Using Functional Neuroimaging Combined With a Think-Aloud Protocol to Explore Clinical Reasoning Expertise in Internal Medicine

Military Medicine, Sep 2012

Durning, Steven J., Graner, John, Artino, Anthony R., Pangaro, Louis N., Beckman, Thomas, Holmboe, Eric, Oakes, Terrance, Roy, Michael, Riedy, Gerard, Capaldi, Vincent, et al.

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Using Functional Neuroimaging Combined With a Think-Aloud Protocol to Explore Clinical Reasoning Expertise in Internal Medicine

MILITARY MEDICINE Using Functional Neuroimaging Combined With a Think-Aloud Protocol to Explore Clinical Reasoning Expertise in Internal Medicine Steven J. Durning 3 John Graner 3 CDR Anthony R. Artino Jr. MC USN 3 Louis N. Pangaro 3 Thomas Beckman 0 Eric Holmboe 2 Terrance Oakes 3 COL Michael Roy MC USA 3 Gerard Riedy 4 CPT Vincent Capaldi MC USA 4 CPT Robert Walter MC USA 4 Cees van der Vleuten Lambert Schuwirth 0 Mayo Clinic , 200 First Street SW, Rochester, MN 55905 , USA 1 77 , Washington, DC 20307 , USA 2 American Board of Internal Medicine , 510 Walnut Street, Suite 1700, Philadelphia, PA 19106 , USA 3 Uniformed Services University of the Health Sciences , 4301 Jones Bridge Road, Bethesda, MD 20814 , USA 4 Walter Reed Army Medical Center , 6900 Georgia Avenue, NW , USA Background: Clinical reasoning is essential to medical practice, but because it entails internal mental processes, it is difficult to assess. Functional magnetic resonance imaging (fMRI) and think-aloud protocols may improve understanding of clinical reasoning as these methods can more directly assess these processes. The objective of our study was to use a combination of fMRI and think-aloud procedures to examine fMRI correlates of a leading theoretical model in clinical reasoning based on experimental findings to date: analytic (i.e., actively comparing and contrasting diagnostic entities) and nonanalytic (i.e., pattern recognition) reasoning. We hypothesized that there would be functional neuroimaging differences between analytic and nonanalytic reasoning theory. Methods: 17 board-certified experts in internal medicine answered and reflected on validated U.S. Medical Licensing Exam and American Board of Internal Medicine multiple-choice questions (easy and difficult) during an fMRI scan. This procedure was followed by completion of a formal think-aloud procedure. Results: fMRI findings provide some support for the presence of analytic and nonanalytic reasoning systems. Statistically significant activation of prefrontal cortex distinguished answering incorrectly versus correctly ( p < 0.01), whereas activation of precuneus and midtemporal gyrus distinguished not guessing from guessing ( p < 0.01). Conclusions: We found limited fMRI evidence to support analytic and nonanalytic reasoning theory, as our results indicate functional differences with correct vs. incorrect answers and guessing vs. not guessing. However, our findings did not suggest one consistent fMRI activation pattern of internal medicine expertise. This model of employing fMRI correlates offers opportunities to enhance our understanding of theory, as well as improve our teaching and assessment of clinical reasoning, a key outcome of medical education. INTRODUCTION Expertise in clinical reasoning improves patient care1,2 and involves establishing a diagnosis and an individual care plan; it is an essential outcome of medical education. Clinical reasoning encompasses the sum of the thinking and decision-making processes within clinical practice.2 However, investigating clinical reasoning involves making inferences about internal mental processes. Despite being at the core of clinical expertise, the difficulty in assessing clinical reasoning greatly challenges our understanding.3 Until recently, researchers have largely avoided investigating the functional activation of complex psychological constructs such as cognition.4 However, functional magnetic resonance imaging (fMRI) enables the assessment of regional brain activity by detecting changes in oxygenation reflecting perfusion. Regions that use more oxygen to process stimuli (an “artifact” of thought) evoke a rapid feedback loop that dilates blood vessels to more markedly increase oxygenation to such areas. These changes can be reliably detected by fMRI (blood oxygen level-dependent signal). Pairing fMRI with a thinkaloud procedure, whereby participants are asked to vocalize whatever comes to mind as they work through a task such as solving a clinical case, could facilitate identification of links between cognition and its neural substrate, providing insight into the cognitive processes underlying clinical reasoning. Clinical reasoning, like many outcomes in medical education, is difficult to measure. One current gold standard for physician performance is multiple-choice exams. Indeed, to become a practicing physician, one must pass a series of multiple-choice question (MCQ) examinations. A primary goal of the Long-Term Career Outcome Study is tracking the performance (outcomes) of our graduates. Given the limitations of MCQ examinations, we therefore investigated fMRI neuroimaging patterns of our graduates and other graduates who practice in the Department of Defense to enhance our understanding of what these MCQ examinations are measuring. Such understanding could ultimately help us to establish the limits of these MCQ examinations and plan new outcome measures that could be used in our and other systems. Results (...truncated)


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Durning, Steven J., Graner, John, Artino, Anthony R., Pangaro, Louis N., Beckman, Thomas, Holmboe, Eric, Oakes, Terrance, Roy, Michael, Riedy, Gerard, Capaldi, Vincent, Walter, Robert, van der Vleuten, Cees, Schuwirth, Lambert. Using Functional Neuroimaging Combined With a Think-Aloud Protocol to Explore Clinical Reasoning Expertise in Internal Medicine, Military Medicine, 2012, pp. 72-78, Volume 177, Issue suppl_9, DOI: 10.7205/MILMED-D-12-00242