasoning, and the different functional roles that consciousness has in cognition. The article concludes by arguing in favor of the alternative framework, which attempts to unify the different forms of reasoning identified by dual-process theorists under a single system.
PMID: 15875969 [PubMed - indexed for MEDLINE]
15. J Biomed Inform. 2002 Feb;35(1):52-75.
Emerging paradigms of cognition in medical decision-making.
Patel VL, Kaufman DR, Arocha JF.
Laboratory for Decision Making and Cognition, Departments of Medical Informatics and Psychiatry, Columbia University, Vanderbilt Clinic Bldg., 5th Floor, 622 West 168th Street, New York 1003, USA. [email protected]
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 10
The limitations of the classical or traditional paradigm of decision research are increasingly apparent, even though there has been a substantial body of empirical research on medical decision-making over the past 40 years. As decision-support technology continues to proliferate in medical settings, it is imperative that "basic science" decision research develop a broader-based and more valid foundation for the study of medical decision-making as it occurs in the natural setting. This paper critically reviews both traditional and recent approaches to medical decision making, considering the integration of problem-solving and decision-making research paradigms, the role of conceptual knowledge in decision- making, and the emerging paradigm of naturalistic decision-making. We also provide an examination of technology-mediated decision-making. Expanding the scope of decision research will better enable us to understand optimal decision processes, suitable coping mechanisms under suboptimal conditions, the development of expertise in decision-making, and ways in which decision-support technology can successfully mediate decision processes.
PMID: 12415726 [PubMed - indexed for MEDLINE]
Blog Posts http://lesswrong.com/lw/531/how_you_make_judgments_the_elephant_and_its_rider/ A very brief laymen’s explanation of the Dual Process Theory.
Books
Kattan, Michael W, and Mark E. Cowen. Encyclopedia of Medical Decision Making. Thousand Oaks, Calif: SAGE Publications, 2009. Print.
Links http://en.wikipedia.org/wiki/Dual_process_theory Wikipedia link that explains the basics of the dual process model theory. http://thoughtbroadcast.com/tag/dual-process-model/ A brief overview of the dual process model theory pertaining to clinical diagnosis.
Slides http://www.slideshare.net/notmy2ndopinion/differential-diagnosis-16351069 Slides by Clinton Pong from Tufts/Cambridge Health Alliance http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&ved=0CFAQFjAF&url=http%3A %2F%2Fqualellc.files.wordpress.com%2F2010%2F01%2Fintuitive-decision-making-presentation-2010- short.ppt&ei=suKfUY_MMYPmiwK44IHgDg&usg=AFQjCNGxcFzR1X2S5o7GzILfRkIzaSNDYw&sig2=wMc2V 4J8AR9RFlTprEl3gQ&bvm=bv.47008514,d.cGE&cad=rja
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13 11
Powerpoint presentation by Robert Patterson, Ph.D. Slides 7 & 8 are great examples of what dual process decision making is.
Thesis
Dual-Process Theories and the Rationality Debate: Contributions from Cognitive Neuroscience Trevor Hannesson Kvaran http://digitalarchive.gsu.edu/cgi/viewcontent.cgi?article=1019&context=philosophy_theses
Video http://www.learner.org/series/discoveringpsychology/11/e11expand.html
“Judgement and Decision Making is the eleventh program in the DISCOVERING PSYCHOLOGY series. This program looks at the process of making decisions and judgements, how and why people make different choices, the factors that influence decisions, and the psychology of risk taking.”
Searched by Saori Wendy Herman, MLIS, AHIP Updated 5/24/13