Physiatry Forward: Training Residents in Dual Mode Processing
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Training Residents in Dual Mode of Information Processing

Author: Alex Moroz, MD, MHPE
Residency Program Director, NYU Langone Health/ Rusk Rehabilitation

Medical errors involve both system and physician factors.(2) Of the latter, physician cognitive factors (information processing), rather than knowledge or data collection, probably account for majority of diagnostic errors.(8)

Conceptual framework of dual process of reasoning originated in cognitive psychology(1) and has been widely accepted to explain and study physician clinical reasoning(9).

‘Reflexive’ mode (System 1) is a rapid, intuitive pattern recognition process, largely outside of conscious control. In contrast, ‘reflective’ mode (System 2) is slower, and involves deliberate and intentional systematic analysis of available data. Empiric evidence regarding the preferential accuracy of the two systems is mixed.

Structured, deliberate reflection resulted in better diagnostic performance than immediate generation of differential diagnoses in senior medical students(5) and internal medicine residents(10). Sibbald and de Bruin echoed these findings and discovered that regardless of strategy used initially, instructions to systematically analyze data rather than look for patterns resulted in improved diagnostic accuracy.(11)

In contrast, in a large multicenter randomized study that involved students, residents, and faculty, Ilgen found that instructions to trust one’s first impressions resulted in similar diagnostic performance compared with instructions to engage in systematic analysis.(3) Similarly, encouraging residents to slow down and engage in analytical reasoning did not result in increased diagnostic accuracy, and that incorrectly diagnosed cases took longer regardless of the reasoning strategy used.(9)

In a more recent systematic review, guided reflection interventions emerged as consistently successful, and cognitive forcing strategies improved accuracy and confidence judgements.(4)

Developing effective clinical reasoning habits while in training is important as it may foster continued professional development and facilitate progression to expertise, reduce diagnostic errors, and ultimately improve patient safety.

In the first baby step, two brief workshops focusing on musculoskeletal diagnoses were developed for PM&R residents.(6,7) The workshops (available online, see links in references) were effective in engaging residents and resulted in high resident satisfaction and perception of increased ability to tackle clinical problems. Faculty time required was moderate after the initial setup, which primarily involved uploading content into an online learning management system.

Questions for future research are whether residents’ diagnostic accuracy is enhanced using directed training designed to foster switching between these two modes of processing (reflexive and reflective), and what is the comparative effectiveness and feasibility of available instructional methods.


  1. Evans, J. (2008). Dual processing accounts of cognitive reasoning, judgment, and social cognition. Annual Review of Psychology, 59, 255-278.
  2. Graber, M., Franklin, N., Gordon, R. (2005). Diagnostic errors in internal medicine. Archives of Internal Medicine, 165, 1493-1499.
  3. Ilgen J.S., Bowen J.L., McIntyre L.A., Banh, K.V., Barnes, D., Coates, W.C., et al. (2013). Comparing diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought. Academic Medicine, 88:1545–1551
  4. Lambe KA, O'Reilly G, Kelly BD, et al. (2016). Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf, 25:808-820.
  5. Mamede, S., van Gog, T., Moura, A.S., de Faria, R.M.D., Peixoto, J.M., Rikers, R.M.J.P., Schmidt, H.G. (2012). Reflection as a strategy to foster medical students' acquisition of diagnostic competence. Medical Education, 46, 464-472.
  6. Moroz A. (2017a). Clinical reasoning workshop: cervical spine and shoulder disorders. MedEdPORTAL, 13:10560.
  7. Moroz A. (2017b). Clinical reasoning workshop: lumbosacral spine and hip disorders. MedEdPORTAL, 13:10632.
  8. Norman, G. (2009). Dual processing and diagnostic errors. Advances in Health Science Education, 14, 37-49.
  9. Norman, G., Sherbino, J., Dore, K., Wood, T., Young, M., Gaissmaier, W., Kreuger, S., Monteiro, S. (2014). The etiology of diagnostic errors: A controlled trial of system 1 versus system 2 reasoning. Academic Medicine, 89, 277-284.
  10. Schmidt, H.G., Mamede, S., van den Berge, K., van Gog, T., van Saase, J.L.C.M., Rikers, R.M.J.P. (2014). Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases. Academic Medicine, 89, 285-291.
  11. Sibbald, M., De Bruin, A.B.H. (2012). Feasibility of self-reflection as a tool to balance clinical reasoning strategies. Advances in Health Sciences Education, 17 (3), 419-429.