More on the Causes of Errors in Clinical Reasoning

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We read with great interest the article by Norman and colleagues1 examining the relative contributions of cognitive biases versus knowledge deficits in clinical reasoning errors. The authors conclude that cognitive debiasing strategies may be ineffective and contend that, above all, “Knowledge matters.”1 We commend the authors for their robust review and agree that knowledge is paramount. However, how Type 1 and 2 thinking are activated during knowledge acquisition may be more relevant to eliminating cognitive errors and developing expertise.
Sadly, today’s clinical learning environment constrains Type 2 thinking and inadvertently promotes Type 1 thinking in knowledge acquisition. Time-pressed learners now rely heavily on point-of-care summary resources rather than long-revered textbooks. The former resources distill broader knowledge effectively but fail to promote a deeper understanding of disease. For example, review books train students to recognize the triad of tachycardia, hypertension, and sweating as a pheochromocytoma without mentioning the rarity of the disease or the pitfalls in its diagnostic evaluation.2 Analytical Type 2 processes may be activated during such knowledge acquisition (i.e., the trainee connects the pathophysiology of pheochromocytoma to its symptoms). However, rote memorization of patterns from abbreviated resources propagates cognitive bias at the bedside because of distorted knowledge acquisition and faulty encoding of patterns into learners’ Type 1 thinking.
Seeing patients on the continuum from “common presentation of common diseases” to “uncommon presentations of uncommon diseases” provides a natural experiment for learners to toggle between Type 1 and Type 2 reasoning. Educators must invest the time to optimize Type 2 thinking by engaging trainees’ “toggle function” during clinical and educational activities. Despite Type 2 thinking’s limitations, an early adaption to analytic thinking during training is required for mastering clinical reasoning. We must push learners to refine their diagnostic reasoning with Type 2 thinking in an iterative fashion exemplified by the Dreyfus model of skill acquisition. In such a model, attaining expertise requires analytic thinking through a series of developmental subprocesses.3 Regularly integrating Type 2 thinking into learners’ knowledge acquisition allows learners to progress through the Dreyfus model’s developmental stages.
Having our trainees identify prototypical patterns creates a cadre of incompletely informed clinicians primed to rely on Type 1 reasoning. Snap judgments made with Type 1 thinking further imperil learners’ development and promote overconfidence, another barrier for Type 2 thinking.4 Educators must regularly activate Type 2 thinking as learners acquire and integrate medical knowledge to avoid downstream cognitive errors.
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