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. AIM: 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. CONCLUSION: 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.
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Generalization in out-of-distribution contexts is essential in real-world clinical scenarios, which often demand that reasoning strategies used in familiar, predictable situations be countermanded to consider more optimal approaches.
“Generalization in out-of-distribution contexts is essential in real-world clinical scenarios, which often demand that reasoning strategies used in familiar, predictable situations be countermanded to consider more optimal approaches; this cognitive flexibility is foundational for effective clinical reasoning66.”
From Limitations of large language models in clinical problem-solving arising from inflexible reasoning (2025) · cites this paper as [66]
Cognitive flexibility is foundational for effective clinical reasoning.
“this cognitive flexibility is foundational for effective clinical reasoning66.”
From Limitations of large language models in clinical problem-solving arising from inflexible reasoning (2025) · cites this paper as [66]
Cites
(2011) · Cited by 14,317 · see citing works
AFNI: Software for analysis and visualization of functional magnetic resonance neuroimages
Cox, R. W. (1996) · Computers and Biomedical Research · doi:10.1006/cbmr.1996.0014 · Cited by 10,913 · see citing works
Chase, W. G., & Simon, H. A. (1973) · Cognitive Psychology · doi:10.1016/0010-0285(73)90004-2 · Cited by 4,479 · see citing works
Social Cognitive Neuroscience: A Review of Core Processes
Lieberman, M. D. (2007) · Annual Review of Psychology · doi:10.1146/annurev.psych.58.110405.085654 · Cited by 2,010 · see citing works
Persistent activity in the prefrontal cortex during working memory
Curtis, C. E., & D'Esposito, M. (2003) · Trends in Cognitive Sciences · doi:10.1016/s1364-6613(03)00197-9 · Cited by 2,001 · see citing works
A cognitive perspective on medical expertise
Schmidt, H. G., Norman, G. R., & Boshuizen, H. P. A. (1990) · Academic Medicine · doi:10.1097/00001888-199010000-00001 · Cited by 1,135 · see citing works
The dual pathway to creativity model: Creative ideation as a function of flexibility and persistence
Nijstad, B. A., Dreu, C. K. W. D., Rietzschel, E. F., & Baas, M. (2010) · European Review of Social Psychology · doi:10.1080/10463281003765323 · Cited by 1,062 · see citing works
Vӧllm, B., Taylor, A. N. W., Richardson, P., Corcoran, R., Stirling, J., McKie, S., Deakin, J. F. W., & Elliott, R. (2005) · NeuroImage · doi:10.1016/j.neuroimage.2005.07.022 · Cited by 1,004 · see citing works
Clinical Reasoning in the Health Professions
Higgs, J., & Jones, M. A. (2000) · Cited by 920 · see citing works
Inferring mental states from neuroimaging data: from reverse inference to large-scale decoding
Poldrack, R. A. (2011) · Neuron · doi:10.1016/j.neuron.2011.11.001 · Cited by 821 · see citing works
Neural Substrates of Spontaneous Musical Performance: An fMRI Study of Jazz Improvisation
Limb, C. J., & Braun, A. R. (2008) · PLoS ONE · doi:10.1371/journal.pone.0001679 · Cited by 776 · see citing works
Clinical reasoning in the health professions
Oehme, F. W. (1996) · Toxicology Letters · doi:10.1016/s0378-4274(96)90055-7 · Cited by 615 · see citing works
Neural activity that predicts subsequent memory and forgetting: A meta-analysis of 74 fMRI studies
Kim, H. (2010) · NeuroImage · doi:10.1016/j.neuroimage.2010.09.045 · Cited by 605 · see citing works
Diagnostic error and clinical reasoning
Norman, G. R., & Eva, K. W. (2009) · Medical Education · doi:10.1111/j.1365-2923.2009.03507.x · Cited by 500 · see citing works
Wagner, A. D., Maril, A., Bjork, R. A., & Schacter, D. L. (2001) · NeuroImage · doi:10.1006/nimg.2001.0936 · Cited by 421 · see citing works
Pelaccia, T., Tardif, J., Triby, E., & Charlin, B. (2011) · Medical Education Online · doi:10.3402/meo.v16i0.5890 · Cited by 395 · see citing works
On acquiring expertise in medicine
Schmidt, H. G., & Boshuizen, H. P. A. (1993) · Educational Psychology Review · doi:10.1007/bf01323044 · Cited by 386 · see citing works
Barbey, A., Colom, R., Solomon, J., Krueger, F., Forbes, C. E., & Grafman, J. (2012) · Brain : a journal of neurology · doi:10.1093/brain/aws021 · Cited by 384 · see citing works
Dissociation of mechanisms underlying syllogistic reasoning
Goel, V., Buchel, C., Frith, C., & Dolan, R. J. (2000) · NeuroImage · doi:10.1006/nimg.2000.0636 · Cited by 325 · see citing works
Anatomy of deductive reasoning
Goel, V. (2007) · Trends in Cognitive Sciences · doi:10.1016/j.tics.2007.09.003 · Cited by 309 · see citing works
Neuroimaging creativity: a psychometric view
Arden, R., Chavez, R. S., Grazioplene, R., & Jung, R. E. (2010) · Behavioural Brain Research · doi:10.1016/j.bbr.2010.05.015 · Cited by 287 · see citing works
Neural Correlates of Lyrical Improvisation: An fMRI Study of Freestyle Rap
Liu, S., Chow, H. M., Xu, Y., Erkkinen, M. G., Swett, K. E., Eagle, M. W., Rizik‐Baer, D., & Braun, A. R. (2012) · Scientific Reports · doi:10.1038/srep00834 · Cited by 260 · see citing works
Dual processing and diagnostic errors
Norman, G. R. (2009) · Advances in Health Sciences Education · doi:10.1007/s10459-009-9179-x · Cited by 252 · see citing works
The association between resting functional connectivity and creativity
Takeuchi, H., Taki, Y., Hashizume, H., Sassa, Y., Nagase, T., Nouchi, R., & Kawashima, R. (2012) · Cerebral Cortex · doi:10.1093/cercor/bhr371 · Cited by 240 · cited 2× · see citing works
“Recent neuroimaging evidence suggests that creative behavior and generation of spontaneous and novel ideas require activation of self-monitoring regions of the medial frontal cortex and a subsequent deactivation of cognitive control regions, such as the lateral frontal cortex (Limb & Braun 2008; Liu et al. 2012; Takeu…”
BackgroundEffective Continuing Education for Professionals
Cervero, R. M., & Donaldson, J. F. (1989) · The Journal of Continuing Higher Education · doi:10.1080/07377366.1989.10401172 · Cited by 228 · see citing works
Neuroanatomical Correlates of Human Reasoning
Goel, V., Gold, B. T., Kapur, S., & Houle, S. (1998) · Journal of Cognitive Neuroscience · doi:10.1162/089892998562744 · Cited by 216 · see citing works
Context and clinical reasoning: understanding the perspective of the expert’s voice
Durning, S. J., Artino, A. R., Pangaro, L. N., van der Vleuten, C. P. M., & Schuwirth, L. (2011) · Medical Education · doi:10.1111/j.1365-2923.2011.04053.x · Cited by 206 · see citing works
Self-citationGoel, V., & Dolan, R. (2003) · NeuroImage · doi:10.1016/j.neuroimage.2003.07.027 · Cited by 206 · see citing works
The Brain Network for Deductive Reasoning: A Quantitative Meta-analysis of 28 Neuroimaging Studies
Prado, J., Chadha, A., & Booth, J. R. (2011) · Journal of Cognitive Neuroscience · doi:10.1162/jocn_a_00063 · Cited by 186 · see citing works
Clarifying Assumptions to Enhance Our Understanding and Assessment of Clinical Reasoning
Durning, S. J., Artino, A. R., Schuwirth, L., & van der Vleuten, C. P. M. (2013) · Academic Medicine · doi:10.1097/acm.0b013e3182851b5b · Cited by 178 · see citing works
Self-citationFMRI group analysis combining effect estimates and their variances
Chen, G., Saad, Z. S., Nath, A. R., Beauchamp, M. S., & Cox, R. W. (2011) · NeuroImage · doi:10.1016/j.neuroimage.2011.12.060 · Cited by 164 · see citing works
Quantitative assessment of diagnostic ability
Bordage, G., Grant, J., & Marsden, P. D. (1990) · Medical Education · doi:10.1111/j.1365-2923.1990.tb02650.x · Cited by 153 · see citing works
Reasoning and working memory: common and distinct neuronal processes
Ruff, C. C., Knauff, M., Fangmeier, T., & Spreer, J. (2003) · Neuropsychologia · doi:10.1016/s0028-3932(03)00016-2 · Cited by 134 · see citing works
Lin, W., Tsai, P., Lin, H., & Chen, H. (2013) · Cognition & Emotion · doi:10.1080/02699931.2013.854195 · Cited by 129 · see citing works
Educating professionals: Responding to new expectations for competence and accountability
McCook, K. D. L. P. (1994) · The Journal of Academic Librarianship · doi:10.1016/0099-1333(94)90078-7 · Cited by 109 · see citing works
The neural coding of creative idea generation across adolescence and early adulthood
Kleibeuker, S. W., Koolschijn, P. C. M. P., Jolles, D. D., De Dreu, C. K. W., & Crone, E. A. (2013) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2013.00905 · Cited by 106 · see citing works
Roles of medial prefrontal cortex and orbitofrontal cortex in self-evaluation
Beer, J. S., Lombardo, M. V., & Bhanji, J. P. (2010) · Journal of Cognitive Neuroscience · doi:10.1162/jocn.2009.21359 · Cited by 104 · see citing works
The medial prefrontal cortex is critical for memory retrieval and resolving interferencePreprint
Peters, G. J., David, C. N., Marcus, M. D., & Smith, D. M. (2013) · Learning & Memory · doi:10.1101/lm.029249.112 · Cited by 78 · see citing works
Functional Neuroimaging Correlates of Burnout among Internal Medicine Residents and Faculty Members
Durning, S. J., Costanzo, M. E., Artino, A. R., Dyrbye, L. N., Beckman, T. J., Schuwirth, L., Holmboe, E. S., Roy, M. J., Wittich, C. M., Lipner, R. S., et al. (2013) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2013.00131 · Cited by 72 · see citing works
Self-citationMind the gap: an attempt to bridge computational and neuroscientific approaches to study creativity
Wiggins, G. A., & Bhattacharya, J. (2014) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2014.00540 · Cited by 67 · see citing works
Developing a Unified List of Physicians’ Reasoning Tasks During Clinical Encounters
Goldszmidt, M. A., Minda, J. P., & Bordage, G. (2013) · Academic Medicine · doi:10.1097/acm.0b013e31827fc58d · Cited by 58 · see citing works
Measuring psychological flexibility in medical students and residents: a psychometric analysis
Palladino, C. L., Ange, B., Richardson, D. S., Casillas, R., Decker, M., Gillies, R. A., House, A., Rollock, M., Salazar, W. H., Waller, J. L., et al. (2013) · Medical Education Online · doi:10.3402/meo.v18i0.20932 · Cited by 51 · see citing works
Is the self special in the dorsomedial prefrontal cortex? An fMRI study
Yaoi, K., Osaka, N., & Osaka, M. (2009) · Social Neuroscience · doi:10.1080/17470910903027808 · Cited by 50 · see citing works
Asymmetrical involvement of frontal lobes in social reasoning
Goel, V. (2004) · Brain · doi:10.1093/brain/awh086 · Cited by 48 · see citing works
Sobral, D. T. (1995) · Medical Education · doi:10.1111/j.1365-2923.1995.tb02849.x · Cited by 46 · see citing works
Shen, J., Zhang, G., Yao, L., & Zhao, X. (2015) · Neuroscience · doi:10.1016/j.neuroscience.2014.12.071 · Cited by 35 · see citing works
Durning, S. J., Graner, J. L., Artino, A. R., et al. (2012) · Military Medicine · doi:10.7205/milmed-d-12-00242 · Cited by 34 · see citing works
Self-citationBrain Imaging, Forward Inference, and Theories of Reasoning
Heit, E. (2015) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2014.01056 · Cited by 29 · see citing works
Jones, U. (1997) · Medical Teacher · doi:10.3109/01421599709019366 · Cited by 20 · see citing works
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Limitations of large language models in clinical problem-solving arising from inflexible reasoning
Kim, J., Podlasek, A., Shidara, K., Liu, F., Alaa, A., & Bernardo, D. (2025) · Scientific Reports · doi:10.1038/s41598-025-22940-0 · Cited by 78 · see citing works
- Authors
- Durning, S. J., Costanzo, M. E., Beckman, T. J., Artino, A. R., Roy, M. J., van der Vleuten, C., Holmboe, E. S., Lipner, R. S., & Schuwirth, L.
- Affiliations
- Uniformed Services University of the Health Sciences (US)
- Mayo Clinic (US)
- Maastricht University, The Netherlands,
- American Board of Internal Medicine (US)
- Flinders University (AU)
- Corresponding author
- Durning, Steven J.
- ORCID
- Venue
- Medical Teacher
- Publisher
- Informa UK Limited
- Published
- 2015-06-16
- Volume
- 38
- Issue
- 6
- Pages
- 570-577
- ISSN
- 0142-159X (ISSN-L)
- 1466-187X
- OpenAlex
- W1854828342
- Cited by
- 27
- References
- 49
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 2 · 2023: 2 · 2022: 2 · 2021: 3 · 2020: 1 · 2019: 3 · 2018: 2 · 2017: 2 · 2016: 4 · 2015: 2
- FWCI
- 3.91
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Medical Teacher (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (submittedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- Funders
- Uniformed Services University of the Health Sciences
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
- Keywords
- diagnostic reasoning, clinical reasoning, cognitive flexibility, memory structure, dual-process theory, prefrontal cortex, neuroimaging correlates, analytical thinking, physician expertise, medical education
- MeSH terms
- Clinical Decision-Making, Clinical Competence, Education, Medical, Humans, Magnetic Resonance Imaging, Thinking, Functional Neuroimaging
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