A Universal Model of Diagnostic Reasoning

Clinical judgment is a critical aspect of physician performance in medicine. It is essential in the formulation of a diagnosis and key to the effective and safe management of patients. Yet, the overall diagnostic error rate remains unacceptably high. In more than four decades of research, a variety of approaches have been taken, but a consensus approach toward diagnostic decision making has not emerged. In the last 20 years, important gains have been made in psychological research on human judgment. Dual-process theory has emerged as the predominant approach, positing two systems of decision making, System 1 (heuristic, intuitive) and System 2 (systematic, analytical). The author proposes a schematic model that uses the theory to develop a universal approach toward clinical decision making. Properties of the model explain many of the observed characteristics of physicians' performance. Yet the author cautions that not all medical reasoning and decision making falls neatly into one or the other of the model's systems, even though they provide a basic framework incorporating the recognized diverse approaches. He also emphasizes the complexity of decision making in actual clinical situations and the urgent need for more research to help clinicians gain additional insight and understanding regarding their decision making.