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Response to: Functional neuroimaging and diagnostic reasoning

tools to measure it such as the [Diagnostic Thinking Inventory] (DTI) is situation specific as opposed to being relatively stable’’. In their study, the DTI was administered to each participant after they completed 32 ‘‘most likely diagnosis’’ MCQs. The DTI scores were then used as global measures of each participant’s diagnostic thinking. Such use of global, generic reasoning scores is in direct violation of the case specificity principle. For example, a clinician could have very different memory structure or flexibility scores depending on which MCQ they were completing. The DTI, in accordance with case specificity, is the best used as a debriefing instrument in relation to one or two specific cases, not as a generic measure. Second, Durning et al. used the DTI memory structure score as a proxy measure of non-analytical reasoning and the flexibility of thinking score as a proxy measure of analytical reasoning. The DTI scores were not meant to be used or interpreted in this specific manner and they are unlikely to offer a valid reflection of those mental processes. For example, item one on the DTI, which is associated with the memory structure scale, reads ‘‘When the patient presents his symptoms, I think of the symptoms in more abstract terms (vs. patient’s words)’’. That has an analytical, abstract transformational connotation rather than implying a nonanalytical orientation. The two dimensions of diagnostic reasoning on the DTI are not exclusive or specific to non-analytical or analytical reasoning. In fact, the non-exclusivity of non-analytical and analytical reasoning casts further fundamental doubt on the interpretation of the fMRI results. Non-analytic reasoning is considered to be fast on the order of milliseconds, not minutes. Consistent with this, it is well established that clinicians become aware of diagnostic hypotheses within seconds of a case presenting. To assume that the physicians in this study did not have diagnoses come spontaneously to mind and did not begin to analytically consider their differential diagnosis until the MCQ response alternatives presented 60 s later creates a serious threat to the validity of their procedure for separating the influence or location of different clinical reasoning processes.