The Arrival of Neuroscience to Diagnostic Reasoning: Four Issues to Keep in Mind

Learning to diagnose X-rays: a neuroscientific study of practice-related activation changes in the prefrontal cortex

OBJECTIVES

Medical expertise manifests itself by the ability of a physician to rapidly diagnose patients. How this expertise develops from a neural-activation perspective is not well understood. The objective of the present study was to investigate practice-related activation changes in the prefrontal cortex (PFC) as medical students learn to diagnose chest X-rays.

METHODS

The experimental paradigm consisted of a learning and a test phase. During the learning phase, 26 medical students were trained to diagnose four out of eight chest X-rays. These four cases were presented repeatedly and corrective feedback was provided. During the test phase, all eight cases were presented together with near- and far-transfer cases to examine whether participants' diagnostic learning went beyond simple rote recognition of the trained X-rays. During both phases, participants' PFC was scanned using functional near-infrared spectroscopy. Response time and diagnostic accuracy were recorded as behavioural indicators. One-way repeated measures ANOVA were conducted to analyse the data.

RESULTS

Results revealed that participants' diagnostic accuracy significantly increased during the learning phase (F=6.72, p<0.01), whereas their response time significantly decreased (F=16.69, p<0.001). Learning to diagnose chest X-rays was associated with a significant decrease in PFC activity (F=33.21, p<0.001) in the left dorsolateral prefrontal cortex, the orbitofrontal area, the frontopolar area and the frontal eye field. Further, the results of the test phase indicated that participants' diagnostic accuracy was significantly higher for the four trained cases, second highest for the near-transfer, third highest for the far-transfer cases and lowest for the untrained cases (F=167.20, p<0.001) and response time was lowest for the trained cases, second lowest for the near-transfer, third lowest for the far-transfer cases and highest for the untrained cases (F=9.72, p<0.001). In addition, PFC activity was lowest for the trained and near-transfer cases, followed by the far-transfer cases and highest for the untrained cases (F=282.38, p<0.001).

CONCLUSIONS

The results suggest that learning to diagnose X-rays is associated with a significant decrease in PFC activity. In terms of dual-process theory, these findings support the notion that students initially rely more on slow analytical system-2 reasoning. As expertise develops, system-2 reasoning transitions into faster and automatic system-1 reasoning.

Evidence supporting dual-process theory of medical diagnosis: a functional near-infrared spectroscopy study

PURPOSE

The objective of this study was to determine the extent to which the dual-process theory of medical diagnosis enjoys neuroscientific support. To that end, the study explored whether neurological correlates of system-2 thinking could be located in the brain. It was hypothesised that system-2 thinking could be observed as the activation of the prefrontal cortex.

METHOD

An experimental paradigm was applied that consisted of a learning and a test phase. During the learning phase, 22 medical students were trained in diagnosing chest X-rays. Four of these eight cases were presented repeatedly, to develop a high level of expertise for these cases. During the test phase, all eight cases were presented and the participants' prefrontal cortex was scanned using functional near-infrared spectroscopy. Response time and diagnostic accuracy were recorded as behavioural indicators.

RESULTS

The results revealed that participants' diagnostic accuracy in the test phase was significantly higher for the trained cases as compared with the untrained cases (F[1, 21] = 138.80, p < 0.001, η²  = 0.87). Also, their response time was significantly shorter for these cases (F[1, 21] = 18.12, p < 0.001, η²  = 0.46). Finally, the results revealed that only for the untrained cases, could a significant activation of the anterolateral prefrontal cortex be observed (F[1, 21] = 21.00, p < 0.01, η²  = 0.34).

CONCLUSION

The fact that only untrained cases triggered higher levels of blood oxygenation in the prefrontal cortex is an indication that system-2 thinking is a cognitive process distinct from system 1. Implications of these findings for the validity of the dual-process theory are discussed.