Abstract
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.
Similar content being viewed by others
Notes
In contrast to the modern (psychological) view of intuition as an unconscious, automatic, biased process that may fall short of rationality, the ancient (philosophical) view saw it as a superior form of intelligent and rational reasoning reflecting a supreme state of mind. The change appears to have occurred quite recently in the early twentieth century, influenced by the work of the French philosopher Henri Bergson (Henden 2004).
References
Berner, E. S., & Graber, M. L. (2008). Overconfidence as a cause of diagnostic error in medicine. The American Journal of Medicine, 121(5, Supplement 1), S2–S23.
Brown, D. E. (1991). Human universals. New York: McGraw Hill.
Buschman, T. J., & Miller, E. K. (2007). Top-down versus bottom-up control of attention in the prefrontal and posterior parietal cortices. Science, 315(5820), 1860–1862.
Cartwright, J. (2008). Evolution and human behavior: Darwinian perspectives on human nature (2nd ed.). Cambridge, MA: MIT Press.
Croskerry, P. (2005). The theory and practice of clinical decision making. Canadian Journal of Anesthesia, 52, R1–R8.
Croskerry, P. (2008). Cognitive and affective dispositions to respond. In P. Croskerry, K. Cosby, S. Schenkel, & R. Wears (Eds.), Patient safety in emergency medicine (pp. 219–227). Philadelphia: Lippincott, Williams & Wilkins.
Croskerry, P. (2009a). A universal model for diagnostic reasoning. Academic Medicine, 84, 1022–1028.
Croskerry, P. (2009b). Context is everything, or: How could I have been that stupid? Healthcare Quarterly, 12, 167–173.
Croskerry, P., Abbass, A., & Wu, A. W. (2008). How doctors feel: Affective issues in patient safety. Lancet, 372, 1205–1206.
Croskerry, P., & Norman, G. (2008). Overconfidence in clinical decision making. The American Journal of Medicine, 121(5, Supplement 1), S24–S29.
Dawes, R., Faust, D., & Meehl, P. (2002). Clinical versus actuarial judgment. In T. Gilovich, D. Griffin, & D. Kahneman (Eds.), Heruistics and biases: The psychology of intuitive judgment (pp. 716–729). New York: Cambridge University Press.
Dawson, N. V. (1993). Physician judgment in clinical settings: Methodological influences and cognitive performance. Clinical Chemistry, 39, 1468–1480.
Evans, J. S. (2008). Dual-processing accounts of reasoning, judgment, and social cognition. Annual Review of Psychology, 59, 255–278.
Fodor, J. (1983). The modularity of mind. Cambridge, MA: MIT Press.
Gilbert, D. T., Pelham, B. W., & Krull, D. S. (2003). The psychology of good ideas. Psychological Inquiry, 14(3), 258–260.
Graber, M. (2005). Diagnostic errors in medicine: A case of neglect. Joint Commission Journal on Quality and Patient Safety, 31(2), 106–113.
Groopman, J. (2007). How doctors think. New York: Houghton Mifflin Company.
Hammond, K. (2000). Human judgment and social policy: Irreducible uncertainty, inevitable error, unavoidable injustice. New York, NY: Oxford University Press.
Hardman, D. (2009). Judgment and decision making: Psychological perspectives. Oxford: Blackwell.
Henden, G. (2004). Intuition and its role in strategic thinking. Doctoral dissertation. BI Norwegian School of Management. Accessed January 4 2009. http://web.bi.no/forskning/papers.nsf/349b2672a809db42c1256e620044a25f/2682ad7f82929fdfc1256ecc002d3841/$FILE/2004-04-henden.pdf
Jacoby, L. L. (1999). Deceiving the elderly: Effects of accessibility bias in cued-recall performance. Cognitive Neuropsychology, 16, 417–436.
Lieberman, M. D. (2000). Intuition: A social cognitive neuroscience approach. Psychological Bulletin, 126(1), 109–137.
Lieberman, M. D., Jarcho, J. M., & Satpute, A. B. (2004). Evidence-based and intuition-based self-knowledge: An FMRI study. Journal of Personality and Social Psychology, 87(4), 421–435.
Montgomery, K. (2006). How doctors think: Clinical judgment and the practice of medicine. Oxford: Oxford University Press.
Mumford, A. D., & Banning, A. P. (1997). Minimising delays to thrombolysis in patients developing acute myocardial infarction in hospital. Postgraduate Medical Journal, 73(862), 491–495.
Norman, G. R., & Eva, K. W. (2005). Does clinical experience make up for failure to keep up to date? Evidence-Based Medicine, 10(3), 66–68.
Oades, R. D., Lasky-Su, J., Christiansen, H., Faraone, S. V., Sonuga-Barke, E. J. S., Banaschewski, T., et al. (2008). The influence of serotonin and other genes on impulsive behavioral aggression and cognitive impulsivity in children with attention-deficit/hyperactivity disorder (ADHD): Findings from a family-based association test (FVAT) analysis. 10-20-2008.
Pacini, R., & Epstein, S. (1999). The relation of rational and experiential information processing styles to personality, basic beliefs, and the ratio-bias phenomenon. Journal of Personality and Social Psychology, 76(6), 972–987.
Peters, E., Finucane, M., MacGregor, D., & Slovic, P. (2000). The bearable lightness of aging: Judgment and decision processes in older adults. In P. Stern & L. Carstensen (Eds.), The aging mind: Opportunities in cognitive research (pp. 144–165). Washington, DC: National Academy Press.
Rorty, A. O. (1980). Where does the akratic break take place? Australasian Journal of Philosophy, 58(4), 333–346.
Simon, H. (1990). Alternate visions of reality. In P. K. Moser (Ed.), Rationality in action: Contemporary approaches (pp. 189–204). New York: Cambridge University Press.
Slovic, P., Finucane, M., Peters, E., & MacGregor, D. (2002). The affect heuristic. In Press. In T. Gilovich, D. Griffin, & D. Kahneman (Eds.), Heuristics and biases: The psychology of intuitive judgment (pp. 397–420). Cambridge, UK: Cambridge University Press.
Stanovich, K. E. (1993). Dysrationalia: A new specific learning disability. Journal of learning disabilities, 26(8), 501–515.
Stanovich, K. E. (2004). The robot’s rebellion: Finding meaning in the age of Darwin. Chicago: The University of Chicago Press.
Thompson, C., Yang, H. (2009). Nurses’ decisions, irreducible uncertainty and maximizing nurses’ contribution to patient safety. Healthcare Quarterly, 12, 172–179.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Croskerry, P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv in Health Sci Educ 14 (Suppl 1), 27–35 (2009). https://doi.org/10.1007/s10459-009-9182-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10459-009-9182-2