The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking
Open accessAbstract
Contemporary theories of clinical reasoning espouse a dual processing model, which consists of a rapid, intuitive component (Type 1) and a slower, logical and analytical component (Type 2). Although the general consensus is that this dual processing model is a valid representation of clinical reasoning, the causes of diagnostic errors remain unclear. Cognitive theories about human memory propose that such errors may arise from both Type 1 and Type 2 reasoning. Errors in Type 1 reasoning may be a consequence of the associative nature of memory, which can lead to cognitive biases. However, the literature indicates that, with increasing expertise (and knowledge), the likelihood of errors decreases. Errors in Type 2 reasoning may result from the limited capacity of working memory, which constrains computational processes. In this article, the authors review the medical literature to answer two substantial questions that arise from this work: (1) To what extent do diagnostic errors originate in Type 1 (intuitive) processes versus in Type 2 (analytical) processes? (2) To what extent are errors a consequence of cognitive biases versus a consequence of knowledge deficits? The literature suggests that both Type 1 and Type 2 processes contribute to errors. Although it is possible to experimentally induce cognitive biases, particularly availability bias, the extent to which these biases actually contribute to diagnostic errors is not well established. Educational strategies directed at the recognition of biases are ineffective in reducing errors; conversely, strategies focused on the reorganization of knowledge to reduce errors have small but consistent benefits.
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- Authors
- Norman, G. R., Monteiro, S. D., Sherbino, J., Ilgen, J. S., Schmidt, H. G., & Mamede, S.
- Affiliations
- McMaster University (CA)
- University of Washington (US)
- Erasmus University Rotterdam (NL)
- S. Mamedeis associate professor, Department of Psychology, Erasmus University, Rotterdam, the Netherlands.
- Corresponding author
- Norman, Geoffrey R.
- Venue
- Academic Medicine
- Publisher
- Oxford University Press (OUP)
- Published
- 2017-01
- Volume
- 92
- Issue
- 1
- Pages
- 23-30
- ISSN
- 1040-2446 (ISSN-L)
- OpenAlex
- W2545846385
- Cited by
- 594
- References
- 70
- Citations by year
- 2026: 89 · 2025: 71 · 2024: 60 · 2023: 54 · 2022: 64 · 2021: 77 · 2020: 67 · 2019: 49 · 2018: 34 · 2017: 27 · 2016: 1
- FWCI
- 45.12
- Type
- journal article
- Language
- en
- Open access
- green
- pure.eur.nl
- Licence
- other-oa
- Locations
- Academic Medicine (publishedVersion)
- PubMed (publishedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Social Sciences › Decision Sciences › General Decision Sciences › Decision-Making and Behavioral Economics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Keywords
- diagnostic errors, clinical reasoning, dual-process theory, cognitive biases, availability bias, knowledge deficit, working memory, expertise, associative memory, knowledge restructuring, medical education
- MeSH terms
- Cognition, Diagnostic Errors, Humans, Memory, Thinking, Bias
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