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The Etiology of Diagnostic Errors: A Controlled Trial of System 1 Versus System 2 Reasoning
Abstract
Purpose Diagnostic errors are thought to arise from cognitive biases associated with System 1 reasoning, which is rapid and unconscious. The primary hypothesis of this study was that the instruction to be slow and thorough will have no advantage in diagnostic accuracy over the instruction to proceed rapidly. Method Participants were second-year residents who volunteered after they had taken the Medical Council of Canada (MCC) Qualifying Examination Part II. Participants were tested at three Canadian medical schools (McMaster, Ottawa, and McGill) in 2010 (n = 96) and 2011 (n = 108). The intervention consisted of 20 computer-based internal medicine cases, with instructions either (1) to be as quick as possible but not make mistakes (the Speed cohort, 2010), or (2) to be careful, thorough, and reflective (the Reflect cohort, 2011). The authors examined accuracy scores on the 20 cases, time taken to diagnose cases, and MCC examination performance. Results Overall accuracy in the Speed condition was 44.5%, and in the Reflect condition was 45.0%; this was not significant. The Speed cohort took an average of 69 seconds per case versus 89 seconds for the Reflect cohort (P Conclusions The study demonstrates that simply encouraging slowing down and increasing attention to analytical thinking is insufficient to increase diagnostic accuracy.
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“it can also lead to judgment errors and cognitive biases [92,93], such as anchoring, confirmation, attribution, availability, confidence, and delay discounting.”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [92]
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“Some core skills and knowledge tested, such as problem-solving and clinical decision-making, have been shown to correlate with diagnostic accuracy in practice [92].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [92]
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References 34 · Cited by 174
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Metadata
- Authors
- Norman, G., Sherbino, J., Dore, K., Wood, T., Young, M., Gaissmaier, W., Kreuger, S., & Monteiro, S.
- Affiliations
- Medical Council of Canada (CA)
- Corresponding author
- Norman, Geoffrey
- Venue
- Academic Medicine
- Publisher
- Oxford University Press (OUP)
- Published
- 2014-02
- Volume
- 89
- Issue
- 2
- Pages
- 277-284
- ISSN
- 1040-2446 (ISSN-L)
- OpenAlex
- W1974039834
- Cited by
- 174
- References
- 34
- Citations by year
- 2026: 6 · 2025: 9 · 2024: 13 · 2023: 9 · 2022: 14 · 2021: 19 · 2020: 15 · 2019: 14 · 2018: 18 · 2017: 16 · 2016: 16 · 2015: 13 · 2014: 9
- FWCI
- 11.60
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Academic Medicine (publishedVersion)
- PubMed (publishedVersion)
- Max Planck Institute for Plasma Physics (submittedVersion)
- Funders
- McGill University
- McMaster University
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Social Sciences › Education › Innovations in Medical Education
- Social Sciences › Decision Sciences › General Decision Sciences › Decision-Making and Behavioral Economics
- Keywords
- diagnostic errors, diagnostic accuracy, cognitive biases, reflective thinking, analytical thinking, internal medicine residents, time to diagnosis, medical licensing examinations
- MeSH terms
- Attention, Canada, Clinical Competence, Decision Making, Diagnostic Errors, Humans, Internal Medicine, Internship and Residency, Prospective Studies, Time Factors, Cohort Studies
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