title: Functional neuroimaging correlates of thinking flexibility and knowledge structure in memory: Exploring the relationships between clinical reasoning and diagnostic thinking.
abstract: BACKGROUND
  Diagnostic reasoning involves the thinking steps up to and including arrival at a diagnosis. Dual process theory posits that a physician's thinking is based on both non-analytic or fast, subconscious thinking and analytic thinking that is slower, more conscious, effortful and characterized by comparing and contrasting alternatives. Expertise in clinical reasoning may relate to the two dimensions measured by the diagnostic thinking inventory (DTI): memory structure and flexibility in thinking.
  
  
  OBJECTIVE
  Explored the functional magnetic resonance imaging (fMRI) correlates of these two aspects of the DTI: memory structure and flexibility of thinking.
  
  
  METHODS
  Participants answered and reflected upon multiple-choice questions (MCQs) during fMRI. A DTI was completed shortly after the scan. The brain processes associated with the two dimensions of the DTI were correlated with fMRI phases - assessing flexibility in thinking during analytical clinical reasoning, memory structure during non-analytical clinical reasoning and the total DTI during both non-analytical and analytical reasoning in experienced physicians.
  
  
  RESULTS
  Each DTI component was associated with distinct functional neuroanatomic activation patterns, particularly in the prefrontal cortex.
  
  
  CONCLUSIONS
  Our findings support diagnostic thinking conceptual models and indicate mechanisms through which cognitive demands may induce functional adaptation within the prefrontal cortex. This provides additional objective validity evidence for the use of the DTI in medical education and practice settings.
authors.affiliation: a Uniformed Services University of the Health Sciences , USA .
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Durning
authors.affiliation: a Uniformed Services University of the Health Sciences , USA .
authors.forename: Michelle E
authors.initials: ME
authors.lastname: Costanzo
authors.affiliation: b Mayo Clinic College of Medicine , USA .
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Beckman
authors.affiliation: a Uniformed Services University of the Health Sciences , USA .
authors.forename: Anthony R
authors.initials: AR
authors.lastname: Artino
authors.affiliation: a Uniformed Services University of the Health Sciences , USA .
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Roy
authors.affiliation: c Maastricht University , The Netherlands .
authors.forename: Cees
authors.initials: C
authors.lastname: van der Vleuten
authors.affiliation: d American Board of Internal Medicine , USA .
authors.forename: Eric S
authors.initials: ES
authors.lastname: Holmboe
authors.affiliation: d American Board of Internal Medicine , USA .
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Lipner
authors.affiliation: e Flinders University , Australia.
authors.forename: Lambert
authors.initials: L
authors.lastname: Schuwirth
mesh_terms: D002983:Clinical Competence; D000066491:Clinical Decision-Making; D004501:Education, Medical; D059907:Functional Neuroimaging; D006801:Humans; D008279:Magnetic Resonance Imaging; D013850:Thinking / Q000502:physiology*