Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review

BMJ Qual Saf. 2016 Oct;25(10):808-20. doi: 10.1136/bmjqs-2015-004417. Epub 2016 Feb 12.


Background: Diagnostic error incurs enormous human and economic costs. The dual-process model reasoning provides a framework for understanding the diagnostic process and attributes certain errors to faulty cognitive shortcuts (heuristics). The literature contains many suggestions to counteract these and to enhance analytical and non-analytical modes of reasoning.

Aims: To identify, describe and appraise studies that have empirically investigated interventions to enhance analytical and non-analytical reasoning among medical trainees and doctors, and to assess their effectiveness.

Methods: Systematic searches of five databases were carried out (Medline, PsycInfo, Embase, Education Resource Information Centre (ERIC) and Cochrane Database of Controlled Trials), supplemented with searches of bibliographies and relevant journals. Included studies evaluated an intervention to enhance analytical and/or non-analytical reasoning among medical trainees or doctors.

Findings: Twenty-eight studies were included under five categories: educational interventions, checklists, cognitive forcing strategies, guided reflection, instructions at test and other interventions. While many of the studies found some effect of interventions, guided reflection interventions emerged as the most consistently successful across five studies, and cognitive forcing strategies improved accuracy and confidence judgements. Significant heterogeneity of measurement approaches was observed, and existing studies are largely limited to early-career doctors.

Conclusions: Results to date are promising and this relatively young field is now close to a point where these kinds of cognitive interventions can be recommended to educators. Further research with refined methodology and more diverse samples is required before firm recommendations may be made for medical education and policy; however, these results suggest that such interventions hold promise, with much current enthusiasm for new research.

Keywords: Cognitive biases; Decision making; Diagnostic errors; Medical education.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Checklist
  • Cognition*
  • Diagnostic Errors / prevention & control*
  • Diagnostic Errors / psychology*
  • Education, Continuing
  • Humans
  • Physicians / psychology*
  • Thinking*