To answer this week’s discussion questions will require that you read three articles on dual processing theory and reducing diagnostic errors. You are expected to apply the course readings mentioned below (these can be found in the Week 4 Assigned readings) YOU WILL NOT BE ABLE TO ANSWER THIS WEEK’S DISCUSSION QUESTION WITHOUT READING THE ASSIGNED ARTICLES, See the questions outlined below. 

Djulbegovic et al. (2012)

Monteiro et al., (2019)

Pierret (2016 

Case: 1

Chief Complaint: “Pain in Right Side” A 40-year-old man presents to his primary care provider (PCP) with right upper quadrant (RUQ) pain for 2 days. The pain is described as “sore” and rated 4 on 1 to 10 pain scale. The pain is intermittent and not worsening. He reports food does not seem to make it better or worse. No nausea or vomiting or diarrhea or constipation are reported. 

Vital signs: heart rate, 75; blood pressure, 122/78; respiration rate, 15; afebrile. 

Examination: No acute distress. Abdomen: mildly tender on palpation at RUQ; no masses, hepatomegaly or splenomegaly. 

Diagnosis: Gallbladder disease. 

Plan: Abdominal ultrasound with reflexive cholescintigraphy (hepatobiliary iminodiacetic acid) scan within 1 week. Patient instructed to call provider if worsening symptoms occur. He is also told to avoid any fatty foods or alcohol consumption. The patient is agreeable to plan. 

Follow-up: Two days after the initial visit, the patient calls his PCP with worsening RUQ pain. Ultrasound imaging was scheduled for later that day. Patient then started having shortness of breath while at home and went to the local emergency department (ED). Computed tomography angiography of the chest revealed a right-sided pulmonary embolism. Patient did not have any family history of clotting disorders and no recent surgery, immobilization, or travel. Patient had been on testosterone injections for several years for low testosterone levels, and this was not updated in his medical record at his PC

Case 2

Chief Complaint: “Fever and Sleepy” A 3-year-old girl presents with her mother to a walk-in clinic with fever, nasal drainage, and fatigue for 2 days. She was observed hiding her head into her mother’s chest during the examination. 

Presentation occurred during flu season. The clinician had 6 positive flu tests that day, all with similar symptoms, but most including a cough. 

Vital signs: heart rate, 125; respiration rate, 20; blood pressure, 100/72; temperature, 100.8F. 

Examination: Lungs clear, heart rate regular, no murmur. Head, eyes, ears, nose, and throat: normocephalic, conjunctivae clear, tympanic membrane without bulging or redness, pharynx normal, nares normal with clear drainage, tonsils 1þ, no erythema or exudate. Patient did not want to look at the clinician in a brightly lit room. The patient was lethargic and had limited tearing when crying. Rapid flu test: Negative. 

Diagnosis: Presumptive seasonal influenza. 

Plan: Supportive care, including encouraging fluids, Over the counter acetaminophen for fever, and age-appropriate antiviral medication for the flu was prescribed. 

Follow-up: Parents were unable to keep her fever down over the next 1 day, and she progressively became more lethargic. Patient was taken to the ED, and a diagnosis of viral meningitis and dehydration was made. Patient spent several days in the hospital, but did completely recover.

  1. Describe the Dual Process Theory and Reasoning Process and how it applies to making decisions for the advanced practice nurse. 
  2. What are cognitive dispositions to respond? How are these applied in the APN setting. 
  3. Describe cognitive debiasing?
  4. Describe how Type 1 (System 1) and Type 2 (System 2) processes and strategies can be applied to each case to help the NP make decisions and to decrease potential diagnostic error? 
  5. What considerations for change to practice should the NP consider in each situation as a way to decrease the chance of future diagnostic and care decisions. 

Please be sure to adhere to the following when posting your weekly discussions: all discussion posts must be minimum 250 words, references must be cited in APA format 7th Edition, and must include minimum of 2 scholarly resources published within the past 5-7 years. 

Djulbegovic et al. BMC Medical Informatics and Decision Making 2012, 12:94


Dual processing model of medical
Benjamin Djulbegovic1,2,3,7*, Iztok Hozo4, Jason Beckstead5, Athanasios Tsalatsanis1,2 and Stephen G Pauker6


Background: Dual processing theory of human cognition postulates that reasoning and decision-making can be
described as a function of both an intuitive, experiential, affective system (system I) and/or an analytical, deliberative
(system II) processing system. To date no formal descriptive model of medical decision-making based on dual
processing theory has been developed. Here we postulate such a model and apply it to a common clinical
situation: whether treatment should be administered to the patient who may or may not have a disease.

Methods: We developed a mathematical model in which we linked a recently proposed descriptive psychological
model of cognition with the threshold model of medical decision-making and show how this approach can be
used to better understand decision-making at the bedside and explain the widespread variation in treatments
observed in clinical practice.

Results: We show that physician’s beliefs about whether to treat at higher (lower) probability levels compared to
the prescriptive therapeutic thresholds obtained via system II processing is moderated by system I and the ratio of
benefit and harms as evaluated by both system I and II. Under some conditions, the system I decision maker’s
threshold may dramatically drop below the expected utility threshold derived by system II. This can explain the
overtreatment often seen in the contemporary practice. The opposite can also occur as in the situations where
empirical evidence is considered unreliable, or when cognitive processes of decision-makers are biased through
recent experience: the threshold will increase relative to the normative threshold value derived via system II using
expected utility threshold. This inclination for the higher diagnostic certainty may, in turn, explain undertreatment
that is also documented in the current medical practice.

Conclusions: We have developed the first dual processing model of medical decision-making that has potential to
enrich the current medical decision-making field, which is still to the large extent dominated by expected utility
theory. The model also provides a platform for reconciling two groups of competing dual processing theories
(parallel competitive with default-interventionalist theories).

Dual processing theory is currently widely accepted as a
dominant explanation of cognitive processes that charac-
terizes human decision-making [1-9]. It assumes that
cognitive processes are governed by so called system I
(which is intuitive, automatic, fast, narrative, experiential
and affect-based) and system

66  | Medical Education. 2020;54:66–73.© 2019 John Wiley & Sons Ltd and The Association
for the Study of Medical Education


Virtually everyone would agree that a primary, yet
insufficiently met, goal of schooling is to enable stu-
dents to think critically. (Willingham, 20071)

Not everyone. We do not agree. In this paper, we defend the po-
sition that the above assertion (ie that the central focus of education
should be to inculcate general skills like critical thinking, problem solv-
ing, clinical reasoning and reflection) is indeed a myth. Although the
idea of general thinking skills has a long history, it first emerged as a

major focus of curriculum reform and research effort in the 1960s, was
discounted by evidence in the 1970s and 1980s, but has re- emerged
under different banners in the new millennium.

Our central claim is that the preponderance of evidence, in medical
education and cognitive psychology, does not support this assertion.
Instead, the evidence demonstrates again and again that the essence
of expertise is the possession of a large, organised and retrievable
body of both formal and experiential knowledge, not any kind of gen-
eral thinking skills. In this paper, we annotate a brief history of the
rise and fall, and rise again, of this assertion, providing the perspective
from both cognitive psychology and medical education research.

Received: 30 May 2018  |  Revised: 10 October 2018  |  Accepted: 13 February 2019

DOI: 10.1111/medu.13872


Critical thinking, biases and dual processing: The enduring
myth of generalisable skills

Sandra Monteiro1,2  | Jonathan Sherbino2,3 | Matthew Sibbald2,3  |
Geoff Norman1,2

1Health Research Methods, Evidence and
Impact, McMaster University, Hamilton,
Ontario, Canada
2McMaster Education Research, Innovation
and Theory Programme, McMaster
University, Hamilton, Ontario, Canada
3Department of Medicine, McMaster
University, Hamilton, Ontario, Canada

Sandra Monteiro, David Braley Health
Sciences Centre, McMaster University, 100
Main Street, 5th Floor, Hamilton, ON L8P
1H6, Canada.
Email: [email protected]

Context: The myth of generalisable thinking skills in medical education is gaining
popularity once again. The implications are significant as medical educators decide
on how best to use limited resources to prepare trainees for safe medical practice.
This myth- busting critical review cautions against the proliferation of curricular inter-
ventions based on the acquisition of generalisable skills.
Structure: This paper begins by examining the recent history of general thinking skills,
as defined


Nurse Practitioners’ Versus Physicians’
Diagnostic Reasoning Style and Use
of Maxims: A Comparative Study
Alison M. Pirret, PhD, NP

The study used an intuitive/analytic reasoning instrument and maxims questionnaire to compare 1) the
diagnostic reasoning style of 30 nurse practitioners (NPs) and 16 resident doctors and 2) its influence on their
diagnostic reasoning abilities of a complex case. The results showed NPs incorporated more system I
(intuitive) processes when compared with residents; however, both groups identified with certain maxims.
Diagnostic reasoning style was not related to participants’ diagnostic reasoning abilities, indicating they
triggered system II (analytic) processes when required. Although system I processes are essential, clinicians
need to be aware of the value and pitfalls associated with them.

Keywords: diagnostic reasoning style, maxims, nurse practitioner
� 2016 Elsevier Inc. All rights reserved.

he first New Zealand (NZ) nurse practi-
tioner (NP) was registered in 2002, with

Tthe 100th NP being registered in early

2012.1 In NZ, the title NP is legally protected and
can only be used by nurses with a master’s degree
who have passed rigorous assessment processes.2

Legislation in NZ allows NPs to practice
independently without physician supervision.2

Research shows NPs and resident doctors have
similar patient outcomes and diagnostic reasoning
abilities.2 Diagnostic reasoning requires clinicians to
collect relevant assessment data, retrieve memorized
knowledge, and integrate data in the working
memory. Because of limited capacity in the working
memory, this process can overstretch the cognitive
resources and create congitive overload, which risks
diagnostic error.3 Singh et al4 suggest 12 million
United States adults are affected by diagnostic error
every year. Because diagnostic reasoning style
impacts on diagnostic accuracy,5 it is worthy of
further exploration.

This study compared NPs’ and resident doctors’
diagnostic reasoning style and use of maxims to guide
their diagnostic reasoning. It answered 3 questions:
1) How does NP diagnostic reasoning style compare
with that of residents? 2) How do maxims used
by NPs in their diagnostic reasoning compare with

those used by residents? and 3) Are NPs’ and resi-
dents’ diagnostic reasoning ability scores described
by Pirret et al2 influenced by their diagnostic
reasoning style and use of maxims in everyday
practice? The first 2 questions were based on the
assumption that as NZ NPs were expected to
have more years of experience than residents, they
were more likely to use system I processes in their
diagnostic reasoning.

Dual process theory identifies diagnostic reasoning
uses system I (intuitive) and system II (analytic)
processes; the degree to which each is used is