Low-Beer, Naomi

Rosby, Lucy Victoria

Rotgans, Jerome. I.

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Health Professions Education 2 (2016) 1–2http://dx.doi.org
2452-3011/& 20
article under the
Peer review u
Medical Educatiwww.elsevier.com/locate/hpeThe relevance of neuroscientiﬁc research for understanding
clinical reasoningThe current debate on clinical reasoning revolves
primarily around Dual-Process Theory. This theory sug-
gests that there are two distinctively separate cognitive
systems underlying thinking and reasoning; commonly
referred to as System 1 and System 2.1 System 1 is
considered intuitive, fast and reliant on automatic activation
of “illness scripts” stored in memory and leading to
effortless pattern recognition. System 2 on the other hand
is considered analytic, slow, deliberate, and systematic. The
clinical reasoning literature is divided; one group of
researchers defending System 1 reasoning as the hallmark
of expert decision-making, whereas the other camp of
researchers considers System 2 reasoning as superior and
more likely to achieve diagnostic accuracy.2,3 Some also
argue that System 2 is less prone to biases (premature
closure, conﬁrmation bias etc.).4
Although researchers in both camps acknowledge that
System 1 and 2 reasoning processes are intertwined and
overlap, in the end, the preference for one side appears to
take prevalence and data are projected against their
preferred System 1 or 2 background.5 There is a chance
that this practice may result in a deadlock in which little
progress is made in advancing our understanding of clinical
reasoning other than trying to convince the opponents of
the superiority of their ﬁndings.
Perhaps it is time to take a step back and re-examine the
very premise of the argument. The premise is that there are
two distinct reasoning systems in the brain. But what if
there are not? What if there are more than two reasoning
systems? Alternatively, what if there is only one system
that relies on the same cognitive pathways but at different
intensities, such as changing gears from automatic to
controlled, from low effort to high effort, from implicit
to explicit, from associative to rule-based etc./10.1016/j.hpe.2016.02.001
16 King Saud bin AbdulAziz University for Health Scienc
CC BY-NC-ND license (http://creativecommons.org/licens
nder responsibility of AMEEMR: the Association for
on in the Eastern Mediterranean Region.This raises the question; what empirical evidence is
there to support the dichotomy? One has to note that
System 1 and 2 found a relatively recent introduction to the
ﬁeld of clinical reasoning and has a longer history in social
psychology, philosophy, cognitive psychology, and eco-
nomics. It is therefore that the bulk of evidence for Dual-
Process Theory emanated from these disciplines. In addi-
tion, most of the research on this distinction is behavioural,
and thus one has to infer the underlying cognitive brain
processes from observational data.
For instance, a well-established line of research concerns
the “belief-bias effect” in syllogistic reasoning tasks. Belief
bias refers to the tendency of people to be more likely to
accept the conclusion of a syllogism if they ﬁnd it
believable than if they disbelieve it, irrespective of its
actual logical validity.6 A believable syllogism is “no
mammals are birds and all dogs are mammals, therefore no
dogs are birds.” An example of an unbelievable conclusion
of a syllogism is “no mammals are birds and all pigeons
are mammals, therefore no pigeons are birds.” It is argued
that this belief bias results from the competition between
System 1 and 2 reasoning when evaluating such argu-
ments: Since we know that pigeons are birds we reject the
latter (in itself correct) syllogism. De Neys manipulated
working memory capacity during syllogistic reasoning.7
He did this by introducing a second—distractor—task. The
assumption is that having to engage in two tasks at the
same time makes reasoning more difﬁcult. Results suggest
that when a correct response could be produced by System
1 reasoning, a distractor task did not inﬂuence that correct
response. Subsequently, belief bias was introduced by
presenting an unbelievable syllogism, which resulted in
reduced performance when the distractor task was initiated.
These outcomes support the notion that System 1 is indeed
automatic and is not dependent on the limited size of
working memory, while System 2 is.es. Production and Hosting by Elsevier B.V. This is an open access
es/by-nc-nd/4.0/).
nCorrespondence to: Ofﬁce of Education Research, Nanyang
Technological University, 1 Nanyang Walk, 637616, Singapore.
Editorial / Health Professions2A more direct manner to test Dual-Process Theory is to
examine whether there are two autonomous regions in the
brain that act independently. That would imply looking at
the brain itself when physicians engage in clinical reason-
ing. It is then possible to directly examine if anatomically
distinct parts of the brain are associated with the two
distinct reasoning modes. With the availability of func-
tional Magnetic Resonance Imaging (fMRI) and other
scanning hardware, neuroscientiﬁc research seems to come
into closer reach to researchers. This emerging trend is
visible in the current literature on reasoning in which
increasingly reference is made to neuroscientiﬁc evidence
in support of the distinction between System 1 and 2.
However, as with the behavioural studies cited above,
“neuroscientiﬁc evidence” is produced in studies of
syllogistic reasoning, rather than clinical reasoning. For
instance, Tsujii and colleagues utilised Near Infra-red
Spectroscopy (NIRS) while conducting belief-bias experi-
ments.6 They found that only in the case of unbelievable
syllogisms, the right inferior frontal cortex (IFC) was
activated, an anatomical region associated with analytical
reasoning (i.e., System 2).8–10
The critical question is whether these ﬁndings can a
priori be translated to the ﬁeld of clinical reasoning.
Generic syllogism tasks do not require specialized knowl-
edge. However, a characteristic of clinical reasoning is that
large amounts of previously acquired knowledge must be
used in order to solve clinical cases. In medicine, when
trying to make sense of signs and symptoms in order to
arrive at a correct diagnosis, physicians employ knowledge
acquired through learning and experience. Therefore, one
cannot exclude the possibility that clinical reasoning is
qualitatively different from syllogistic reasoning.
To address this issue of ecological validity, it appears
timely to conduct neuroscientiﬁc studies that investigate the
complexity of clinical reasoning, through direct imaging of
the brain. That is not an easy task to accomplish. How to
present a clinical case with all its complexity? New
experimental materials and procedures are needed that
can simulate the complexity of clinical reasoning. Once we
succeed, however, these data will help to clarify the status
of Dual-Process Theory in the ﬁeld of clinical reasoning
and whether it is justiﬁed to think of it as a dichotomy
between System 1 and System 2.
Disclosure
Ethical approval
N/A.
Funding
None.Other disclosure
None.
References
1. Evans J. The heuristic-analytic theory of reasoning: extension
and evaluation. Psychon Bull Rev 2006;13(3):378–395.
2. Norman, GR, et al. The etiology of diagnostic errors: a
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Med 2014;89(2):277–284.
3. Croskerry P. Clinical cognition and diagnostic error: applications
of a dual process model of reasoning. Adv Health Sci Educ
2009;14(1):27–35.
4. McLaughlin K, Eva KW, Norman GR. Reexamining our bias
against heuristics. Adv Health Sci Educ 2014;19(3):457–464.
5. Rotgans JI. It is time to progress beyond the System 1 versus
System 2 dichotomy. Perspect Med Educ 2015:1–2.
6. Tsujii T, Watanabe S. Neural correlates of dual-task effect on
belief-bias syllogistic reasoning: a near-infrared spectroscopy
study. Brain Res 2009;1287:118–125.
7. De Neys W. Dual processing in reasoning two systems but one
reasoner. Psychol Sci 2006;17(5):428–433.
8. Tsujii, T, et al. The role of inferior frontal cortex in belief-bias
reasoning: an rTMS study. Neuropsychologia 2010;48(7):2005–2008.
9. Tsujii T, Watanabe S. Neural correlates of belief-bias reasoning
under time pressure: a near-infrared spectroscopy study. Neuro-
image 2010;50(3):1320–1326.
10. Tsujii, T, et al. Evaluating the roles of the inferior frontal gyrus
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Education 2 (2016) 1–2Jerome. I. Rotgansn
Lee Kong Chian School of Medicine, Nanyang
Technological University, Singapore
E-mail address: rotgans@gmail.comNaomiLow-Beer
Lee Kong Chian School of Medicine, Nanyang
Technological University, SingaporeLucy Victoria Rosby
Lee Kong Chian School of Medicine, Nanyang
Technological University, Singapore
18 February 2016; accepted 18 February 2016


The relevance of neuroscientific research for understanding clinical reasoning 

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The relevance of neuroscientific research for understanding clinical reasoning

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