Dual processing model of medical decision-making
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.
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.
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.
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).
- Kahneman D: Maps of bounded rationality: psychology for behavioral economics. Am Econ Rev 2003, 93:1449–1475. CrossRef
- Kahnemen D: Thinking fast and slow. Farrar, Straus and Giroux, New York; 2011.
- Evans JSTBT: Hypothethical thinking. Dual processes in reasoning and judgement. Psychology Press: Taylor and Francis Group, New York; 2007.
- Stanovich KE, West RF: Individual differences in reasoning:implications for the rationality debate? Behavioral and Brain Sciences 2000, 23:645–726. CrossRef
- Stanovich KE: Rationality and the Reflective Mind. Oxford University Press, Oxford; 2011.
- Croskerry P: Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract 2009,14(Suppl 1):27–35. CrossRef
- Croskerry P: A universal model of diagnostic reasoning. Acad Med 2009,84(8):1022–1028. CrossRef
- Croskerry P, Abbass A, Wu AW: Emotional influences in patient safety. J Patient Saf 2010,6(4):199–205. CrossRef
- Croskerry P, Nimmo GR: Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb 2011,41(2):155–162. CrossRef
- Slovic P, Finucane ML, Peters E, MacGregor DG: Risk as analysis and risk as feelings: some thoughts about affect, reason, risk, and rationality. Risk Anal 2004,24(2):311–322. CrossRef
- Mukherjee K: A dual system model of preferences under risk. Psychol Rev 2010,177(1):243–255. CrossRef
- Djulbegovic B, Hozo I, Lyman GH: Linking evidence-based medicine therapeutic summary measures to clinical decision analysis. MedGenMed 2000,2(1):E6.
- Pauker S, Kassirer J: Therapeutic decision making: a cost benefit analysis. N Engl J Med 1975, 293:229–234. CrossRef
- Pauker SG, Kassirer J: The threshold approach to clinical decision making. N Engl J Med 1980, 302:1109–1117. CrossRef
- Djulbegovic B, Desoky AH: Equation and nomogram for calculation of testing and treatment thresholds. Med Decis Making 1996,16(2):198–199. CrossRef
- Djulbegovic B, Hozo I, Schwartz A, McMasters K: Acceptable regret in medical decision making. Med Hypotheses 1999, 53:253–259. CrossRef
- Hozo I, Djulbegovic B: When is diagnostic testing inappropriate or irrational? Acceptable regret approach. Med Decis Making 2008,28(4):540–553. CrossRef
- Hozo I, Djulbegovic B: Will insistence on practicing medicine according to expected utility theory lead to an increase in diagnostic testing? Medical Decision Making 2009, 29:320–322. CrossRef
- Hozo I, Djulbegovic B: Clarification and corrections of acceptable regret model. Medical Decision Making 2009, 29:323–324. CrossRef
- Kahneman D, Wakker PP, Sarin RK: Back to Bentham? Explorations of experienced utility. Q J Econ 1997, 112:375–405. CrossRef
- Berwick DM, Hackbarth AD: Eliminating waste in US health care. JAMA: The Journal of the American Medical Association 2012,307(14):1513–1516. CrossRef
- Manchikanti L, Falco FJ, Boswell MV, Hirsch JA: Facts, fallacies, and politics of comparative effectiveness research: part 2 - implications for interventional pain management. Pain Physician 2010,13(1):E55-E79.
- Manchikanti L, Falco FJ, Boswell MV, Hirsch JA: Facts, fallacies, and politics of comparative effectiveness research: part I. Basic considerations. Pain Physician 2010,13(1):E23-E54.
- Hsee CK, Rottenstreich Y: Music, pandas and muggers: on the affective psychology of value. J Exp Psychol 2004, 133:23–30.
- Rottenstreich Y, Hsee CK: Money, kisses, and electric shock: On the affective psychology of risk. Psychol Sci 2001, 12:185–190. CrossRef
- Evans JSTBT: Thinking Twice. Two Minds in One Brain. Oxford University Press, Oxford; 2010.
- Evans JSTBT: Dual-process theories of reasoning: contemporary issues and developmental applications. Dev Rev 2011, 31:86–102. CrossRef
- Edwards W, Miles R Jr, vonWinterfeld D: Advances in decision analysis. From foundations to applications. Cambridge University Press, New York; 2007. CrossRef
- Simon HA: Information processsing models of cognition. Ann Review Psychol 1979, 30:263–296.
- Reyna VF, Brainerd CJ: Dual processes in decision making and developmental neuroscience: a fuzzy-trace model. Dev Rev 2011,31(2–3):180–206.
- Reyna VF, Hamilton AJ: The importance of memory in informed consent for surgical risk. Med Decis Making 2001,21(2):152–155. CrossRef
- Kahneman D, Tversky A: The psychology of preferences. Sci American 1982, 246:160–173. CrossRef
- Tversky A, Kahneman D: Judgements under uncertainty: heuristics and biases. Science 1974, 185:1124–1131. CrossRef
- Djulbegovic B, Hozo II, Fields KK, Sullivan D: High-dose chemotherapy in the adjuvant treatment of breast cancer: benefit/risk analysis. Cancer Control 1998,5(5):394–405.
- Djulbegovic B, Hozo I: When should potentially false research findings be considered acceptable? PLoS Medicine 2007,4(2):e26. CrossRef
- Djulbegovic B, Hozo I: Linking evidence-based medicine to clinical decision analysis. Med Decision Making 1998, 18:464. abstract
- Zeelenberg M, Pieters R: A theory of regret regulation 1.0. J Consumer Psychol 2007, 17:3–18. CrossRef
- Zeelenberg M, Pieters R: A theory of regret regulation 1.1. J Consumer Psychol 2007, 17:29–35. CrossRef
- Tsalatsanis A, Hozo I, Vickers A, Djulbegovic B: A regret theory approach to decision curve analysis: a novel method for eliciting decision makers’ preferences and decision-making. BMC Medical Informatics and Decision Making 2010,10(1):51. CrossRef
- Evans JSTBT: On the resolution of conflict in dual process theories of reasoning. Think Reasoning 2007,13(4):321–339. CrossRef
- Hammond KR: Human judgment and social policy. irreducible uncertainty, inevitable error, unavoidable injustice. Oxford University Press, Oxford; 1996.
- Duhigg C: The power of habit: why we do what we do in life and business. Random House, New York; 2012.
- Thompson VA, Prowse Turner JA, Pennycook G: Intuition, reason, and metacognition. Cogn Psychol 2011, 63:107–140. CrossRef
- Brandstatter E, Gigerenzer G: The priority heuristic: making choices without trade-offs. Psychol Rev 2006, 113:409–432. CrossRef
- Sox HC: Better care for patients with suspected pulmonary embolism. Ann Intern Med 2006,144(3):210–212.
- Barritt DW, Jordan SC: Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet 1960, 1:1309–1312. CrossRef
- Segal JB, Eng J, Jenckes MW, Tamariz LJ, Bolger DT, Krishnan JA, Streiff MB, Harris KA, Feuerstein CJ, Bass EB: Diagnosis and treatment of deep venous thrombosis and pulmonary embolism. In AHRQ Publication No 03-E016. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Washington, DC; 2003.
- Linkins L-A, Choi PT, Douketis JD: Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med 2003,139(11):893–900.
- Roy PM, Durieux P, Gillaizeau F, Legall C, Armand-Perroux A, Martino L, Hachelaf M, Dubart AE, Schmidt J, Cristiano M, et al.: A computerized handheld decision-support system to improve pulmonary embolism diagnosis: a randomized trial. Ann Intern Med 2009,151(10):677–686.
- Roy P-M, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G: Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ 2005,331(7511):259. CrossRef
- Hull RD: Diagnosing pulmonary embolism with improved certainty and simplicity. JAMA 2006,295(2):213–215. CrossRef
- Koreth J, Schlenk R, Kopecky KJ, Honda S, Sierra J, Djulbegovic BJ, Wadleigh M, DeAngelo DJ, Stone RM, Sakamaki H, et al.: Allogeneic stem cell transplantation for acute myeloid leukemia in first complete remission: systematic review and meta-analysis of prospective clinical trials. Jama 2009,301(22):2349–2361. CrossRef
- Cornelissen JJ, Van Putten WL, Verdonck LF, Theobald M, Jacky E, Daenen SM, van Marwijk Kooy M, Wijermans P, Schouten H, Huijgens PC, et al.: Results of a HOVON/SAKK donor versus no-donor analysis of myeloablative HLA-identical sibling stem cell transplantation in first remission acute myeloid leukemia in young and middle-aged adults: benefits for whom? Blood 2007,109(9):3658–3666. CrossRef
- Djulbegovic B: Principles of reasoning and decision-making. In Decision Making in Oncology Evidence-based management. Edited by: Djulbegovic B, Sullivan DS. Churchill Livingstone, Inc, New York; 1997:1–14.
- Feinstein AR: The ‘chagrin factor’ and qualitative decision analysis. Arch Intern Med 1985, 145:1257–1259. CrossRef
- Detsky AS: Regional variation in medical care. N Engl J Med 1995, 333:5890590. CrossRef
- Dilts DM: Practice variation: the Achilles’ Heel in quality cancer care. J Clin Oncol 2005,23(25):5881–5882. CrossRef
- Eddy DM: Variations in physician practice: the role of uncertainty. Health Aff 1984,3(2):74–89. CrossRef
- Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL: The implications of regional variations in medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003,138(4):288–298.
- Sirovich BE, Gottlieb DJ, Welch HG, Fisher ES: Regional variations in health care intensity and physician perceptions of quality of care. Ann Intern Med 2006,144(9):641–649.
- Zhang Y, Baicker K, Newhouse JP: Geographic variation in medicare drug spending. N Engl J Med 2010,363(5):405–409. CrossRef
- Hozo I, Djulbegovic B: Explaining variation in practice: acceptable regret approoach. 28th Annual Meeting of the Society for Medical Decision Making, Boston; 2006.
- Shaw NJ, Dear PR: How do parents of babies interpret qualitative expressions of probability? Arch Dis Child 1990,65(5):520–523. CrossRef
- Reyna VF: Theories of medical decision making and health: an evidence-based approach. Med Decis Making 2008,28(6):829–833. CrossRef
- Djulbegovic B, Paul A: From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep. JAMA 2011,305(19):2005–2006. CrossRef
- Ofri D: The emotional epidemiology of H1N1 influenza vaccination. N Engl J Med 2009,361(27):2594–2595. CrossRef
- Poland GA: The 2009–2010 influenza pandemic: effects on pandemic and seasonal vaccine uptake and lessons learned for seasonal vaccination campaigns. Vaccine 2010,28(Supplement 4(0)):D3-D13. CrossRef
- Krantz DH, Kunreuther HC: Goals and plans in decision making. Judgement and Decision Making 2007,2(3):137–168.
- Zimmerman HJ: Fuzzy set theory anf its applications. 3rd edition. Kluwer, Boston; 1996.
- Society for simulation in healthcare http://ssih.org/about-simulation (Last accessed: August 27,2012)
- Kassirer JP, Kopelman RI: Learning clinical reasoning. Williams & Wilkins, Baltimore; 1991.
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/12/94/prepub
- Dual processing model of medical decision-making
- Open Access
- Available under Open Access This content is freely available online to anyone, anywhere at any time.
BMC Medical Informatics and Decision Making
- Online Date
- September 2012
- Online ISSN
- BioMed Central
- Additional Links
- Author Affiliations
- 1. Center for Evidence-based Medicine and Health Outcomes Research, Tampa, FL, USA
- 2. Department of Internal Medicine, Division of Evidence-based Medicine and Health Outcomes Research University of South Florida, Tampa, FL, USA
- 3. Departments of Hematology and Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- 7. USF Health, 12901 Bruce B. Downs Boulevard, MDC27, Tampa, FL, 33612, USA
- 4. Department of Mathematics, Indiana University Northwest, Gary, IN, USA
- 5. College of Nursing, University of South Florida, Tampa, FL, USA
- 6. Division of Clinical Decision Making, Department of Medicine, Tufts Medical Center, Boston, USA