Accepted Manuscript

Intuition, analysis and reflection: An experimental study into the decision-making

processes and thinking dispositions of osteopathy students

Jonathan Spadaccini, Jorge E. Esteves

PII: S1746-0689(14)00029-7
DOI: 10.1016/j.ijosm.2014.04.004
Reference: IJOSM 329

To appear in: International Journal of Osteopathic Medicine

Received Date: 17 February 2014

Revised Date: 9 April 2014
Accepted Date: 16 April 2014

Please cite this article as: Spadaccini J, Esteves JE, Intuition, analysis and reflection: An experimental
study into the decision-making processes and thinking dispositions of osteopathy students, International
Journal of Osteopathic Medicine (2014), doi: 10.1016/j.ijosm.2014.04.004.

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Intuition, analysis and reflection: An experimental study into the decision-making

processes and thinking dispositions of osteopathy students

Authors

Jonathan Spadaccini

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Research Center, The British School of Osteopathy 275 Borough High Street, London,
United Kingdom, SE1 1JE

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Jorge E. Esteves*

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Research Center, The British School of Osteopathy 275 Borough High Street, London,
United Kingdom, SE1 1JE

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*Corresponding Author Details:
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Dr Jorge E. Esteves

The British School of Osteopathy

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275 Borough High Street

London SE1 1JE

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Tel + 44 (0)20 7089 5310

Email: j.esteves@bso.ac.uk
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Abstract

Background

Decision-making and reflective thinking are fundamental aspects of clinical reasoning. How

osteopathy students think and make decisions will therefore have far-reaching implications

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throughout their professional lives. Models of decision-making are firmly established in

cognitive science literature and their application is universal, yet the decision-making

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processes and thinking dispositions of osteopathy students remain relatively unexplored.

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Objectives and Method

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Using the Cognitive Reflection Test (CRT)13 to measure decision-making preferences and

the 41-item Actively Open-minded Thinking disposition scale (AOT)29, this study set out to
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explore how osteopathy students at the start (novice; n=44) and end (intermediate; n=32) of

their pre-professional training make decisions and how reflectively they think.
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Results
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Intermediate level practitioners demonstrate significantly more analytical decision-making

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than their novice peers (p = 0.007; effect size = 0.31); however, reflective thinking

dispositions do not change as participants progress through their training (p = 0.07). No

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significant association was found between analytical decision-making and reflective thinking

(p = 0.85).
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Conclusions

The trend for intermediate level practitioners to demonstrate more analytical decision-making

than novices, without significant differences in reflective thinking processes, supports other

research that suggests osteopathic education promotes deductive over inductive reasoning

in its graduates and that reasoning and thinking dispositions may develop independently of

each other, given the skills and knowledge-based requirements of osteopathic education.
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Intuition, analysis and reflection: An experimental study into the decision-making

processes and thinking dispositions of osteopathy students

1. Introduction

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Clinical reasoning is the thinking and decision-making process that informs and underpins

autonomous clinical practice, involving the interrogation and application of both declarative

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and procedural knowledge, reflection, and evaluation.1 Clinical reasoning in autonomous

health professions such as osteopathy is likely to make use of higher-order cognitive

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processes associated with, for example, reasoning, problem-solving and decision-making.

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Thinking and decision-making remain, however, an under-researched topic in osteopathy.

This is despite independent and responsible decision-making being the hallmarks of an

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autonomous profession.2 The literature in the field of cognitive science is awash with

concepts and models of decision-making and during the last two decades, the Dual Process
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theory has become widely accepted and established as a model of human reasoning and
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decision-making.3 Dual Process theorists propose that everyday’s’ decision making is

underpinned by two distinct systems of judgment, which cluster at either end of a continuum
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of cognitive effort.4-6 System 1 is an associative system, which uses basic cognitive

processes such as similarity, association, and memory retrieval; judgments are fast,
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automatic, intuitive and largely unconscious. In contrast, System 2 is a rule-based system;

judgments are slow, deliberative and conscious.7, 8 The Dual Process theory illustrates the
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two main forms of human reasoning: inductive and deductive.8 Whereas inductive reasoning
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is primarily based on the rapid retrieval, and appraisal of world knowledge, i.e., System 1;

deductive reasoning depends on rule-based, formal procedures, i.e., System 2.

It has been claimed that osteopathy is distinguished from other health care professions by

the fact that it is practised according to an articulated philosophy.9 However, it can be argued

that the decision-making processes and thinking dispositions of osteopathic practitioners are
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universal. Although firmly established as a model of reasoning and decision-making in the

field of cognitive science, the application of the Dual Process theory to medicine remains

uncommon10 and only limited attempts have been made to explore it in the context of

osteopathy.11, 12
In the UK, as primary contact practitioners, osteopaths have a statutory

obligation to demonstrate appropriate thinking skills in order to justify their clinical decision-

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making, but also to regularly engage in reflective thinking to ensure their knowledge remains

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relevant.13 The present study is especially timely as osteopathy’s inclusion in national

guidelines for the management of non-specific low back pain14 must make it more available

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for scrutiny in the context of changing health care purchasing and provision.15

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As a general psychological construct, System 1 processes can be adaptive and useful

strategies to reach reasonable, if not always considered, conclusions.16 Although there may
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have been certain evolutionary advantages to fast intuitive thinking, it continues to exert

considerable control over human decision-making today.3 Frederick17 illustrates this well in
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his extensive research involving over 3000 subjects across 35 separate studies. Despite
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some methodological flaws, Frederick demonstrated an overwhelming tendency for subjects

to resort to System 1 processes to answer a simple three-item ‘Cognitive Reflection Test’

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(CRT). Frederick17 argued that the items on the test are easily understood when the solutions

are explained, that high level mathematical skills are not needed, but that in order to reach
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the correct answer, an erroneous, impulsive and intuitive response must be suppressed: “A
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bat and ball cost $1.10 in total. The bat cost $1.00 more than the ball. How much does the

ball cost?” Although the correct answer is 5¢, the more common (and incorrect System 1)
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answer given is 10¢. As a result of such examples, there is now considerable consensus in

the medical literature, often without criticism or investigation, on how faulty reasoning results

in diagnostic errors.18-22 On this point, Croskerry18 argues that whereas the majority of errors

occur with System 1 judgments and are to some extent expected, errors made with System 2

judgments are infrequent and unexpected.

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An additional feature of Frederick’s17 CRT may be its ability to implicate thinking dispositions,

especially those related to thinking reflectively. Performance on the CRT demands that a pre-

potent and incorrect response is overridden in favour of a more reflective (and therefore

correct) one. Baron23, p. 172 defines good thinking as a complex process that demonstrates the

“optimal search for possibilities, evidence and goals”. In contrast, poor thinking is

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characterised by an inadequate search for evidence and the general tendency of people to

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allow their own biases to affect their reasoning. The zenith of Baron’s23, p. 173 good thinking is

termed ‘actively open-minded thinking’, in which enhanced objectivity is ensured during the

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search for, and review of, the evidence.

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The existence of a dual process model of decision-making is well established. Indeed,

functional neuroimaging studies have demonstrated that depending on cognitive demand,

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different cortical regions are recruited8 and that they differently affect human physiology.24

Notwithstanding this, the literature in the field of medical cognition is clearly divided over the
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merits of one system over the other, and recent developments in cognitive science seem to
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support combined approaches as a model of improved decision-making.25, 26

Despite this

growing evidence, however, research exploring decision-making and thinking dispositions in

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osteopathy is scarce.
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How osteopathy students think and make decisions will have potentially far-reaching

implications throughout their professional lives. In particular, given that the nature of
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osteopathic intervention demands analysis and that as a profession, osteopathy has a

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patient-centred responsibility to continue to reflect upon and evaluate its impact.27 It is also

assumed that throughout training, thinking and reasoning styles develop as clinical

experience and understanding grow. This study therefore set out to ask: what are the levels

of analytical decision-making and reflective open-minded thinking in osteopathy students at

different stages in their pre-registration education? In doing so, this study explores whether

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osteopathy students favour System 1 or System 2 processes when making decisions; and

whether there is any relationship between students’ decision-making preferences and

thinking disposition. Finally, it also explored whether final year (intermediate practitioner)

students demonstrate more analytical decision-making and reflective thinking than their first

year (novice practitioner) colleagues, measured using the CRT and Actively Open-minded

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Thinking Scale (AOT) scales respectively.

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2. Methods

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2.1 Study design

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A quasi-experimental design was used to explore links between year of pre-professional

training, decision-making and reflective thinking preferences. The independent variable was
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expertise, with two levels (novice vs. intermediate), and dependent variables were decision-

making and reflective thinking preferences, measured using the Cognitive Reflection Test
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(CRT) and the Actively Open-Minded Thinking Scale (AOT) respectively. This study draws
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upon methodology commonly used in the field of cognitive science exploring decision-making

and thinking dispositions.17, 28-31

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2.2 Participants
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Seventy-six undergraduate students drawn from a convenience sample of students studying

at the British School of Osteopathy (BSO) and taken from years 1 (novices: n = 44) and final
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year (intermediates: n = 32) of a four-year, pre-registration osteopathy course, initially

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recruited through email invitation, participated in the study. Following the model of medical

expertise development initially proposed by Schmidt and colleagues32, students were

classified as novices or intermediates. Typically, in studies conducted by Schmidt and

colleagues33 in the domain of allopathic medicine, novices are students in their pre-clinical

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training years whereas intermediates are students who have already completed a substantial

portion of their clinical training.

2.2.1 Inclusion criteria

All students from both years were contacted via their year forum intranet address. They

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received written details of the study with an instruction to contact the researchers directly if

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they wished to participate.

2.2.2 Exclusion criteria

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In line with existing research in the field of cognitive science, English as second language

and familiarity with the tests were not regarded as exclusion criteria.28, 31 The items on the
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CRT and AOT demonstrate sufficient internal reliability and validity that they may be easily

completed even with English as a second language. Moreover, Costa and colleagues.34 have
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recently found that performance on the CRT is not affected by language; foreign language

does not reduce the impact of System 1 on participants’ decisions. Additionally, it was
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assumed that students on the course possess competence in the English language, having
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already fulfilled the entry requirements for the osteopathy pre-registration masters’ course.

With regard to familiarity with the CRT, it was reasoned that although some participants may
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have already been familiar with items on the CRT, it is unlikely that they would have

memorised the correct answers. Therefore, even familiarity required participants to think
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more analytically to score well. Finally, we did not screen participants for their cognitive
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ability for two main reasons: firstly, we assumed they possessed the cognitive ability to study

at undergraduate level; and secondly, cognitive ability was not one of the study’s outcome

measures.

2.3 Equipment and procedure

2.3.1 Cognitive Reflection Test (CRT)

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The Cognitive Reflection Test introduced by Frederick17 is a brief 3-item test, which

differentiates between more impulsive and more reflective decision-makers.30 The CRT’s

three items are: “1) A bat and ball cost $1.10 in total. The bat cost $1.00 more than the ball.

How much does the ball cost?; 2) If it takes 5 machines 5 minutes to make 5 widgets, how

long would it take 100 machines to make 100 widgets?; 3) In a lake there is a patch of lily

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pads. Every day, the patch doubles in size. If it takes 48 days for the patch to cover the entire

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lake, how long would it take for the patch to cover half of the lake?” The CRT demonstrates

high levels of internal reliability (Cronbach’s Alpha = 0.83).28 It is scored in terms of accuracy,

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thus subjects can score between 0 and 3 out of 3, with higher scores reflecting more

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analytical and deliberative (System 2) decision-making.

2.3.2 Actively Open-Minded Thinking Scale (AOT)

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The Actively Open-minded Thinking Scale35 is a 41-item thinking disposition scale in which
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participants are asked to mark in the box which best describes their thoughts on each item,

from “Strongly Disagree” to “Strongly Agree” (with 4 other options between). Examples of
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items include, “People should always take into consideration evidence that goes against their
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beliefs”. Some of the items are reversed scored and a total score is achieved by summing

the responses. Higher scores implicate more open-minded thinking.36 The AOT also shows
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high internal reliability and validity (Cronbach’s Alpha = 0.81)28 in assessing whether subjects

are able to separate prior beliefs and opinions from the evaluation of current evidence and
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arguments.
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Participants completed both the CRT and AOT individually during a single session, lasting on

average around ten minutes per person. Participants were able to complete the scales in any

order they preferred. They were advised verbally and in writing they could leave blank any of

the CRT questions they felt unable to answer, but to complete all 41 statements on the AOT.

Anonymity was assured verbally and in writing. All participants completed the scales in a

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classroom setting with instruction to complete both measures without discussing their

answers with their peers, during or after completion. This study was approved by the BSO

Research Ethics Committee and conducted according to the 1964 Declaration of Helsinki.

2.4 Data analysis

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Descriptive statistics were computed for each group to establish the normality of the CRT

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and AOT scores (Skewness and kurtosis; Shapiro-Wilk test and histogram inspections) and

to report measures of central tendency and spread of data. To examine the null hypothesis

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“there is no difference in ‘intermediate’ and ‘novice’ students’ decision-making preferences

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and reflective thinking skills”, we used a Mann-Whitney U test, an independent t test and

Spearman’s rank correlation. Cohen’s d and effect size correlations for CRT and AOT scores
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were calculated if they reached statistical significance. The significance level for all analyses

was set at p < 0.05.

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3. Results
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3.1 Cognitive Reflection Test (CRT)

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Figure 1 illustrates the CRT median scores (MDN) across the two levels of expertise (novice

and intermediate). For novices (n=44), 61% failed to answer any of the problems correctly,
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with 4.5% solving all three items. For intermediates (n=32), 38% of participants did not solve

any of the problems, whilst 22% answered all 3 items correctly.

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Differences in participants’ scores were examined using a Mann-Whitney U test. This

analysis revealed a statistically significant difference between intermediates and novices [U =

469.0; p = 0.007; effect size = 0.31] with intermediates scoring higher in the CRT (Mdn = 1)

than novices (Mdn = 0) with a medium effect size (r = 0.31).

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---------------------------------------------

Insert Figure 1 about here

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3.2 Actively Open-minded Thinking Scale (AOT)

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The AOT scores in both groups were tested for normality based on skewness (-2 < Z < 2),

kurtosis (-2 < Z < 2) and Shapiro-Wilk (p > 0.05) values. All of the data were normally

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distributed (novices, p = 0.955; intermediates, p = 0.352)

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Table 1 shows the AOT mean scores (M) and standard deviations (SD). Differences in

participants’ reflective thinking dispositions were examined using an independent samples t

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test. This analysis revealed no significant difference between novice and intermediate

reflective thinking scores [t (76) = 1.85, df = 73.2, p = 0.07].

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Insert Table 1 about here

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3.3 Supplementary Analysis

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Supplementary analyses were conducted to examine the association between decision-

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making preferences (CRT) predicting thinking dispositions (AOT). A Spearman’s rho

correlation did not reveal a statistically significant association between analytical decision-

making (CRT) and reflective thinking (AOT) [rs (74) = -0.022, p = 0.85] (see Figure 2).

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---------------------------------------------

Insert Figure 2 about here

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4. Discussion

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This study explored how pre-registration osteopathy students at different levels of expertise

think and make decisions. It also examined whether any relationship exists between their

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reasoning preferences and thinking dispositions. The results show that students nearing the

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end of their education demonstrate significantly more analytical decision-making than their

novice peers; however, there was no evidence to suggest that reflective thinking dispositions
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change as students progress through their training. Moreover, there was no significant

association between analytical decision-making and reflective thinking. Taken together, the
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results from this study provide preliminary empirical evidence suggesting that in contrast to

novices, students at point of graduation resort to analytical (System 2) decision-making

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strategies. However, they do not engage in significantly more open-minded or reflective

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thinking, despite their lengthier exposure to osteopathic education. The lack of association

between reasoning and reflection suggests that one may not be a predictor of the other.
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Therefore, intermediate practitioners who are not yet separating their beliefs and biases to

think openly and reflectively across a range of domains, may nevertheless have begun to
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develop strategies to override cognitive shortcuts when making decisions.

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Despite the significant difference between the reasoning preferences of each group, overall

median scores suggest that System 1 decision-making strategies may still prevail. This is

consistent with much of the literature in the field of cognitive science, which supports the

notion of a ‘cognitive miser’, predisposing people to resort to heuristics or short-cuts in their

decision-making.17, 37, The term ‘cognitive miser’ was initially proposed by Fiske and Taylor38

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to illustrate the fact that individuals commonly evaluate information and make decisions using

cognitive shortcuts. In the field of clinical reasoning, Kassirer39 argued that the analytical

reasoning approach fails to take into consideration the fact that humans are human, not

computer processors. As a consequence, they tend to jump to conclusions, using intuitive

heuristics. According to Stanovich6, the cognitive system tends to default to the state

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requiring minimal cognitive effort, i.e., the ‘cognitive miser’ function. Importantly, much of the

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medical cognition literature supports this tendency in otherwise thoughtful and educated

individuals (medics) when making clinical decisions.18-22, 40

Notwithstanding this tendency,

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there is a significant move away from this in subjects nearing the end of their osteopathic

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education. That is to say, intermediate practitioners are starting to reason more analytically

and this analytical reasoning may be consistent with the ‘technical rationality’, or the reliance
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27
on factual knowledge and skills applied in predictable ways that Thomson et al argue

current osteopathic education promotes, and which is generally attributed to novice

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healthcare practitioners.41 Intriguingly, the ‘professional artistry’ associated with more

experienced practitioners, comfortable with the ambiguities of clinical practice, implicates a

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much greater predisposition towards the intuitive, pattern recognition approach inherent in
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System 1. If, as it is widely acknowledged within osteopathic literature, that “evaluation within
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osteopathic practice is a complex thing” , then what emerges from the literature is
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curious, as it seems to suggest that with expertise comes pattern recognition and therefore

System 1 reasoning. In contrast, System 2 approaches, encouraged by osteopathic

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education and endorsed by the profession’s governing body13, may overload the system and
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exceed the decision-making capacities of the individual.43 For novices, this then presents

something of a dilemma, as they are more likely to consider the problem as complex and

possess insufficient knowledge, yet may benefit from advice to use their intuition and

experience to solve it.

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This combination of reasoning approaches and reflective thinking required of practitioners

may be regarded as ‘metacognition’44, or the ability of the practitioner to reflect in action.19

This ‘thinking about thinking’ encourages practitioners to constantly monitor and adjust their

thoughts and reasoning processes from both deductive (System 2) and inductive (System 1)

approaches. Certainly, when subjects solve complex everyday problems45 or clinical

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problems25 with specific instruction to use both reasoning strategies, there are fewer

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cognitive or reasoning errors. Arguably, metacognition may provide the link between

analytical and non-analytical processing in clinical decision-making in osteopathic

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medicine.12 However, it would appear that for osteopathy students in this study at least, a

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metacognitive disparity exists if, as the results suggest, components such as reflective

thinking and analytical reasoning develop at different rates and that one may not predict the
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other.

This apparent discrepancy in metacognition, reflected in the lack of association between

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CRT and AOT scores, is consistent with cognitive science research. This research suggests
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that cognitive ability (of any level) is independent of that individual’s ability to decouple their

prior beliefs and opinions from their evaluation of the evidence and arguments before
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them.29, 36
It is therefore possible that pre-registration professional osteopathic education

encourages analytical or deductive reasoning (System 2) as rules, procedures and facts that
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must be learned and understood at a high level before they are applied clinically. Therefore,
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the move towards more analytical reasoning, as demonstrated by the intermediate level

practitioners, is a reflection of this. Consequently, the requirement to demonstrate inductive,

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27, p. 6
or actively open-minded thinking, may develop post-graduation if, as Thomson et al

argue; “an undergraduate curriculum which is excessively skill-based may not promote

critical evaluation”. It is widely acknowledged that metacognition plays an important role in

the development of diagnostic expertise and professional autonomy.46 For example, Rivett

and Jones47, p.406 have argued that expert clinicians are able to effectively use metacognitive

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strategies to self-monitor and self-evaluate their cognitive processes. Consequently, in the

absence of metacognition, clinicians are unable to effectively use their clinical reasoning to

manage clinical complexity.47 Although the concept of ‘professional artistry’ may imply a

greater predisposing towards System 1 processing, we argue that the development of

metacognitive proficiency is a critical component of an osteopath’s clinical competence

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profile. During their professional journey from novice to expert, clinicians should develop their

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skills of criticality and their ability to reflect on, and analyse their practice experiences in and

on action.11, 12

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Investigating the cognitive aspects of clinical reasoning, such as thinking and decision-

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making, inevitably means removing them from the larger context of clinical relevance, as

ultimately subjects were not called upon to make clinical decisions. One of the major flaws of
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this study is a lack of osteopathic context, particularly, as Croskerry20 argues, decision-

making relies heavily on contextual cues, both to provide meaning but also to minimise
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cognitive effort. This is especially important for System 1 reasoning, which, as has been
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shown, may be more prone to error. Future research investigating students’ reasoning and

thinking dispositions may therefore need to consider using clinically relevant scenarios that
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require decisions to be made, or even a more qualitative approach, consistent with previous
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clinical reasoning research in physiotherapy and occupational therapy.48 We also propose
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that in future research, consideration should be given to the inclusion of a group of

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experienced osteopaths in the study design. This may prove to be a useful benchmark for

the two student groups, as it would enable researchers to investigate reasoning strategies
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and reflective thinking dispositions along the continuum from novice to expert.

Other methodological flaws may also limit the validity of these findings beyond pilot study

status, namely the recruitment of peers and the number of subjects ultimately recruited. The

very nature of convenience sampling prevents the significance of these findings being

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applied to a population beyond the institution from where the sample was drawn. Arguably,

those interested in research and willing to participate already demonstrate levels of reflective

thinking and reasoning processes at odds with the rest of the student population. Despite a

medium effect size observed with the CRT outcome, participant numbers may have been

insufficient to identify differences in reflective thinking dispositions, if, as previously

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acknowledged, trends are more subtle and preferences may develop differently over time.

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A final area worth scrutiny concerns the tools used to measure the dependent variables.

Although both the CRT and AOT demonstrate consistent levels of internal validity and

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reliability, the CRT relies on numerical calculation, however basic, and may therefore be a

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measure of intelligence and not reasoning, ultimately correlating with measures of

mathematical ability and predicting bias in tasks of calculation and IQ only. Moreover,
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familiarity with the CRT test items and awareness that deliberative decision making

processes might be required before an answer is given, may have skewed the results.
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Similarly, the length of the AOT and some of the less culturally relevant items, for example, ‘I
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believe the “new morality” of permissiveness is no morality at all’, may limit its relevance in

assessing the true reflective thinking dispositions of current undergraduate students.

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5. Conclusion
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Using a three-item cognitive reflection test and a 41-item thinking disposition scale, this study
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set out to explore the reasoning strategies and reflective thinking dispositions of osteopathy

students. Furthermore, it examined whether exposure to osteopathy education results in

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more analytical and reflective thinking. The results demonstrate that students nearing the

end of their undergraduate education display significantly more analytical decision-making

than their novice peers. However, reflective thinking dispositions do not change with

increased exposure to osteopathic education and nor does analytical reasoning predict

reflective thinking preferences. Results from the CRT are consistent with cognitive science

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research that supports a Dual Process Model of decision-making. However, the trend for

intermediate level practitioners to demonstrate significantly more analytical reasoning lends

support to recent osteopathic research that suggests osteopathic education promotes the

development of deductive (System 2) reasoning in its graduates. This suggested emphasis

on ‘technical rationality’ might ultimately be at the expense of students developing reflective

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thinking styles, which arguably develop alongside reasoning post-graduation to become

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‘metacognition’. The development of metacognitive proficiency is, in our opinion, a critical

component of an osteopath’s clinical competence profile. The lack of association between

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analytical decision-making and reflective thinking in this study supports both this notion and

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previous research that suggests cognitive ability is separate from thinking bias and

preference.
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Statement of Competing Interests

JEE is an Associate Editor of the Int J Osteopath Med but was not involved in review or
editorial decisions regarding this manuscript.

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Tables

Table 1: AOT Results

Figures

Figure 1: Median outcomes for novice (1st yr) and intermediate (4th Yr) groups

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Figure 2: Scatter plot for AOT and CRT scores

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Subjects n M SD
Novices 44 125.2 14.6
Intermediates 32 119.6 11.7

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Implications for practice

• Graduating students display significantly more analytical decision-making

than their novice peers; however, reflective thinking dispositions do not
change with increased exposure to osteopathic education.
• Analytical reasoning does not predict reflective thinking preferences in

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osteopathy students.
• The emphasis on ‘technical rationality’ in osteopathic education might

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prevent students from developing reflective thinking styles, which are
central role to the development of metacognitive proficiency, a critical

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component of an osteopath’s clinical competence profile.

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