Medical Education and Cognitive Continuum Theory: An Alternative Perspective on Medical Problem Solving and Clinical Reasoning

Custers, Eugène J.F.M. PhD

Academic Medicine:
doi: 10.1097/ACM.0b013e31829a3b10

Recently, human reasoning, problem solving, and decision making have been viewed as products of two separate systems: “System 1,” the unconscious, intuitive, or nonanalytic system, and “System 2,” the conscious, analytic, or reflective system. This view has penetrated the medical education literature, yet the idea of two independent dichotomous cognitive systems is not entirely without problems.

This article outlines the difficulties of this “two-system view” and presents an alternative, developed by K.R. Hammond and colleagues, called cognitive continuum theory (CCT). CCT is featured by three key assumptions. First, human reasoning, problem solving, and decision making can be arranged on a cognitive continuum, with pure intuition at one end, pure analysis at the other, and a large middle ground called “quasirationality.” Second, the nature and requirements of the cognitive task, as perceived by the person performing the task, determine to a large extent whether a task will be approached more intuitively or more analytically. Third, for optimal task performance, this approach needs to match the cognitive properties and requirements of the task. Finally, the author makes a case that CCT is better able than a two-system view to describe medical problem solving and clinical reasoning and that it provides clear clues for how to organize training in clinical reasoning.

Author Information

Dr. Custers is medical education researcher, Center for Research and Development of Education, University Medical Center, Utrecht, The Netherlands.

Editor’s Note: A commentary by G. Norman, S.Monteiro, and J. Sherbino appears on page 1058.

Correspondence should be addressed to Dr. Custers, PO Box 85500, 3508 GA, Utrecht, The Netherlands; e-mail:

© 2013 by the Association of American Medical Colleges