Neural basis of nonanalytical reasoning expertise during clinical evaluation

Dual-Process Theory of Thought and Inhibitory Control: An ALE Meta-Analysis

The dual-process theory of thought rests on the co-existence of two different thinking modalities: a quick, automatic, and associative process opposed to a slow, thoughtful, and deliberative process. The increasing interest in determining the neural foundation of the dual-process distinction has yielded mixed results, also given the difficulty of applying the fMRI standard approach to tasks usually employed in the cognitive literature. We report an activation likelihood estimation (ALE) meta-analysis to investigate the neural foundation of the dual-process theory of thought. Eligible studies allowed for the identification of cerebral areas associated with dual-process theory-based tasks without differentiating between fast and slow thinking. The ALE algorithm converged on the medial frontal cortex, superior frontal cortex, anterior cingulate cortex, insula, and left inferior frontal gyrus. These structures partially overlap with the cerebral areas recurrently reported in the literature about the neural basis of the dual-process distinction, where the PARCS theory-based interpretation emphasizes the role of the right inferior gyrus. The results confirm the potential (but still almost unexplored) common ground between the dual-process literature and the cognitive control literature.

Pathologists aren't pigeons: exploring the neural basis of visual recognition and perceptual expertise in pathology

Visual (perceptual) reasoning is a critical skill in many medical specialties, including pathology, diagnostic imaging, and dermatology. However, in an ever-compressed medical curriculum, learning and practicing this skill can be challenging. Previous studies (including work with pigeons) have suggested that using reward-feedback-based activities, novices can gain expert levels of visual diagnostic accuracy in shortened training times. But is this level of diagnostic accuracy a result of image recognition (categorization) or is it the acquisition of diagnostic expertise? To answer this, the authors measured electroencephalographic data (EEG) and two components of the human event-related brain potential (reward positivity and N170) to explore the nature of visual expertise in a novice-expert study in pathology visual diagnosis. It was found that the amplitude of the reward positivity decreased with learning in novices (suggesting a decrease in reliance on feedback, as in other studies). However, this signal remained significantly different from the experts whose reward positivity signal did not change over the course of the experiment. There were no changes in the amplitude of the N170 (a reported neural marker of visual expertise) in novices over time. Novice N170 signals remained statistically and significantly lower in amplitude compared to experts throughout task performance. These data suggest that, while novices gained the ability to recognize (categorize) pathologies through reinforcement learning as quantified by the change in reward positivity, increased accuracy, and decreased time for responses, there was little change in the neural marker associated with visual expertise (N170). This is consistent with the multi-dimensional and complex nature of visual expertise and provides insight into future training programs for novices to bridge the expertise gap.

Neural basis underlying the sense of coherence in medical professionals revealed by the fractional amplitude of low-frequency fluctuations

Although mitigating burnout has long been a pressing issue in healthcare, recent global disasters, including the COVID-19 pandemic and wars, have exacerbated this problem. Medical professionals are frequently exposed to diverse job-induced distress; furthermore, the importance of people's sense of coherence (SOC) over work has been addressed to better deal with burnout. However, the neural mechanisms underlying SOC in medical professionals are not sufficiently investigated. In this study, the intrinsic fractional amplitude of low-frequency fluctuations (fALFF) were measured as an indicator of regional brain spontaneous activity using resting-state functional magnetic resonance imaging in registered nurses. The associations between participants' SOC levels and the fALFF values within brain regions were subsequently explored. The SOC scale scores were positively correlated with fALFF values in the right superior frontal gyrus (SFG) and the left inferior parietal lobule. Furthermore, the SOC levels of the participants mediated the link between their fALFF values in the right SFG and the depersonalization dimension of burnout. The results deepened the understanding of the counter role of SOC on burnout in medical professionals and may provide practical insights for developing efficient interventions.

Use of neuroimaging to measure neurocognitive engagement in health professions education: a scoping review

PURPOSE

To map the current literature on functional neuroimaging use in medical education research as a novel measurement modality for neurocognitive engagement, learning, and expertise development.

METHOD

We searched PubMed, Embase, Cochrane, ERIC, and Web of Science, and hand-searched reference lists of relevant articles on April 4, 2019, and updated the search on July 7, 2020. Two authors screened the abstracts and then full-text articles for eligibility based on inclusion criteria. The data were then charted, synthesized, and analyzed descriptively.

RESULTS

Sixty-seven articles published between 2007 and 2020 were included in this scoping review. These studies used three main neuroimaging modalities: functional magnetic resonance imaging, functional near-infrared spectroscopy, and electroencephalography. Most of the publications (90%, n = 60) were from the last 10 years (2011-2020). Although these studies were conducted in 16 countries, 68.7% (n = 46) were from three countries: the USA (n = 21), UK (n = 15), and Canada (n = 10). These studies were mainly non-experimental (74.6%, n = 50). Most used neuroimaging techniques to examine psychomotor skill development (57%, n = 38), but several investigated neurocognitive correlates of clinical reasoning skills (22%, n = 15).

CONCLUSION

This scoping review maps the available literature on functional neuroimaging use in medical education. Despite the heterogeneity in research questions, study designs, and outcome measures, we identified a few common themes. Included studies are encouraging of the potential for neuroimaging to complement commonly used measures in education research and may help validate/challenge established theoretical assumptions and provide insight into training methods. This review highlighted several areas for further research. The use of these emerging technologies appears ripe for developing precision education, establishing viable study protocols for realistic operational settings, examining team dynamics, and exploring applications for real-time monitoring/intervention during critical clinical tasks.

Thinking fast or slow? Functional magnetic resonance imaging reveals stronger connectivity when experienced neurologists diagnose ambiguous cases

For ∼40 years, thinking about reasoning has been dominated by dual-process theories. This model, consisting of two distinct types of human reasoning, one fast and effortless and the other slow and deliberate, has also been applied to medical diagnosis. Medical experts are trained to diagnose patients based on their symptoms. When symptoms are prototypical for a certain diagnosis, practitioners may rely on fast, recognition-based reasoning. However, if they are confronted with ambiguous clinical information slower, analytical reasoning is required. To examine the neural underpinnings of these two hypothesized forms of reasoning, 16 highly experienced clinical neurologists were asked to diagnose two types of medical cases, straightforward and ambiguous cases, while functional magnetic resonance imaging was being recorded. Compared with reading control sentences, diagnosing cases resulted in increased activation in brain areas typically found to be active during reasoning such as the caudate nucleus and frontal and parietal cortical regions. In addition, we found vast increased activity in the cerebellum. Regarding the activation differences between the two types of reasoning, no pronounced differences were observed in terms of regional activation. Notable differences were observed, though, in functional connectivity: cases containing ambiguous information showed stronger connectivity between specific regions in the frontal, parietal and temporal cortex in addition to the cerebellum. Based on these results, we propose that the higher demands in terms of controlled cognitive processing during analytical medical reasoning may be subserved by stronger communication between key regions for detecting and resolving uncertainty.

The neurocognitive gains of diagnostic reasoning training using simulated interactive veterinary cases

The present longitudinal study ascertained training-associated transformations in the neural underpinnings of diagnostic reasoning, using a simulation game named “Equine Virtual Farm” (EVF). Twenty participants underwent structural, EVF/task-based and resting-state MRI and diffusion tensor imaging (DTI) before and after completing their training on diagnosing simulated veterinary cases. Comparing playing veterinarian versus seeing a colorful image across training sessions revealed the transition of brain activity from scientific creativity regions pre-training (left middle frontal and temporal gyrus) to insight problem-solving regions post-training (right cerebellum, middle cingulate and medial superior gyrus and left postcentral gyrus). Further, applying linear mixed-effects modelling on graph centrality metrics revealed the central roles of the creative semantic (inferior frontal, middle frontal and angular gyrus and parahippocampus) and reward systems (orbital gyrus, nucleus accumbens and putamen) in driving pre-training diagnostic reasoning; whereas, regions implicated in inductive reasoning (superior temporal and medial postcentral gyrus and parahippocampus) were the main post-training hubs. Lastly, resting-state and DTI analysis revealed post-training effects within the occipitotemporal semantic processing region. Altogether, these results suggest that simulation-based training transforms diagnostic reasoning in novices from regions implicated in creative semantic processing to regions implicated in improvised rule-based problem-solving.

Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision-making

Expertise in a medical specialty requires countless hours of learning and practice and a combination of neural plasticity and contextual case experience resulting in advanced gestalt clinical reasoning. This holistic thinking assimilates complex segmented information and is advantageous for timely clinical decision-making in the emergency department and paediatric or neonatal intensive care units. However, the same agile reasoning that is essential acutely may be at odds with the slow deliberative thought required for ethical reasoning and weighing the probability of patient morbidity. Recent studies suggest that inadequate ethical decision-making results in increased morbidity for patients and that clinical ethics consultation may reduce the inappropriate use of life-sustaining treatment. Behavioural psychology research suggests there are two systems of thinking - fast and slow - that control our thoughts and therefore our actions. The problem for experienced clinicians is that fast thinking, which is instinctual and reflexive, is particularly vulnerable to experiential biases or assumptions. While it has significant utility for clinical reasoning when timely life and death decisions are crucial, I contend it may simultaneously undermine the deliberative slow thought required for ethical reasoning to determine appropriate therapeutic interventions that reduce future patient morbidity. Whilst health-care providers generally make excellent therapeutic choices leading to good outcomes, a type of substitutive thinking that conflates clinical reasoning and ethical deliberation in acute decision-making may impinge on therapeutic relationships, have adverse effects on patient outcomes and inflict lifelong burdens on some children and their families.

Identifying developmental features in students' clinical reasoning to inform teaching

BACKGROUND

There is increasing evidence that students at different levels of training may benefit from different methods of learning clinical reasoning. Two of the common methods of teaching are the "whole - case" format and the "serial cue" approach. There is little empirical evidence to guide teachers as to which method to use and when to introduce them.

METHODS

We observed 23 students from different stages of training to examine how they were taking a history and how they were thinking whilst doing this. Each student interviewed a simulated patient who presented with a straightforward and a complex presentation. We inferred how students were reasoning from how they took a history and how they described their thinking while doing this.

RESULTS

Early in their training students can only take a generic history. Only later in training are they able to take a focused history, remember the information they have gathered, use it to seek further specific information, compare and contrast possibilities and analyze their data as they are collecting it.

CONCLUSIONS

Early in their training students are unable to analyze data during history taking. When they have started developing illness scripts, they are able to benefit from the "serial cue" approach of teaching clinical reasoning.

Executive Functions Brain System: An Activation Likelihood Estimation Meta-analytic Study

Background and objective

To characterize commonalities and differences between two executive functions: reasoning and inhibitory control.

Methods

A total of 5,974 participants in 346 fMRI experiments of inhibition or reasoning were selected. First level analysis consisted of Analysis of Likelihood Estimation (ALE) studies performed in two pooled data groups: (a) brain areas involved in reasoning and (b) brain areas involved in inhibition. Second level analysis consisted of two contrasts: (i) brain areas involved in reasoning but not in inhibition and (ii) brain areas involved in inhibition but not in reasoning. Lateralization Indexes were calculated.

Results

Four brain areas appear as the most critical: the dorsolateral aspect of the frontal lobes, the superior parietal lobules, the mesial aspect of the premotor area (supplementary motor area), and some subcortical areas, particularly the putamen and the thalamus. ALE contrasts showed significant differentiation of the networks, with the reasoning > inhibition-contrast showing a predominantly leftward participation, and the inhibition > reasoning-contrast, a clear right advantage.

Conclusion

Executive functions are mediated by sizable brain areas including not only cortical, but also involving subcortical areas in both hemispheres. The strength of activation shows dissociation between the hemispheres for inhibition (rightward) and reasoning (leftward) functions.

Clinical reasoning skills in final-year dental students: A qualitative cross-curricula comparison

AIMS

The aim of this research was to explore the perceptions of undergraduate dental students regarding clinical reasoning skills and also discover the influences of different curriculum designs on the acquisition of these skills by students.

METHODS

Eighteen final-year students from three different dental schools with varied curricula and cultures participated in the current research. The research used qualitative methodology. The study took place in 2013-2014. Interviews captured the participants' own understanding of clinical reasoning and its acquisition plus they "talked through" a clinical problem using a "think-aloud" technique. Thematic analysis was used to analyse the transcripts of the recorded interviews. Results obtained were related to curriculum structure.

RESULTS

Unfamiliarity with the term clinical reasoning was common in students. Students from different schools used different strategies to reason when discussing clinical vignettes. Clinical reasoning process was dominated by pattern recognition. Students' behaviours seemed to be influenced by cultural factors.

CONCLUSIONS

This research contributes to a greater understanding of how students learn, understand and apply dental clinical reasoning which will improve educational practices in the future.

THE ELECTRONIC HEALTH RECORD AND DEVELOPMENT OF MEDICAL STUDENTS' MENTAL PATIENT MODELS

Medical practitioners routinely use dual process clinical reasoning: pattern recognition, termed system 1 thinking, and system 2 thinking or analytic reasoning. System 1 thinking, a hallmark of expertise developed through experience with multiple similar patients and deliberate practice, is rapid and automatic. For decades, the structured written medical write-up and progress notes served an educational as well as a patient care role. The introduction of electronic health records (EHRs) potentially hinders the development of the cognitive models upon which system 1 thinking is predicated. Using a vignette-based extended matching chief complaint examination, we investigated the effects of introducing an inpatient EHR on three classes of third-year medical students before and after the EHR implementation. While some subsection scores were significantly different, there was no overall change in performance. Based on this assessment, the development of cognitive models of patient presentations is not impeded by the introduction of an EHR.

The role of emotion in clinical decision making: an integrative literature review

BACKGROUND

Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM.

METHODS

A systematic search of the bibliographic databases PubMed, PsychINFO, and CINAHL (EBSCO) was conducted to identify empirical studies of clinician populations. Search terms were focused to identify studies reporting clinician emotion OR clinician emotional intelligence OR emotional competence AND clinical decision making OR clinical reasoning.

RESULTS

Twenty three papers were retained for synthesis. These represented empirical work from qualitative, quantitative, and mixed-methods approaches and comprised work with a focus on experienced emotion and on skills associated with emotional intelligence. The studies examined nurses (10), physicians (7), occupational therapists (1), physiotherapists (1), mixed clinician samples (3), and unspecified infectious disease experts (1). We identified two main themes in the context of clinical decision making: the subjective experience of emotion; and, the application of emotion and cognition in CDM. Sub-themes under the subjective experience of emotion were: emotional response to contextual pressures; emotional responses to others; and, intentional exclusion of emotion from CDM. Under the application of emotion and cognition in CDM, sub-themes were: compassionate emotional labour - responsiveness to patient emotion within CDM; interdisciplinary tension regarding the significance and meaning of emotion in CDM; and, emotion and moral judgement.

CONCLUSIONS

Clinicians' experienced emotions can and do affect clinical decision making, although acknowledgement of that is far from universal. Importantly, this occurs in the in the absence of a clear theoretical framework and educational preparation may not reflect the importance of emotional competence to effective CDM.

A functional neuroimaging study of the clinical reasoning of medical students

As clinical reasoning is a fundamental competence of physicians for good clinical practices, medical academics have endeavored to teach reasoning skills to undergraduate students. However, our current understanding of student-level clinical reasoning is limited, mainly because of the lack of evaluation tools for this internal cognitive process. This functional magnetic resonance imaging (fMRI) study aimed to examine the clinical reasoning processes of medical students in response to problem-solving questions. We recruited 24 2nd-year medical students who had completed their preclinical curriculum. They answered 40 clinical vignette-based multiple-choice questions during fMRI scanning. We compared the imaging data for 20 problem-solving questions (reasoning task) and 20 recall questions (recall task). Compared to the recall task, the reasoning task resulted in significantly greater activation in nine brain regions, including the dorsolateral prefrontal cortex and inferior parietal cortex, which are known to be associated with executive function and deductive reasoning. During the recall task, significant activation was observed in the brain regions that are related to memory and emotions, including the amygdala and ventromedial prefrontal cortex. Our results support that medical students mainly solve clinical questions with deductive reasoning involving prior knowledge structures and executive functions. The problem-solving questions induced the students to utilize higher cognitive functions compared with the recall questions. Interestingly, the results suggested that the students experienced some emotional distress while they were solving the recall questions. In addition, these results suggest that fMRI is a promising research tool for investigating students' cognitive processes.

Working memory, reasoning, and expertise in medicine-insights into their relationship using functional neuroimaging

Clinical reasoning is dependent upon working memory (WM). More precisely, during the clinical reasoning process stored information within long-term memory is brought into WM to facilitate the internal deliberation that affords a clinician the ability to reason through a case. In the present study, we examined the relationship between clinical reasoning and WM while participants read clinical cases with functional magnetic resonance imaging (fMRI). More specifically, we examined the impact of clinical case difficulty (easy, hard) and clinician level of expertise (2nd year medical students, senior gastroenterologists) on neural activity within regions of cortex associated with WM (i.e., the prefrontal cortex) during the reasoning process. fMRI was used to scan ten second-year medical students and ten practicing gastroenterologists while they reasoned through sixteen clinical cases [eight straight forward (easy) and eight complex (hard)] during a single 1-h scanning session. Within-group analyses contrasted the easy and hard cases which were then subsequently utilized for a between-group analysis to examine effects of expertise (novice > expert, expert > novice). Reading clinical cases evoked multiple neural activations in occipital, prefrontal, parietal, and temporal cortical regions in both groups. Importantly, increased activation in the prefrontal cortex in novices for both easy and hard clinical cases suggests novices utilize WM more so than experts during clinical reasoning. We found that clinician level of expertise elicited differential activation of regions of the human prefrontal cortex associated with WM during clinical reasoning. This suggests there is an important relationship between clinical reasoning and human WM. As such, we suggest future models of clinical reasoning take into account that the use of WM is not consistent throughout all clinical reasoning tasks, and that memory structure may be utilized differently based on level of expertise.