How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

Christian D. Helfrich*, Adam J. Rose, Christine W. Hartmann, Leti van Bodegom-Vos, Ian D. Graham, Suzanne J. Wood, Barbara R. Majerczyk, Chester B. Good, Leonard M. Pogach, Sherry L. Ball, David H. Au, David C. Aron

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

78 Scopus citations


Rationale and objectives: One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. Results: We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as “the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines.” We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience “reactance,” ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. Conclusions: By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.

Original languageAmerican English
Pages (from-to)198-205
Number of pages8
JournalJournal of Evaluation in Clinical Practice
Issue number1
StatePublished - Feb 2018
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2018 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.


  • de-implementation
  • dual process cognition
  • medical overuse
  • quality improvement
  • substitution
  • unlearning


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