BACKGROUND: Despite efforts to improve undergraduate clinical pharmacology & therapeutics (CPT) education, prescribing errors are still made regularly. To improve CPT education and daily prescribing, it is crucial to understand how therapeutic reasoning works. Therefore, the aim of this study was to gain insight into the therapeutic reasoning process. METHODS: A narrative literature review has been performed for literature on cognitive psychology and diagnostic and therapeutic reasoning. RESULTS: Based on these insights, The European Model of Therapeutic Reasoning has been developed, building upon earlier models and insights from cognitive psychology. In this model, it can be assumed that when a diagnosis is made, a primary, automatic response as to what to prescribe arises based on pattern recognition via therapy scripts (type 1 thinking). At some point, this response may be evaluated by the reflective mind (using metacognition). If it is found to be incorrect or incomplete, an alternative response must be formulated through a slower, more analytical and deliberative process, known as type 2 thinking. Metacognition monitors the reasoning process and helps a person to form new therapy scripts after they have chosen an effective therapy. Experienced physicians have more and richer therapy scripts, mostly based on experience and enabling conditions, instead of textbook knowledge, and therefore their type 1 response is more often correct. CONCLUSION: Because of the important role of metacognition in therapeutic reasoning, more attention should be paid to metacognition in CPT education. Both trainees and teachers should be aware of the possibility to monitor and influence these cognitive processes. Further research is required to investigate the applicability of these insights and the adaptability of educational approaches to therapeutic reasoning.

Clinical Immunology and Osteoarticular Diseases Therapeutic Unit Lapeyronie University Hospital Montpellier France

Department of Fundamental and Applied Medical Sciences Unit of Clinical Pharmacology Ghent University C Heymanslaan 10 9000 Ghent Belgium

Department of Hospital Pharmacy University Medical Center Rotterdam MC Rotterdam The Netherlands

Department of Internal Medicine Unit Pharmacotherapy Amsterdam UMC Vrije Universiteit De Boelelaan 1117 1081 HV Amsterdam The Netherlands

Department of Medical and Surgical Sciences Pharmacology Unit Alma Mater Studiorum University of Bologna Via Zamboni 33 40126 Bologna Italy

Department of Pharmacology Faculty of Medicine Masaryk University Brno Czech Republic

Department of Pharmacology Montpellier University Hospital Avenue du Doyen Gaston Giraud 34090 Montpellier France

Department of Pharmacology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden

Department of Surgery University Medical Center Utrecht Heidelberglaan 100 3584 CX Utrecht The Netherlands

Institute of Experimental and Clinical Pharmacology and Toxicology University of Lübeck Lübeck Germany

Interprofessional Collaboration and Medication Safety Faculty of Health Sports and Social Work InHolland University of Applied Sciences Pina Bauschplein 4 1095PN Amsterdam The Netherlands

IRMB University Montpellier INSERM CHU Montpellier Montpellier France

Pathogenesis and Control of Chronic and Emerging Infections INSERM University Montpellier 34090 Montpellier France

Research and Expertise Centre in Pharmacotherapy Education De Boelelaan 1117 1081 HV Amsterdam The Netherlands

School of Health Science Universidad de La Laguna and Hospital Universitario de Canarias Santa Cruz de Tenerife Calle Padre Herrera S N 38200 La Laguna Tenerife Spain

Unit of Clinical Pharmacology Department of Internal Medicine University Hospital Centre Zagreb and University of Zagreb School of Medicine 12 Kišpatićeva St 10 000 Zagreb Croatia

See more in PubMed

Brinkman DJ, Tichelaar J, Okorie M, Bissell L, Christiaens T, Likic R, et al. Pharmacology and therapeutics education in the European Union needs harmonization and modernization: a cross-sectional survey among 185 medical schools in 27 countries. Clin Pharmacol Ther. 2017;102(5):815–22. PubMed PMC

McLellan L, Tully MP, Dornan T. How could undergraduate education prepare new graduates to be safer prescribers? Br J Clin Pharmacol. 2012;74(4):605–13. PubMed PMC

Bakkum MJ, Richir MC, Papaioannidou P, Likic R, Sanz EJ, Christiaens T, et al. EurOP(2)E - the European open platform for prescribing education, a consensus study among clinical pharmacology and therapeutics teachers. Eur J Clin Pharmacol. 2021;77(8):1209–18. PubMed PMC

Brinkman DJ, Tichelaar J, Mokkink LB, Christiaens T, Likic R, Maciulaitis R, et al. Key learning outcomes for clinical pharmacology and therapeutics education in Europe: a modified Delphi study. Clin Pharmacol Ther. 2018;104(2):317–25. PubMed PMC

Donker E, Brinkman D, Richir M, Papaioannidou P, Likic R, Sanz EJ, et al. European list of essential medicines for medical education: a protocol for a modified Delphi study. BMJ Open. 2021;11(5):e045635. PubMed PMC

Donker EM, Brinkman DJ, Richir MC, Papaioannidou P, Likic R, Sanz EJ, et al. The European prescribing exam: assessing whether European medical students can prescribe rationally and safely. Eur J Clin Pharmacol. 2022;78(6):1049–51. PubMed PMC

Faccenda E, Maxwell S, Szarek JL. The IUPHAR pharmacology education project. Clin Pharmacol Ther. 2019;105(1):45–8. PubMed PMC

Jansen DRM, Keijsers C, Kornelissen MO, OldeRikkert MGM, Kramers C. Towards a “prescribing license” for medical students: development and quality evaluation of an assessment for safe prescribing. Eur J Clin Pharmacol. 2019;75(9):1261–8. PubMed

Maxwell SRJ, Coleman JJ, Bollington L, Taylor C, Webb DJ. Prescribing Safety Assessment 2016: Delivery of a national prescribing assessment to 7343 UK final-year medical students. Br J Clin Pharmacol. 2017;83(10):2249–58. PubMed PMC

Donker EM, SpitaleriTimpone P, Brinkman DJ, Richir MC, Papaioannidou P, Likic R, et al. The European list of key medicines for medical education: a modified Delphi study. Clin Pharmacol Ther. 2024;115(3):515–24. PubMed

Donker EM, Brinkman DJ, van Rosse F, Janssen B, Knol W, Dumont G, et al. Do we become better prescribers after graduation: a 1-year international follow-up study among junior doctors. Br J Clin Pharmacol. 2022;88(12):5218–26. PubMed PMC

Ryan C, Ross S, Davey P, Duncan EM, Francis JJ, Fielding S, et al. Prevalence and causes of prescribing errors: the PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) study. PLoS ONE. 2014;9(1):e79802. PubMed PMC

Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009;32(5):379–89. PubMed

Organization WHO. Medication errors. 2016.

De Vries T, Henning RH, Hogerzeil HV, Fresle D, Policy M, Organization WHO. Guide to good prescribing: a practical manual. World Health Organization; 1994.

Tichelaar J, Richir MC, Avis HJ, Scholten HJ, Antonini NF, De Vries TP. Do medical students copy the drug treatment choices of their teachers or do they think for themselves? Eur J Clin Pharmacol. 2010;66(4):407–12. PubMed PMC

Goldszmidt M, Minda JP, Bordage G. Developing a unified list of physicians’ reasoning tasks during clinical encounters. Acad Med. 2013;88(3):390–7. PubMed

Bissessur SW, Geijteman EC, Al-Dulaimy M, Teunissen PW, Richir MC, Arnold AE, de Vries TP. Therapeutic reasoning: from hiatus to hypothetical model. J Eval Clin Pract. 2009;15(6):985–9. PubMed

Denig P, Haaijer-Ruskamp FM, Zijsling DH. How physicians choose drugs. Soc Sci Med. 1988;27(12):1381–6. PubMed

Tichelaar J, Making better prescribers during a context-based pharmacotherapy learning programme: New insights into the improvement of a pharmacotherapy context-learning programme. 2016.

Tichelaar J, Richir MC, Garner S, Hogerzeil H, de Vries T. WHO guide to good prescribing is 25 years old: quo vadis? Eur J Clin Pharmacol. 2020;76(4):507–13. PubMed

Mariëlle G. Hartjes, Milan C. Richir, Yoann Cazaubon,, Erik M. Donker, Ellen van Leeuwen, Robert Likic, Yves-Marie Pers, Joost D. Piët, Fabrizio de Ponti, Walter Raasch, Floor van Rosse, Jitka Rychlícková, Emilio J. Sanz, Markus Schwaninger, Susanna M. Wallerstedt, Theo P.G.M. de Vries, Michiel A. van Agtmael, Jelle Tichelaar. Understanding therapeutic reasoning: a scientific report. The European Open Platform for Prescribing Education; 2024.

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26(2):91–108. PubMed

The European Open Platform for Prescribing Education [Internet]. Prescrebingeducation.eu. [cited 2024 Sep 27]. Available from: prescribingeducation.eu.

Cook DA, Durning SJ, Sherbino J, Gruppen LD. Management reasoning: implications for health professions educators and a research agenda. Acad Med. 2019;94(9):1310–6. PubMed

Pennycook G, Fugelsang JA, Koehler DJ. What makes us think? A three-stage dual-process model of analytic engagement. Cogn Psychol. 2015;80:34–72. PubMed

Kruglanski AW. Only One? The default interventionist perspective as a unimodel-commentary on Evans & Stanovich (2013). Perspect Psychol Sci. 2013;8(3):242–7. PubMed

De Neys W. On dual- and single-process models of thinking. Perspect Psychol Sci. 2021;16(6):1412–27. PubMed

Hammond K. Beyond rationality: the search for wisdom in a troubled time. 2023.

Evans J. How many dual-process theories do we need? One, two, or many? In two minds: Dual processes and beyond. 2009.

Houdé O. 3-System theory of the cognitive brain: a post-Piagetian approach to cognitive development. 2019. 1–134.

Kahneman D. Thinking, fast and slow. New York: Farrar, Straus and Giroux; 2011. p. 499.

Soh M, Konopasky A, Durning SJ, Ramani D, McBee E, Ratcliffe T, Merkebu J. Sequence matters: patterns in task-based clinical reasoning. Diagnosis. 2020;7(3):281–9. PubMed

Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022–8. PubMed

Stanovich K. Distinguishing the reflective, algorithmic, and autonomous minds: Is it time for a tri-process theory? In two minds: Dual processes and beyond. 2009.

Soon CS, Brass M, Heinze H-J, Haynes J-D. Unconscious determinants of free decisions in the human brain. Nat Neurosci. 2008;11(5):543–5. PubMed

Hackenberger BK. Bayes or not Bayes, is this the question? Croat Med J. 2019;60(1):50–2. PubMed PMC

Gill CJ, Sabin L, Schmid CH. Why clinicians are natural Bayesians. BMJ. 2005;330(7499):1080–3. PubMed PMC

Marcum JA. An integrated model of clinical reasoning: dual-process theory of cognition and metacognition. J Eval Clin Pract. 2012;18(5):954–61. PubMed

Evans JSBT. Reflections on reflection: the nature and function of type 2 processes in dual-process theories of reasoning. Think Reason. 2019;25(4):383–415.

Abdoler EA, O’Brien BC, Schwartz BS. Following the script: an exploratory study of the therapeutic reasoning underlying physicians’ choice of antimicrobial therapy. Acad Med. 2020;95(8):1238–47. PubMed

Denig P, Haaijer-Ruskamp FM. Therapeutic decision making of physicians. Pharm Weekbl Sci. 1992;14(1):9–15. PubMed

Ljungberg C, Lindblad ÅK, Tully MP. Hospital doctors’ views of factors influencing their prescribing. J Eval Clin Pract. 2007;13(5):765–71. PubMed

Overton WF, Ricco RB. Dual-systems and the development of reasoning: competence-procedural systems. Wiley Interdiscip Rev Cogn Sci. 2011;2(2):231–7. PubMed

Fleur DS, Bredeweg B, van den Bos W. Metacognition: ideas and insights from neuro- and educational sciences. NPJ Sci Learn. 2021;6(1):13. PubMed PMC

Richards JB, Hayes MM, Schwartzstein RM. Teaching clinical reasoning and critical thinking: from cognitive theory to practical application. Chest. 2020;158(4):1617–28. PubMed

Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41(1):110–20. PubMed

Neufeld VR, Norman GR, Feightner JW, Barrows HS. Clinical problem-solving by medical students: a cross-sectional and longitudinal analysis. Med Educ. 1981;15(5):315–22. PubMed

Norman GR, Brooks LR. The Non-Analytical Basis of Clinical Reasoning. Adv Health Sci Educ Theory Pract. 1997;2(2):173–84. PubMed

Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. Acad Med. 2017;92(1):23–30. PubMed

Moulton CA, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Acad Med. 2007;82(10 Suppl):S109–16. PubMed

Parsons AS, Wijesekera TP, Rencic JJ. The management script: a practical tool for teaching management reasoning. Acad Med. 2020;95(8):1179–85. PubMed

Cook DA, Stephenson CR, Gruppen LD, Durning SJ. Management reasoning scripts: qualitative exploration using simulated physician-patient encounters. Perspect Med Educ. 2022;11(4):196–206. PubMed PMC

Schmidt HG, Norman GR, Boshuizen HP. A cognitive perspective on medical expertise: theory and implication. Acad Med. 1990;65(10):611–21. PubMed

Cook DA, Stephenson CR, Gruppen LD, Durning SJ. Management reasoning: empirical determination of key features and a conceptual model. Acad Med. 2023;98(1):80–7. PubMed

Custers EJ. Thirty years of illness scripts: Theoretical origins and practical applications. Med Teach. 2015;37(5):457–62. PubMed

Higgins MP, Tully MP. Hospital doctors and their schemas about appropriate prescribing. Med Educ. 2005;39(2):184–93. PubMed

Monajemi A, Rostami ER, Savaj S, Rikers RM. How does patient management knowledge integrate into an illness script? Educ Health (Abingdon). 2012;25(3):153–9. PubMed

Mancuso CA, Rose DN. A model for physicians’ therapeutic decision making. Arch Intern Med. 1987;147(7):1281–5. PubMed

Walker S, Pham TN, Duong QH, Brock TP, Lyons KM. Cognitive and metacognitive processes demonstrated by the pharmacy students when making therapeutic decisions. Am J Pharm Educ. 2022;87(4):ajpe8817. PubMed PMC

Mertens JF, Kempen TGH, Koster ES, Deneer VHM, Bouvy ML, van Gelder T. Cognitive processes in pharmacists’ clinical decision-making. Res Social Adm Pharm. 2024;20(2):105–14. PubMed

Cook DA, Hargraves IG, Stephenson CR, Durning SJ. Management reasoning and patient-clinician interactions: Insights from shared decision-making and simulated outpatient encounters. Med Teach. 2023;45(9):1025–37. PubMed

Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Decis Making. 2015;35(4):539–57. PubMed

Langford BJ, Daneman N, Leung V, Langford DJ. Cognitive bias: how understanding its impact on antibiotic prescribing decisions can help advance antimicrobial stewardship. JAC-Antimicrob Resist. 2020;2(4):dlaa107. PubMed PMC

Livorsi D, Comer A, Matthias MS, Perencevich EN, Bair MJ. Factors influencing antibiotic-prescribing decisions among inpatient physicians: a qualitative investigation. Infect Control Hosp Epidemiol. 2015;36(9):1065–72. PubMed PMC

Evans JS. In two minds: dual-process accounts of reasoning. Trends Cogn Sci. 2003;7(10):454–9. PubMed

Klein G, editor Intuition at Work: why developing your gut instincts will make you better at what you do. 2002.

Klein G. A Recognition Primed Decision (RPD) Model of Rapid Decision Making. 1993.

Cate O, Eugene JF, Durning SJ, editors. Principles and practice of case-based clinical reasoning education: A method for preclinical students. Cham: Springer International Publishing; 2018. PubMed

Tallentire VR, Smith SE, Skinner J, Cameron HS. Understanding the behaviour of newly qualified doctors in acute care contexts. Med Educ. 2011;45(10):995–1005. PubMed

Schmidt HG, Rikers RM. How expertise develops in medicine: knowledge encapsulation and illness script formation. Med Educ. 2007;41(12):1133–9. PubMed

McBee E, Ratcliffe T, Picho K, Schuwirth L, Artino AR Jr, Yepes-Rios AM, et al. Contextual factors and clinical reasoning: differences in diagnostic and therapeutic reasoning in board certified versus resident physicians. BMC Med Educ. 2017;17(1):211. PubMed PMC

Keemink Y, Custers E, van Dijk S, Ten Cate O. Illness script development in pre-clinical education through case-based clinical reasoning training. Int J Med Educ. 2018;9:35–41. PubMed PMC

van Zijl A, van Loon M, ten Cate O. Case-Based Clinical Reasoning in Practice. In: ten Cate O, Custers E, Durning SJ, editors. Principles and Practice of Case-based Clinical Reasoning Education: A Method for Preclinical Students. Cham (CH): Springer; 2018. p. 75–83. PubMed

Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55(1):68–78. PubMed

Di Domenico SI, Ryan RM. The emerging neuroscience of intrinsic motivation: a new frontier in self-determination research. Front Human Neurosci. 2017;11:145. PubMed PMC

Duan H, Fernández G, Dongen E, Kohn N. The effect of intrinsic and extrinsic motivation on memory formation: insight from behavioral and imaging study. Brain Struct Funct. 2020;225. PubMed PMC

Schutte T, Tichelaar J, Dekker RS, Thijs A, de Vries TP, Kusurkar RA, et al. Motivation and competence of participants in a learner-centered student-run clinic: an exploratory pilot study. BMC Med Educ. 2017;17(1):23. PubMed PMC

Sultan R, van den Beukel TO, Reumerman MO, Daelmans HEM, Springer H, Grijmans E, et al. An Interprofessional Student-Run Medication Review Program: The Clinical STOPP/START-Based Outcomes of a Controlled Clinical Trial in a Geriatric Outpatient Clinic. Clin Pharmacol Ther. 2022;111(4):931–8. PubMed PMC

Monteiro S, Norman G, Sherbino J. The 3 faces of clinical reasoning: Epistemological explorations of disparate error reduction strategies. J Eval Clin Pract. 2018;24(3):666–73. PubMed

Shabani K, Mohammad K, Ebadi S. Vygotsky’s Zone of proximal development: instructional implications and teachers’ professional development. English Lang Teach. 2010;3:237–48.

Patel JJ, Goodman R. Uncertainty in Medicine. JAMA Intern Med. 2021;181(10):1417–8. PubMed

Peden NR, Cairncross RG, Harden RM, Crooks J. Assessment of clinical competence in therapeutics: the use of the objective structured clinical examination. Med Teach. 1985;7(2):217–23. PubMed

Jones MD, Liu S, Powell F, Samsor A, Ting FCR, Veliotis N, et al. Exploring the Role of Guidelines in Contributing to Medication Errors: A Descriptive Analysis of National Patient Safety Incident Data. Drug Saf. 2024;47(4):389–400. PubMed PMC

Chew KS, Durning SJ, van Merriënboer JJ. Teaching metacognition in clinical decision-making using a novel mnemonic checklist: an exploratory study. Singapore Med J. 2016;57(12):694–700. PubMed PMC

Cooper N, Bartlett M, Gay S, Hammond A, Lillicrap M, Matthan J, Singh M. Consensus statement on the content of clinical reasoning curricula in undergraduate medical education. Med Teach. 2021;43(2):152–9. PubMed

Cutrer WB, Sullivan WM, Fleming AE. Educational strategies for improving clinical reasoning. Curr Probl Pediatr Adolesc Health Care. 2013;43(9):248–57. PubMed

Gagnon N, Bernier C, Houde S, Xhignesse M. Teaching and learning clinical reasoning: a teacher’s toolbox to meet different learning needs. Br J Hosp Med (Lond). 2020;81(3):1–8. PubMed

Royce CS, Hayes MM, Schwartzstein RM. Teaching Critical Thinking: A Case for Instruction in Cognitive Biases to Reduce Diagnostic Errors and Improve Patient Safety. Acad Med. 2019;94(2):187–94. PubMed

Teixeira Ferraz Grünewald S, Grünewald T, Ezequiel ODS, Lucchetti ALG, Lucchetti G. One-Minute Preceptor and SNAPPS for clinical reasoning: a systematic review and meta-analysis. Intern Med J. 2023;53(5):680–9. PubMed

Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered model for outpatient education. Acad Med. 2003;78(9):893–8. PubMed

Mamede S, Schmidt HG. Deliberate reflection and clinical reasoning: Founding ideas and empirical findings. Med Educ. 2023;57(1):76–85. PubMed PMC

Abdoler EA, Parsons AS, Wijesekera TP. The future of teaching management reasoning: important questions and potential solutions. Diagnosis (Berl). 2023;10(1):19–23. PubMed

Gruenberg K, Abdoler E, O'Brien BC, Schwartz BS, MacDougall C. How do pharmacists select antimicrobials? A model of pharmacists' therapeutic reasoning processes. JACCP: J Am Coll Clin Pharm. 2022;5(4):398–405.

Cook DA, Sherbino J, Durning SJ. Management Reasoning: Beyond the Diagnosis. JAMA. 2018;319(22):2267–8. PubMed