Behaviour change techniques associated with smoking cessation in intervention and comparator groups of randomized controlled trials: a systematic review and meta-regression

AIMS

To estimate the strengths of associations between use of behaviour change techniques (BCTs) and clusters of BCTs in behavioural smoking cessation interventions and comparators with smoking cessation rates.

METHOD

Systematic review and meta-regression of biochemically verified smoking cessation rates on BCTs in interventions and comparators in randomized controlled trials, adjusting for a priori-defined potential confounding variables, together with moderation analyses. Studies were drawn from the Cochrane Tobacco Addiction Group Specialised Register. Data were extracted from published and unpublished (i.e. obtained from study authors) study materials by two independent coders. Adequately described intervention (k = 143) and comparator (k = 92) groups were included in the analyses (n = 43 992 participants). Using bivariate mixed-effects meta-regressions, while controlling for key a priori confounders, we regressed smoking cessation on (a) three BCT groupings consistent with dual-process theory (i.e. associative, reflective motivational and self-regulatory), (b) 17 expert-derived BCT groupings (i.e. BCT taxonomy version 1 clusters) and (c) individual BCTs from the BCT taxonomy version 1.

RESULTS

Among person-delivered interventions, higher smoking cessation rates were predicted by BCTs targeting associative and self-regulatory processes (B = 0.034, 0.041, P < 0.05), and by three individual BCTs (prompting commitment, social reward, identity associated with changed behaviour). Among written interventions, BCTs targeting taxonomy cluster 10a (rewards) predicted higher smoking cessation (B = 0.394, P < 0.05). Moderation effects were observed for nicotine dependence, mental health status and mode of delivery.

CONCLUSIONS

Among person-delivered behavioural smoking cessation interventions, specific behaviour change techniques and clusters of techniques are associated with higher success rates.

Motivational Mechanisms and Outcome Expectancies Underlying the Approach Bias toward Addictive Substances

Human behavior can be paradoxical, in that actions can be initiated that are seemingly incongruent with an individual’s explicit desires. This is most commonly observed in drug addiction, where maladaptive behavior (i.e., drug seeking) appears to be compulsive, continuing at great personal cost. Approach biases toward addictive substances have been correlated with actual drug-use in a number of studies, suggesting that this measure can, in some cases, index everyday maladaptive tendencies. At present it is unclear whether this bias to drug cues is a Pavlovian conditioned approach response, a habitual response, the result of a Pavlovian-instrumental transfer process, or a goal-directed action in the sense that expectancy of the rewarding effects of drugs controls approach. We consider this question by combining the theoretical framework of associative learning with the available evidence from approach bias research. Although research investigating the relative contributions of these mechanisms to the approach bias is to date relatively limited, we review existing studies and also outline avenues for future research.

On the need to better specify the concept of "control" in brain-computer-interfaces/neurofeedback research

Aiming at a better specification of the concept of “control” in brain-computer-interfaces (BCIs) and neurofeedback (NF) research, we propose to distinguish “self-control of brain activity” from the broader concept of “BCI control”, since the first describes a neurocognitive phenomenon and is only one of the many components of “BCI control”. Based on this distinction, we developed a framework based on dual-processes theory that describes the cognitive determinants of self-control of brain activity as the interplay of automatic vs. controlled information processing. Further, we distinguish between cognitive processes that are necessary and sufficient to achieve a given level of self-control of brain activity and those which are not. We discuss that those cognitive processes which are not necessary for the learning process can hamper self-control because they cannot be completely turned-off at any time. This framework aims at a comprehensive description of the cognitive determinants of the acquisition of self-control of brain activity underlying those classes of BCI which require the user to achieve regulation of brain activity as well as NF learning.

Does Mindfulness Enhance Critical Thinking? Evidence for the Mediating Effects of Executive Functioning in the Relationship between Mindfulness and Critical Thinking

Mindfulness originated in the Buddhist tradition as a way of cultivating clarity of thought. Despite the fact that this behavior is best captured using critical thinking (CT) assessments, no studies have examined the effects of mindfulness on CT or the mechanisms underlying any such possible relationship. Even so, mindfulness has been suggested as being beneficial for CT in higher education. CT is recognized as an important higher-order cognitive process which involves the ability to analyze and evaluate evidence and arguments. Such non-automatic, reflective responses generally require the engagement of executive functioning (EF) which includes updating, inhibition, and shifting of representations in working memory. Based on research showing that mindfulness enhances aspects of EF and certain higher-order cognitive processes, we hypothesized that individuals higher in facets of dispositional mindfulness would demonstrate greater CT performance, and that this relationship would be mediated by EF. Cross-sectional assessment of these constructs in a sample of 178 university students was achieved using the observing and non-reactivity sub-scales of the Five Factor Mindfulness Questionnaire, a battery of EF tasks and the Halpern Critical Thinking Assessment. Our hypotheses were tested by constructing a multiple meditation model which was analyzed using Structural Equation Modeling. Evidence was found for inhibition mediating the relationships between both observing and non-reactivity and CT in different ways. Indirect-only (or full) mediation was demonstrated for the relationship between observing, inhibition, and CT. Competitive mediation was demonstrated for the relationship between non-reactivity, inhibition, and CT. This suggests additional mediators of the relationship between non-reactivity and CT which are not accounted for in this model and have a negative effect on CT in addition to the positive effect mediated by inhibition. These findings are discussed in the context of the Default Interventionist Dual Process Theory of Higher-order Cognition and previous studies on mindfulness, self-regulation, EF, and higher-order cognition. In summary, dispositional mindfulness appears to facilitate CT performance and this effect is mediated by the inhibition component of EF. However, this relationship is not straightforward which suggests many possibilities for future research.

The Acute and Chronic Effects of Dual-Task on the Motor and Cognitive Performances in Athletes: A Systematic Review

Athletes must distribute their attention to many relevant cues during a match. Therefore, athletes’ ability to deal with dual-tasks may be different from the non-athlete population, demanding a deeper investigation within the sports domain. This study aimed to systematically review the acute and chronic effects of dual-tasks in motor and cognitive performances in athletes from different modalities. The search for articles followed all the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The keywords used were: “dual-task” OR “double task” OR “multi-task” OR “divided attention” OR “secondary task” OR “second task” AND “working memory” OR “visual” OR “decision making” OR “gaze behavior” OR “attention” AND “sports” OR “athletes” OR “players”. The Scopus, Pubmed, and Web of Science databases were screened for studies comparing single and dual-tasks, in which the participants were athletes competing at any level, and in which at least one of the following variables were investigated: working memory, decision-making, visual search behavior, perception, anticipation, attention, or motor tasks. Articles were screened using pre-defined selection criteria, and methodological quality was assessed by two researchers independently. Following the eligibility criteria, we included 18 articles in the review: 13 on the acute effects, and five on the chronic effects. This review showed that the acute effect of dual-tasks impairs the motor and cognitive performances of athletes (dual-task cost). However, training with dual-tasks (chronic effect) improved working memory skills and attentional control. We conclude that dual-tasks acutely and chronically impacts motor and cognitive performance.

Analytic cognitive style, not delusional ideation, predicts data gathering in a large beads task study

INTRODUCTION

It has been proposed that deluded and delusion-prone individuals gather less evidence before forming beliefs than those who are not deluded or delusion-prone. The primary source of evidence for this "jumping to conclusions" (JTC) bias is provided by research that utilises the "beads task" data-gathering paradigm. However, the cognitive mechanisms subserving data gathering in this task are poorly understood.

METHODS

In the largest published beads task study to date (n = 558), we examined data gathering in the context of influential dual-process theories of reasoning.

RESULTS

Analytic cognitive style (the willingness or disposition to critically evaluate outputs from intuitive processing and engage in effortful analytic processing) predicted data gathering in a non-clinical sample, but delusional ideation did not.

CONCLUSION

The relationship between data gathering and analytic cognitive style suggests that dual-process theories of reasoning can contribute to our understanding of the beads task. It is not clear why delusional ideation was not found to be associated with data gathering or analytic cognitive style.

Exploring a New Simulation Approach to Improve Clinical Reasoning Teaching and Assessment: Randomized Trial Protocol

BACKGROUND

Helping trainees develop appropriate clinical reasoning abilities is a challenging goal in an environment where clinical situations are marked by high levels of complexity and unpredictability. The benefit of simulation-based education to assess clinical reasoning skills has rarely been reported. More specifically, it is unclear if clinical reasoning is better acquired if the instructor's input occurs entirely after or is integrated during the scenario. Based on educational principles of the dual-process theory of clinical reasoning, a new simulation approach called simulation with iterative discussions (SID) is introduced. The instructor interrupts the flow of the scenario at three key moments of the reasoning process (data gathering, integration, and confirmation). After each stop, the scenario is continued where it was interrupted. Finally, a brief general debriefing ends the session. System-1 process of clinical reasoning is assessed by verbalization during management of the case, and System-2 during the iterative discussions without providing feedback.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of Simulation with Iterative Discussions versus the classical approach of simulation in developing reasoning skills of General Pediatrics and Neonatal-Perinatal Medicine residents.

METHODS

This will be a prospective exploratory, randomized study conducted at Sainte-Justine hospital in Montreal, Qc, between January and March 2016. All post-graduate year (PGY) 1 to 6 residents will be invited to complete one SID or classical simulation 30 minutes audio video-recorded complex high-fidelity simulations covering a similar neonatology topic. Pre- and post-simulation questionnaires will be completed and a semistructured interview will be conducted after each simulation. Data analyses will use SPSS and NVivo softwares.

RESULTS

This study is in its preliminary stages and the results are expected to be made available by April, 2016.

CONCLUSIONS

This will be the first study to explore a new simulation approach designed to enhance clinical reasoning. By assessing more closely reasoning processes throughout a simulation session, we believe that Simulation with Iterative Discussions will be an interesting and more effective approach for students. The findings of the study will benefit medical educators, education programs, and medical students.

Determinants of judgment and decision making quality: the interplay between information processing style and situational factors

A framework is presented to better characterize the role of individual differences in information processing style and their interplay with contextual factors in determining decision making quality. In Experiment 1, we show that individual differences in information processing style are flexible and can be modified by situational factors. Specifically, a situational manipulation that induced an analytical mode of thought improved decision quality. In Experiment 2, we show that this improvement in decision quality is highly contingent on the compatibility between the dominant thinking mode and the nature of the task. That is, encouraging an intuitive mode of thought led to better performance on an intuitive task but hampered performance on an analytical task. The reverse pattern was obtained when an analytical mode of thought was encouraged. We discuss the implications of these results for the assessment of decision making competence, and suggest practical directions to help individuals better adjust their information processing style to the situation at hand and make optimal decisions.

The Influence of Effortful Thought and Cognitive Proficiencies on the Conjunction Fallacy: Implications for Dual-Process Theories of Reasoning and Judgment

Human judgment often violates normative standards, and virtually no judgment error has received as much attention as the conjunction fallacy. Judgment errors have historically served as evidence for dual-process theories of reasoning, insofar as these errors are assumed to arise from reliance on a fast and intuitive mental process, and are corrected via effortful deliberative reasoning. In the present research, three experiments tested the notion that conjunction errors are reduced by effortful thought. Predictions based on three different dual-process theory perspectives were tested: lax monitoring, override failure, and the Tripartite Model. Results indicated that participants higher in numeracy were less likely to make conjunction errors, but this association only emerged when participants engaged in two-sided reasoning, as opposed to one-sided or no reasoning. Confidence was higher for incorrect as opposed to correct judgments, suggesting that participants were unaware of their errors.

Dual processing theory and experts' reasoning: exploring thinking on national multiple-choice questions

BACKGROUND

An ongoing debate exists in the medical education literature regarding the potential benefits of pattern recognition (non-analytic reasoning), actively comparing and contrasting diagnostic options (analytic reasoning) or using a combination approach. Studies have not, however, explicitly explored faculty's thought processes while tackling clinical problems through the lens of dual process theory to inform this debate. Further, these thought processes have not been studied in relation to the difficulty of the task or other potential mediating influences such as personal factors and fatigue, which could also be influenced by personal factors such as sleep deprivation. We therefore sought to determine which reasoning process(es) were used with answering clinically oriented multiple-choice questions (MCQs) and if these processes differed based on the dual process theory characteristics: accuracy, reading time and answering time as well as psychometrically determined item difficulty and sleep deprivation.

METHODS

We performed a think-aloud procedure to explore faculty's thought processes while taking these MCQs, coding think-aloud data based on reasoning process (analytic, nonanalytic, guessing or combination of processes) as well as word count, number of stated concepts, reading time, answering time, and accuracy. We also included questions regarding amount of work in the recent past. We then conducted statistical analyses to examine the associations between these measures such as correlations between frequencies of reasoning processes and item accuracy and difficulty. We also observed the total frequencies of different reasoning processes in the situations of getting answers correctly and incorrectly.

RESULTS

Regardless of whether the questions were classified as 'hard' or 'easy', non-analytical reasoning led to the correct answer more often than to an incorrect answer. Significant correlations were found between self-reported recent number of hours worked with think-aloud word count and number of concepts used in the reasoning but not item accuracy. When all MCQs were included, 19 % of the variance of correctness could be explained by the frequency of expression of these three think-aloud processes (analytic, nonanalytic, or combined).

DISCUSSION

We found evidence to support the notion that the difficulty of an item in a test is not a systematic feature of the item itself but is always a result of the interaction between the item and the candidate. Use of analytic reasoning did not appear to improve accuracy. Our data suggest that individuals do not apply either System 1 or System 2 but instead fall along a continuum with some individuals falling at one end of the spectrum.

Outcome Value and Task Aversiveness Impact Task Procrastination through Separate Neural Pathways

The temporal decision model of procrastination has proposed that outcome value and task aversiveness are two separate aspects accounting for procrastination. If true, the human brain is likely to implicate separate neural pathways to mediate the effect of outcome value and task aversiveness on procrastination. Outcome value is plausibly constructed via a hippocampus-based pathway because of the hippocampus's unique role in episodic prospection. In contrast, task aversiveness might be represented through an amygdala-involved pathway. In the current study, participants underwent fMRI scanning when viewing both tasks and future outcomes, without any experimental instruction imposed. The results revealed that outcome value increased activations in the caudate, and suppressed procrastination through a hippocampus-caudate pathway. In contrast, task aversiveness increased activations in the anterior insula, and increased procrastination via an amygdala-insula pathway. In sum, this study demonstrates that people can incorporate both outcome value and task aversiveness into task valuation to decide whether to procrastinate or not; and it elucidates the separate neural pathways via which this occurs.

tDCS Over DLPFC Leads to Less Utilitarian Response in Moral-Personal Judgment

The profound nature of moral judgment has been discussed and debated for centuries. When facing the trade-off between pursuing moral rights and seeking better consequences, most people make different moral choices between two kinds of dilemmas. Such differences were explained by the dual-process theory involving an automatic emotional response and a controlled application of utilitarian decision-rules. In neurocognitive studies, the bilateral dorsolateral prefrontal cortex (DLPFC) has been demonstrated to play an important role in cognitive “rational” control processes in moral dilemmas. However, the profile of results across studies is not entirely consistent. Although one transcranial magnetic stimulation (TMS) study revealed that disrupting the right DLPFC led to less utilitarian responses, other TMS studies indicated that inhibition of the right DLPFC led to more utilitarian choices. Moreover, the right temporoparietal junction (TPJ) is essential for its function of integrating belief and intention in moral judgment, which is related to the emotional process according to the dual-process theory. Relatively few studies have reported the causal relationship between TPJ and participants' moral responses, especially in moral dilemmas. In the present study, we aimed to demonstrate a direct link between the neural and behavioral results by application of transcranial direct current stimulation (tDCS) in the bilateral DLPFC or TPJ of our participants. We observed that activating the right DLPFC as well as inhibiting the left DLPFC led to less utilitarian judgments, especially in moral-personal conditions, indicating that the right DLPFC plays an essential role, not only through its function of moral reasoning but also through its information integrating process in moral judgments. It was also revealed that altering the excitability of the bilateral TPJ using tDCS negligibly altered the moral response in non-moral, moral-impersonal and moral-personal dilemmas, indicating that bilateral TPJ may have little influence over moral judgments in moral dilemmas.

Enhancing the Wisdom of the Crowd With Cognitive-Process Diversity: The Benefits of Aggregating Intuitive and Analytical Judgments

Drawing on dual-process theory, we suggest that the benefits that arise from combining several quantitative individual judgments will be heightened when these judgments are based on different cognitive processes. We tested this hypothesis in three experimental studies in which participants provided estimates for the dates of different historical events (Study 1, N = 152), made probabilistic forecasts for the outcomes of soccer games (Study 2, N = 98), and estimated the weight of individuals on the basis of a photograph (Study 3, N = 3,695). For each of these tasks, participants were prompted to make judgments relying on an analytical process, on their intuition, or (in a control condition) on no specific instructions. Across all three studies, our results show that an aggregation of intuitive and analytical judgments provides more accurate estimates than any other aggregation procedure and that this advantage increases with the number of aggregated judgments.

Coping with Stress, Executive Functions, and Depressive Symptoms: Focusing on Flexible Responses to Stress

Coping flexibility is conceptually similar to both inhibition and set-shifting. Though they serve different functions, all three are robustly associated with depression. Coping flexibility is the ability to relinquish a coping strategy regarded as ineffective and to devise and implement an alternative one; the concept is based on stress and coping theory. Inhibition is the ability to suppress responses selectively according to a change in the situation, while set-shifting is the process of switching flexibly between task sets, mental sets, or response rules. Inhibition and set-shifting are both executive functions in cognitive mechanisms. We hypothesized that coping flexibility was associated with a lower risk of depression, even when the effects of inhibition and set-shifting were controlled for. In total, 200 Japanese university students (100 women and 100 men) completed questionnaires that measured coping flexibility and depression and performed the Stroop Color and Word Test and the Wisconsin Card Sorting Test, which measured inhibition and set-shifting. We found that greater coping flexibility was associated with a lower risk of depression, even when the effects of inhibition and set-shifting were controlled for. Our findings suggest that, although coping flexibility is conceptually similar to inhibition and set-shifting, its association with depression differs from theirs.

Differential associations between scale-free neural dynamics and different levels of cognitive ability

As indicators of cognitive function, scale-free neural dynamics are gaining increasing attention in cognitive neuroscience. Although the functional relevance of scale-free dynamics has been extensively reported, one fundamental question about its association with cognitive ability remains unanswered: is the association universal across a wide spectrum of cognitive abilities or confined to specific domains? Based on dual-process theory, we designed two categories of tasks to analyze two types of cognitive processes-automatic and controlled-and examined their associations with scale-free neural dynamics characterized from resting-state electroencephalography (EEG) recordings obtained from a large sample of human adults (N = 102). Our results showed that resting-state scale-free neural dynamics did not predict individuals' behavioral performance in tasks that primarily engaged the automatic process but did so in tasks that primarily engaged the controlled process. In addition, by fitting the scale-free parameters separately in different frequency bands, we found that the cognitive association of scale-free dynamics was more strongly manifested in higher-band EEG spectrum. Our findings indicate that resting-state scale-free dynamics are not universal neural indicators for all cognitive abilities but are mainly associated with high-level cognition that entails controlled processes. This finding is compatible with the widely claimed role of scale-free dynamics in reflecting properties of complex dynamic systems.

An exploration of decision aid effectiveness: the impact of promoting affective vs. deliberative processing on a health-related decision

BACKGROUND

Decision aids (DAs) are non-directive communication tools that help patients make value-consistent health-care decisions. However, most DAs have been developed without an explicit theoretical framework, resulting in a lack of understanding of how DAs achieve outcomes.

OBJECTIVE

To investigate the effect of promoting affective vs. deliberative processing on DA effectiveness based on dual-process theory.

DESIGN, SETTING AND PARTICIPANTS

One hundred and forty-eight female university students participated in a randomized controlled experiment with three conditions: emotion-focused, information-focused and control. Preference-value consistency, knowledge, decisional conflict and satisfaction were compared across the conditions using planned contrast analyses.

INTERVENTION

The intervention comprised two different DAs and instructional manipulations. The emotion-focused condition received a modified DA with affective content and instructions to induce an affective reaction. The information-focused and control conditions received the same DA without the affective content. The information-focused condition received additional instructions to induce deliberative processing.

RESULTS

Controlling for the experiment-wise error rate at P < 0.017, the emotion-focused and information-focused conditions had significantly higher decisional satisfaction than the control condition (P < 0.001). The emotion-focused condition did not demonstrate preference-value consistency. There were no significant differences for decisional conflict and knowledge.

DISCUSSION

Results suggest that the promotion of affective processing may hinder value-consistent decision making, while deliberative processing may enhance decisional satisfaction.

CONCLUSIONS

This investigation of the effect of affective and deliberative processes in DA-supported decision making has implications for the design and use of DAs. DA effectiveness may be enhanced by incorporating a simple instruction to focus on the details of the information.

Can taking the perspective of an expert debias human decisions? The case of risky and delayed gains

In several previously reported studies, participants increased their normative correctness after being instructed to think hypothetically, specifically taking the perspective of an expert or researcher (Beatty and Thompson, 2012; Morsanyi and Handley, 2012). The goal of this paper was to investigate how this manipulation affects risky or delayed payoffs. In two studies, participants (n = 193) were tested online (in exchange for money) using the adjusting procedure. Individuals produced certain/immediate equivalents for risky/delayed gains. Participants in the control group were solving the problem from their own perspective, while participants in the experimental group were asked to imagine "what would a reliable and honest advisor advise them to do." Study 1 showed that when taking the perspective of an expert, participants in experimental group became more risk aversive compared to participants in the control group. Additionally, their certain equivalents diverged from the expected value to a greater extent. The results obtained from the experimental group in Study 2 suggest that participants became less impulsive, which means they tried to inhibit their preferences. This favors the explanation, which suggests that the perspective shift forced individuals to override their intuitions with the social norms. Individuals expect to be blamed for impatience or risk taking thus expected an expert to advise them to be more patient and risk aversive.

Reframing Single- and Dual-Process Theories as Cognitive Models: Commentary on De Neys (2021)

De Neys (this issue) argues that the debate between single- and dual-process theorists of thought has become both empirically intractable and scientifically inconsequential. I argue that this is true only under the traditional framing of the debate-when single- and dual-process theories are understood as claims about whether thought processes share the same defining properties (e.g., making mathematical judgments) or have two different defining properties (e.g., making mathematical judgments autonomously versus via access to a central working memory capacity), respectively. But if single- and dual-process theories are understood in cognitive modeling terms as claims about whether thought processes function to implement one or two broad types of algorithms, respectively, then the debate becomes scientifically consequential and, presumably, empirically tractable. So, I argue, the correct response to the current state of the debate is not to abandon it, as De Neys suggests, but to reframe it as a debate about cognitive models.

Trust in Autonomous Cars: Exploring the Role of Shared Moral Values, Reasoning, and Emotion in Safety-Critical Decisions

OBJECTIVE

Autonomous cars (ACs) controlled by artificial intelligence are expected to play a significant role in transportation in the near future. This study investigated determinants of trust in ACs.

BACKGROUND

Trust in ACs influences different variables, including the intention to adopt AC technology. Several studies on risk perception have verified that shared value determines trust in risk managers. Previous research has confirmed the effect of value similarity on trust in artificial intelligence. We focused on moral beliefs, specifically utilitarianism (belief in promoting a greater good) and deontology (belief in condemning deliberate harm), and tested the effects of shared moral beliefs on trust in ACs.

METHOD

We conducted three experiments (N = 128, 71, and 196, for each), adopting a thought experiment similar to the well-known trolley problem. We manipulated shared moral beliefs (shared vs. unshared) and driver (AC vs. human), providing participants with different moral dilemma scenarios. Trust in ACs was measured through a questionnaire.

RESULTS

The results of Experiment 1 showed that shared utilitarian belief strongly influenced trust in ACs. In Experiment 2 and Experiment 3, however, we did not find statistical evidence that shared deontological belief had an effect on trust in ACs.

CONCLUSION

The results of the three experiments suggest that the effect of shared moral beliefs on trust varies depending on the values that ACs share with humans.

APPLICATION

To promote AC implementation, policymakers and developers need to understand which values are shared between ACs and humans to enhance trust in ACs.

Numeracy and the Motivational Mind: The Power of Numeric Self-efficacy

BACKGROUND

Objective numeracy appears to support better medical decisions and health outcomes. The more numerate generally understand and use numbers more and make better medical decisions, including more informed medical choices. Numeric self-efficacy-an aspect of subjective numeracy that is also known as numeric confidence-also relates to decision making via emotional reactions to and inferences from experienced difficulty with numbers and via persistence linked with numeric comprehension and healthier behaviors over time. Furthermore, it moderates the effects of objective numeracy on medical outcomes.

PURPOSE

We briefly review the numeracy and decision-making literature and then summarize more recent literature on 3 separable effects of numeric self-efficacy. Although dual-process theories can account for the generally superior decision making of the highly numerate, they have neglected effects of numeric self-efficacy. We discuss implications for medical decision-making (MDM) research and practice. Finally, we propose a modification to dual-process theories, adding a "motivational mind" to integrate the effects of numeric self-efficacy on decision-making processes (i.e., inferences from experienced difficulty with numbers, greater persistence, and greater use of objective-numeracy skills) important to high-quality MDM.

CONCLUSIONS

The power of numeric self-efficacy (confidence) has been little considered in MDM, but many medical decisions and behaviors require persistence to be successful over time (e.g., comprehension, medical-recommendation adherence). Including numeric self-efficacy in research and theorizing will increase understanding of MDM and promote development of better decision interventions.

HIGHLIGHTS

Research demonstrates that objective numeracy supports better medical decisions and health outcomes.The power of numeric self-efficacy (aka numeric confidence) has been little considered but appears critical to emotional reactions and inferences that patients and others make when encountering numeric information (e.g., in decision aids) and to greater persistence in medical decision-making tasks involving numbers.The present article proposes a novel modification to dual-process theory to account for newer findings and to describe how numeracy mechanisms can be better understood.Because being able to adapt interventions to improve medical decisions depends in part on having a good theory, future research should incorporate numeric self-efficacy into medical decision-making theories and interventions.

Thinking fast or slow? Functional magnetic resonance imaging reveals stronger connectivity when experienced neurologists diagnose ambiguous cases

For ∼40 years, thinking about reasoning has been dominated by dual-process theories. This model, consisting of two distinct types of human reasoning, one fast and effortless and the other slow and deliberate, has also been applied to medical diagnosis. Medical experts are trained to diagnose patients based on their symptoms. When symptoms are prototypical for a certain diagnosis, practitioners may rely on fast, recognition-based reasoning. However, if they are confronted with ambiguous clinical information slower, analytical reasoning is required. To examine the neural underpinnings of these two hypothesized forms of reasoning, 16 highly experienced clinical neurologists were asked to diagnose two types of medical cases, straightforward and ambiguous cases, while functional magnetic resonance imaging was being recorded. Compared with reading control sentences, diagnosing cases resulted in increased activation in brain areas typically found to be active during reasoning such as the caudate nucleus and frontal and parietal cortical regions. In addition, we found vast increased activity in the cerebellum. Regarding the activation differences between the two types of reasoning, no pronounced differences were observed in terms of regional activation. Notable differences were observed, though, in functional connectivity: cases containing ambiguous information showed stronger connectivity between specific regions in the frontal, parietal and temporal cortex in addition to the cerebellum. Based on these results, we propose that the higher demands in terms of controlled cognitive processing during analytical medical reasoning may be subserved by stronger communication between key regions for detecting and resolving uncertainty.

System 2 Diagnostic Process for the Next Generation of Physicians: "Inside" and "Outside" Brain-The Interplay between Human and Machine

Improving diagnosis has been one of the most critical issues in medicine for the last two decades. In the context of the rise of digital health and its augmentation and human diagnostic thinking, it has become necessary to integrate the concept of digital diagnosis into dual-process theory (DPT), which is the fundamental axis of the diagnostic thinking process physicians. Particularly, since the clinical decision support system (CDSS) corresponds to analytical thinking (system 2) in DPT, it is necessary to redefine system 2 to include the CDSS. However, to the best of my knowledge there has been no concrete conceptual model based on this need. The innovation and novelty of this paper are that it redefines system 2 to include new concepts and shows the relationship among the breakdown of system 2. In this definition, system 2 is divided into “inside” and “outside” brains, where “inside” includes symptomatologic, anatomical, biomechanical–physiological, and etiological thinking approaches, and “outside” includes CDSS. Moreover, this paper discusses the actual and possible future interplay between “inside” and “outside.” The author envisions that this paper will serve as a cornerstone for the future development of system 2 diagnostic thinking strategy.

Attitudinal Effects of Stimulus Co-occurrence and Stimulus Relations: Paradoxical Effects of Cognitive Load

Research suggests that evaluations of an object can be jointly influenced by (a) the mere co-occurrence of the object with a pleasant or unpleasant stimulus (e.g., mere co-occurrence of object A and negative event B) and (b) the object's specific relation to the co-occurring stimulus (e.g., object A starts vs. stops negative event B). Three experiments investigated the impact of cognitive load during learning on the effects of stimulus co-occurrence and stimulus relations. Counter to the shared prediction of competing theories suggesting that effects of stimulus relations should be reduced by cognitive load during learning, effects of stimulus relations were greater (rather than smaller) under high-load compared with low-load conditions. Effects of stimulus co-occurrence were not significantly affected by cognitive load. The results are discussed in terms of theories suggesting that cognitive load can influence behavioral outcomes via strategic shifts in resource allocation in response to task-specific affordances.