title: Working memory, reasoning, and expertise in medicine-insights into their relationship using functional neuroimaging.
abstract: 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.
authors.affiliation: Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: Pam
authors.initials: P
authors.lastname: Hruska
authors.affiliation: Neuroscience Program, Centre for Biomedical Research, and School of Exercise Science, Physical, and Health Education, University of Victoria, Victoria, BC, Canada.
authors.forename: Olav
authors.initials: O
authors.lastname: Krigolson
authors.affiliation: Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: Sylvain
authors.initials: S
authors.lastname: Coderre
authors.affiliation: Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: Kevin
authors.initials: K
authors.lastname: McLaughlin
authors.affiliation: Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
authors.forename: Filomeno
authors.initials: F
authors.lastname: Cortese
authors.affiliation: Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: Christopher
authors.initials: C
authors.lastname: Doig
authors.affiliation: Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: Tanya
authors.initials: T
authors.lastname: Beran
authors.affiliation: Division of Medical Sciences, University of Victoria, Victoria, BC, Canada.
authors.forename: Bruce
authors.initials: B
authors.lastname: Wright
authors.affiliation: Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. kghecker@ucalgary.ca.|Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada. kghecker@ucalgary.ca.
authors.forename: Kent G
authors.initials: KG
authors.lastname: Hecker
mesh_terms: D000328:Adult; D001931:Brain Mapping / Q000379:methods*; D002983:Clinical Competence; D000066491:Clinical Decision-Making; D005260:Female; D005762:Gastroenterology / Q000193:education*; D005767:Gastrointestinal Diseases / Q000175:diagnosis*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008570:Memory, Short-Term / Q000502:physiology*; D008875:Middle Aged; D010820:Physicians / Q000523:psychology*; D013337:Students, Medical / Q000523:psychology*; D013850:Thinking
keywords: Clinical reasoning; Functional magnetic resonance imaging; Novice expert studies; Working memory