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Abstract

With the rapidly increasing access to brain imaging facilities, we are potentially at the dawn of a new era for understanding diagnostic reasoning. Although, this may sound bold, and appears to echo the many claims made in other disciplines, we will highlight in this paper why neuroscience can be a useful tool for advancing diagnostic reasoning research. But first some cautionary notes. Fact is that all too often the high expectations of neuroscience are not met, such as the expectation in “educational neuroscience” that the insights of the brain will transform classroom teaching and learning.1 There is currently no compelling evidence that this has happened on any scale.2 Therefore, a healthy dose of scepticism is required when considering the potential role neuroscience can play in the understanding of diagnostic reasoning. With that in mind, we do however believe that the role neuroscience can play in advancing our understanding of diagnostic reasoning is quite different compared with education. Here, the primary objective is not to pursue a wholesale change of educational practice, but to test a fundamental assumption of a cognitive theory that claims to help our understanding of what diagnostic reasoning is about; Dual-Process Theory.3 Dual-Process Theory claims that there are two systems in the brain. System 1 is considered intuitive, fast and reliant on automatic activation of “illness scripts” stored in memory and leading to effortless pattern recognition. System 2 on the other hand is considered analytic, slow, deliberate, and systematic. The clinical reasoning literature is divided; one group of researchers defending System 1 reasoning as the hallmark of expert decision-making, whereas the other camp of researchers considering System 2 reasoning as superior and more likely to achieve diagnostic accuracy.4,5 Neuroscience can make a significant contribution to help scrutinise the validity of DualProcess Theory by examining if these two systems exist in different anatomical regions in the brain. Currently the evidence for the existence of these two systems is derived mainly from two behavioural variables: (1) response time and (2) diagnostic accuracy scores.6 Neuroscience could help connect these two key variables with distinct brain regions. This means neuroscience is not to replace behavioural data by looking at the brain alone, but to combine behavioural measures with brain imaging data to get a more comprehensive picture of what is going on when a physician is making a diagnosis. To further exemplify this point, consider the following example. AlQatani and colleagues investigated whether subjecting residents to time pressure results in more diagnostic errors.7 The results of their study suggest that this was indeed the case: 37% more errors occurred in the group that was subjected to time-pressure. This was particularly prevalent for residents with less experience. The researchers proposed that this is the case because less experienced residents did not have time to switch to the more analytical and slower System 2. They were forced to rely on System 1, which was less developed considering their lack of experience and knowledge. If neuro-imaging would have been used in this study, the researchers would have been in a better position to directly test this assumption by comparing brain activation in the prefrontal cortex between both conditions. (The assumption being that the activation of intuitive System 1 leads to less activation in that region). Thus, combining neuroimaging with behavioural research currently employed can throw a new light on the underlying brain and reasoning mechanisms as they occur in real time.

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