How doctors generate diagnostic hypotheses: a study of radiological diagnosis with functional magnetic resonance imaging

Abstract

Background: In medical practice, diagnostic hypotheses are often made by physicians in the first moments of contact with patients; sometimes even before they report their symptoms. We propose that generation of diagnostic hypotheses in this context is the result of cognitive processes subserved by brain mechanisms that are similar to those involved in naming objects or concepts in everyday life.

Methodology and principal findings: To test this proposal we developed an experimental paradigm with functional magnetic resonance imaging (fMRI) using radiological diagnosis as a model. Twenty-five radiologists diagnosed lesions in chest X-ray images and named non-medical targets (animals) embedded in chest X-ray images while being scanned in a fMRI session. Images were presented for 1.5 seconds; response times (RTs) and the ensuing cortical activations were assessed. The mean response time for diagnosing lesions was 1.33 (SD ±0.14) seconds and 1.23 (SD ±0.13) seconds for naming animals. 72% of the radiologists reported cogitating differential diagnoses during trials (3.5 seconds). The overall pattern of cortical activations was remarkably similar for both types of targets. However, within the neural systems shared by both stimuli, activation was significantly greater in left inferior frontal sulcus and posterior cingulate cortex for lesions relative to animals.

Conclusions: Generation of diagnostic hypotheses and differential diagnoses made through the immediate visual recognition of clinical signs can be a fast and automatic process. The co-localization of significant brain activation for lesions and animals suggests that generating diagnostic hypotheses for lesions and naming animals are served by the same neuronal systems. Nevertheless, diagnosing lesions was cognitively more demanding and associated with more activation in higher order cortical areas. These results support the hypothesis that medical diagnoses based on prompt visual recognition of clinical signs and naming in everyday life are supported by similar brain systems.

Figure 1. A trio of chest X-ray images with pairing of a lesion, an animal, and a letter*.

*Arrows pointing to targets in the image; not present in the original images.

Figure 2. Cortical activations while diagnosing lesions and naming animals and letters versus control baseline *.

*family wise error rate corrected p<0.05. Statistical parametric maps rendered on an International Consortium of Brain Mapping individual brain.

Figure 3. Contrast estimates* in cortical areas more active for diagnosing lesions^#.

* 90% confidence interval. # contrast [lesions>(animals and letters)] inclusively masked with lesions>baseline, lesions>animals, and lesions>letters at p = 0.001.