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Working memory, reasoning, and expertise in medicine—insights into their relationship using functional neuroimaging

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An Erratum to this article was published on 25 July 2017

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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.

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  • 25 July 2017

    An erratum to this article has been published.

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Author information

Authors and Affiliations

  1. Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Pam Hruska, Tanya Beran & Kent G. Hecker

  2. Neuroscience Program, Centre for Biomedical Research, and School of Exercise Science, Physical, and Health Education, University of Victoria, Victoria, BC, Canada

    Olav Krigolson

  3. Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Sylvain Coderre & Kevin McLaughlin

  4. Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada

    Filomeno Cortese

  5. Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Christopher Doig

  6. Division of Medical Sciences, University of Victoria, Victoria, BC, Canada

    Bruce Wright

  7. Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada

    Kent G. Hecker

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  1. Pam Hruska
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Correspondence to Kent G. Hecker.

Additional information

An erratum to this article is available at https://doi.org/10.1007/s10459-017-9786-x.

Appendices

Appendix 1: example clinical case: easy (concordant)

A 38 year-old man, diagnosed 18 years ago with ulcerative colitis, is referred to your outpatient clinic with itching and abnormal liver enzymes.

Past medical history

Non-smoker, drinks 1–2 beers/day. No history of blood transfusions, IV drug use or high-risk sexual behaviour. No history of psychiatric illness. No family history of liver disease. Has had 3 courses of prednisone for ulcerative colitis flares approximately every 6 years.

Recent history

Just finished a course of corticosteroids (prednisone) 6 months ago. Complaining of a mild, generalized itching in the last 3 months without demonstrable skin rash.

Medications

Asacol (mesalamine) 3 g/d for ulcerative colitis maintenance.

Assessment

No diabetes, no joint pains, no lung disease. Physical exam normal. Normal body mass index. Has one soft non-bloody bowel movement/day. Eating well. No abdominal pain.

Additional tests

Ultrasound results: normal gallbladder with no biliary dilation.

Lab findings

  • ALT 45 (7–40)

  • AST 32 (5–35)

  • Alk Phos 536 (30–145)

  • GGT 540 (20–35)

  • Total Bili 12 (5–22)

  • Hgb 155 (140–180)

  • WBC 9.1 (3.5–12)

  • PLT 180 (150–400)

  • INR 1.0 (0.9–1.1)

Appendix 2: example clinical case: hard (discordant)

A 38-year-old man diagnosed with ulcerative colitis 18 years ago, is referred to your outpatient clinic with itching and abnormal liver enzymes.

Previous medical history

Had one initial course of prednisone for first ulcerative colitis flare, but since then requires no medications. Was a daily IV heroin user from the ages of 18–21. Non-smoker. Emphatic that he does not drink more than 1–2 beers/day. No family history of liver disease. No diabetes, no joint pain, no lung disease, no psychiatric history.

Recent history

States eating well but feels quite nauseated lately with occasional abdominal cramping. Has one soft, non-bloody bowel movement/day. Is itchy over the last 3 months, but usually gets eczema around this time of year.

Medications

Tylenol 2 tabs/day for abdominal cramping.

Assessment

Normal BMI. Patches of eczema.

Additional tests

Ultrasound showed normal gallbladder and no biliary dilatation.

Lab findings

  • ALT 465 (7–40)

  • AST 432 (5–35)

  • Alk Phos 106 (30–145)

  • GGT 34 (20–35)

  • Total Bili 22 (5–22)

  • Conj Bili 16

  • Hgb 145 (140–180)

  • WBC 8.1 (3.5–12)

  • PLT 130 (150–400)

  • INR 1.2 (0.9–1.1)

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Hruska, P., Krigolson, O., Coderre, S. et al. Working memory, reasoning, and expertise in medicine—insights into their relationship using functional neuroimaging. Adv in Health Sci Educ 21, 935–952 (2016). https://doi.org/10.1007/s10459-015-9649-2

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