title: Hemispheric activation differences in novice and expert clinicians during clinical decision making.
abstract: Clinical decision making requires knowledge, experience and analytical/non-analytical types of decision processes. As clinicians progress from novice to expert, research indicates decision-making becomes less reliant on foundational biomedical knowledge and more on previous experience. In this study, we investigated how knowledge and experience were reflected in terms of differences in neural areas of activation. Novice and expert clinicians diagnosed simple or complex (easy, hard) cases while functional magnetic resonance imaging (fMRI) data were collected. Our results highlight key differences in the neural areas activated in novices and experts during the clinical decision-making process. fMRI data were collected from ten second year medical students (novices) and ten practicing gastroenterologists (experts) while they diagnosed sixteen (eight easy and eight hard) clinical cases via multiple-choice questions. Behavioral data were collected for diagnostic accuracy (correct/incorrect diagnosis) and time taken to assign a clinical diagnosis. Two analyses were performed with the fMRI data. First, data from easy and hard cases were compared within respective groups (easy > hard, hard > easy). Second, neural differences between novices and experts (novice > expert, expert > novice) were assessed. Experts correctly diagnosed more cases than novices and made their diagnoses faster than novices on both easy and hard cases (all p's < 0.05). Time taken to diagnose hard cases took significantly longer for both novices and experts. While similar neural areas were activated in both novices and experts during the decision making process, we identified significant hemispheric activation differences between novice and expert clinicians when diagnosing hard clinical cases. Specifically, novice clinicians had greater activations in the left anterior temporal cortex and left ventral lateral prefrontal cortex whereas expert clinicians had greater activations in the right dorsal lateral, right ventral lateral, and right parietal cortex. Hemispheric differences in activation were not observed between novices and experts while diagnosing easy clinical cases. While clinical decision-making engaged the prefrontal cortex (PFC) in both novices and experts, interestingly we observed expertise related differences in the regions and hemispheres of PFC activation between these groups for hard clinical cases. Specifically, in novices we observed activations in left hemisphere neural regions associated with factual rule-based knowledge, whereas in experts we observed right hemisphere activation in neural regions associated with experiential knowledge. Importantly, at the neural level, our data highlight differences in so called type 2 clinical decision-making processes related to prior knowledge and experience.
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: 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
authors.affiliation: Undergraduate Medical Education, Cumming School of Medicine, Calgary, AB, Canada.
authors.forename: Sylvain
authors.initials: S
authors.lastname: Coderre
authors.affiliation: Undergraduate Medical Education, Cumming School of Medicine, 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, 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: Neuroscience Program, Centre for Biomedical Research, School of Exercise Science, Physical, and Health Education, University of Victoria, Victoria, BC, Canada.
authors.forename: Olav
authors.initials: O
authors.lastname: Krigolson
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; D008875:Middle Aged; D010820:Physicians / Q000523:psychology*; D013337:Students, Medical / Q000523:psychology*; D013997:Time Factors
keywords: Clinical decision making; Dual process theories; Functional magnetic resonance imaging; Novice expert studies