POSITION PAPER Use of the Dual-Processing Theory to Develop Expert Clinical Reasoning in Physical Therapy Students Tricia R. Prokop, PT, EdD, MS, CSCS Background and Purpose. Cognitive er- ror as a result of poor judgment accounts for a significant percentage of diagnostic errors in medicine. Use of judgment in the clinical setting can be described as clinical reasoning. erefore, if educators of PT students intend to cultivate safe and ef- fective practitioners, it is imperative to assist students in the development of ef- fective judgment in addition to requisite knowledge and skills. Despite the impor- tance, there are currently many limitations in clinical reasoning research in the field of physical therapy education. e purposes of this article are to introduce dual- processing theory as a means of concep- tualizing clinical reasoning in physical therapy education and to provide recom- mendations for development of clinical reasoning. Position and Rationale. Clinical reason- ing in physical therapy education lacks a unified theoretical framework from which to base instructional methods. It is the opinion of this author that in con- junction with an understanding of the development of expertise and expert per- formance, the dual-processing theory of reasoning provides an optimal foundation for clinical reasoning instruction and as- sessment. e dual-processing theory is underused despite being the prevailing theory to describe reasoning in health care providers. e dual-processing theory describes clinical reasoning as a balance between type I, intuitive, and type II, an- alytical processing. e final decision made is the result of the interaction be- tween the two types of processing rather than sole reliance on analytical or intuitive thinking alone. is balance is how health care providers make decisions during the evaluation, examination, and treatment of patients. A key component in the ability to accurately manage the use of both types of processing is the awareness of the accuracy of thought processes. is awareness is also referred to as metacognition and is the necessary component of accurate clinical reasoning. Discussion and Conclusion. is posi- tion paper addresses one of the current limitations in clinical reasoning research in physical therapy by providing a theo- retical rationale for use of the dual- processing theory in conceptualizing the components of clinical reasoning. PT stu- dents must cultivate an awareness of the accuracy of their thought processes in addition to acquiring deep-structure dis- ciplinary knowledge. In accordance with the dual-processing theory as the theo- retical framework for clinical reasoning, explicit teaching of accurate metacognitive self-monitoring in physical therapy edu- cation is integral to effective clinical reasoning. Key Words: Entry-level education, Learning theory, Student learning. BACKGROUND AND PURPOSE Clinical reasoning is a concept that has been increasingly emphasized in the field of phys- ical therapy education, 1 including four articles in the spring 2017 issue of this journal. 2-5 Clinical reasoning is considered necessary for successful evaluation and treatment of patients and is regularly assessed in the aca- demic setting to determine student’s pre- paredness for immersion in the clinical setting. Conversely, ineffective clinical rea- soning is believed to be a major contributor to the prevalence of adverse events in medical practice. erefore, students who possess in- effective clinical reasoning lack abilities nec- essary for success in the clinical setting. As of 2013, medical errors rank behind heart disease and cancer as the third leading cause of death in the United States. 6 Di- agnostic error is a subset of medical error that is an identified causal factor in 14–59% of adverse events in clinical practice. 7-10 Al- though diagnostic error can be system related or patient related, 11 cognitive error is the predominant cause, contributing to 95–96% of diagnostic errors. 8,9,12 Cognitive error can be the result of poor judgment, memory, or knowledge. 13 Of those factors, error in judgment accounts for the greatest percentage of diagnostic error at a rate of 72–87%. 11-14 erefore, to make the greatest influence on the reduction of di- agnostic error in medicine, emphasis should be placed on developing judgment in students of health professions, including PT students. e use of judgment in clinical practice shall herein be described as “clinical reasoning,” which is defined as the critical thinking and decision making when providing clinical care to patients. 15 With an understanding of the magnitude of importance of effective clinical reasoning skills for success in the clinical setting, clinical rea- soning research in the field of physical therapy is ever increasing. PT educators are in- vestigating best methods to facilitate and assess clinical reasoning. Some of the current rec- ommendations to develop clinical reasoning in students include use of case-based learning, deliberate modeling by experts, clinical expe- riences, and written or verbal external re- flection. 4,16-19 Various assessments of clinical reasoning have been trialed in physical therapy education including, but not limited to, the Clinical Reasoning Grading Rubric, the ink Aloud Standardized Patient Examination, the Health Sciences Reasoning Test, the APTA’s Physical erapist Clinical Performance In- strument, the Watson-Glaser Critical inking Appraisal, the Self-Assessment of Clinical Reasoning and Reflection, the Diagnostic inking Inventory, and individually created grading rubrics. 4,16,17,19,20 Despite the growing body of literature, current limitations in clinical reasoning re- search in physical therapy education as identified by Wainwright and Gwyer in 2017 include the following: lack of application and Tricia R. Prokop is a clinical assistant professor, Department of Rehabilitation Sciences, Univer- sity of Hartford, West Hartford, CT 06117 (prokop@hartford.edu). Please address all cor- respondence to Tricia R. Prokop. e author declares no conflicts of interest. Received January 9, 2018, and accepted May 11, 2018. Copyright © 2018 Academy of Physical erapy Education, APTA DOI: 10.1097/JTE.0000000000000062 Vol 32, No 4, 2018 Journal of Physical Therapy Education 355 Copyright ª 2018 Academy of Physical Therapy Education, APTA. Unauthorized reproduction of this article is prohibited.