Dual Process Theory and Intermediate Effect: Are Faculty and Residents' Performance on Multiple-Choice, Licensing Exam Questions Different?

Background: Clinical reasoning is essential for the practice of medicine. Dual process theory conceptualizes reasoning as falling into two general categories: nonanalytic reasoning (pattern recognition) and analytic reasoning (active comparing and contrasting of alternatives). The debate continues regarding how expert performance develops and how individuals make the best use of analytic and nonanalytic processes. Several investigators have identified the unexpected finding that intermediates tend to perform better on licensing examination items than experts, which has been termed the "intermediate effect." Purpose: We explored differences between faculty and residents on multiple-choice questions (MCQs) using dual process measures (both reading and answering times) to inform this ongoing debate. Method: Faculty (board-certified internists; experts) and residents (internal medicine interns; intermediates) answered live licensing examination MCQs (U.S. Medical Licensing Examination Step 2 Clinical Knowledge and American Board of Internal Medicine Certifying Examination) while being timed. We conducted repeated analysis of variance to compare the 2 groups on average reading time, answering time, and accuracy on various types of items. Results: Faculty and residents did not differ significantly in reading time [F (1,35) = 0.01, p = 0.93], answering time [F (1,35) = 0.60, p = 0.44], or accuracy [F (1,35) = 0.24, p = 0.63] regardless of easy or hard items. Discussion: Dual process theory was not evidenced in this study. However, this lack of difference between faculty and residents may have been affected by the small sample size of participants and MCQs may not reflect how physicians made decisions in actual practice setting.