Table 2

Interventions to improve intuitive (system 1) and deliberate (system 2) processes in decision-making

Author (Year)Study type and participantsInterventionOutcome measuresResultsConclusionsOutcomes RatingStrength of Conclusions (1–5)
Improve system 1 processing: improve training on intuitive processing and its shortcomings
Sherbino et al19 (2011)Case series with 4th year residentsTeaching cognitive forcing strategies to introduce diagnostic error risk, identify and countermand biases.Diagnostic accuracy in various domains after varying delays.After training about half the subjects still committed bias. Performance suffered even further after a delay.Teaching cognitive forcing strategies may reduce diagnostic errors in a transferable way (though it is difficult to tell without performance measures prior to training). Also, the effects were short-lived.32
Eva et al20 (2007)Randomised control trial with undergraduate psychology studentsUse combined approach to reasoning including pattern recognition and careful consideration of presenting features when diagnosing ECGs with biasing information.Diagnostic accuracy of ECG readings.Diagnostic accuracy improved for subjects using combined reasoning approach even in presence of biasing information.Trainees can benefit from explicit guidance of a combined approach to clinical reasoning, suggesting a value to both analytic and non-analytical reasoning tendencies.4b4
Improve system 1 processing: improve metacognition, intuition and reflective practice
Mamede et al21 (2010)Before/after with 1st and 2nd year residentsIncorporation of reflective reasoning to reduce diagnostic errors.Diagnostic errors produced before and after reflective reasoning.Significant number or diagnoses were corrected after reflective reasoning, presumably reducing bias.Diagnostic accuracy may be improved with reflective reasoning. More research needed to disentangle reflective reasoning from additional time assessing a case to determine if reflection generalises to experts.32
Coderre et al22 (2010)Before/after with 1st year medical studentsHave students reflect on initial hypothesis established prior to reviewing all clinical evidence. Then present additional concordant or discordant evidence.Diagnostic accuracy.With discordant data, significant increase in diagnostic accuracy. No difference in accuracy with concordant data. Overall, no significant difference in diagnostic accuracy.Providing students with additional information after an initial diagnosis affects diagnostic accuracy differently depending on the type of information received. More research needed to determine validity of the intervention.31
Improve system 1 processing: consider alternatives, consider the opposite, use prospective hindsight, think like an outsider
Wolpaw et al23 (2009)Randomised control trial with 3rd year medical studentsIncorporation of SNAPPS technique during case presentation to facilitate learning.Diagnostic reasoning measures including number of minutes to present findings, was summary concise and thorough, etc.SNAPPS group showed more diagnostic reasoning than a feedback comparison and a control group.Using the SNAPPS technique may result in correction of flawed reasoning, reduction of diagnostic and therapeutic errors. Study only measured amount of reasoning and not accuracy thereof, so it is unclear how this intervention would improve diagnostic accuracy.2b3
  • Outcomes Ratings reflect the level of impact for each intervention on reducing diagnostic errors.9 ,10 Strength of Conclusions was rated on a numerical scale (1–5) in accordance with Best Evidence in Medical Education guidelines (5=strongest).9 ,11 SNAPPS: Summarize history and findings, Narrow the differential, Analyze the differential, Probe preceptor about uncertainties, Plan management, Select case-related issues for self-study.