In diagnostic pathology, automated feedback may be possible by parsing medical images into diagnostically relevant versus irrelevant regions of interest (ROIs) using expert annotations and/or automated machine-vision techniques (Bruny et al., 2014; Mercan et al., 2016; Nagarkar et al., 2016). Psychological Science, 15(5), 302306. Terms and Conditions, Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Journal of Graduate Medical Education, 10(3), 340341. 2022 BioMed Central Ltd unless otherwise stated. Several perceptual and cognitive mechanisms have been proposed to account for why search errors occur, including low target prevalence, satisfaction of search, distraction, and resource depletion. New York: Routledge. Cognitive psychology: rare items often missed in visual searches. Investigative Radiology, 25, 890896. By using this website, you agree to our Changes in breast cancer detection and mammography recall rates after the introduction of a computer-aided detection system. Medical Education, 18, 284297. When that occurs, there is a transient increase in pupil diameter that is thought to reflect a shift from exploring the scene (i.e., searching) to exploiting perceived information that is relevant to the task (Privitera, Renninger, Carney, Klein, & Aguilar, 2010; Usher, Cohen, Servan-Schrieber, Rajkowski, & Aston-Jones, 1999).

Bligh, J., Prideaux, D., & Parsell, G. (2001). Learning and Instruction, 20(2), 146154. https://doi.org/10.1037/0278-7393.24.6.1521. Laeng, B., Sirois, S., & Gredeback, G. (2012). https://doi.org/10.1097/00004424-199008000-00004. Psychological Bulletin, 128(4), 612637. In other words, can EMMEs move beyond providing explicit hints and cues that enable interpretation and diagnosis in highly similar contexts and cases, to accelerating rule and strategy learning that enhances performance on highly dissimilar contexts and cases (Ball & Litchfield, 2017)? https://doi.org/10.1148/radiographics.7.6.3423330. Journal of the American Medical Informatics Association: JAMIA, 10(1), 3951. Chetwood, A. S. A., Kwok, K. W., Sun, L. W., Mylonas, G. P., Clark, J., Darzi, A., & Yang, G. Z. Dougherty, M. R. P., & Hunter, J. E. (2003). The role of locus coeruleus in the regulation of cognitive performance. (2009b). ocular seguimiento neuromarketing cents cro seobutler tcnicas Bond, R. R., Zhu, T., Finlay, D. D., Drew, B., Kligfield, P. D., Guldenring, D., Clifford, G. D. (2014). Thus, one can only be truly certain that successful recognition has occurred (i.e., mapping a perceived feature to an accurate knowledge structure) if converging evidence is gathered during the interpretive process. https://doi.org/10.1111/j.1553-2712.2008.00148.x. Through the learners eyes: eye-tracking augmented debriefing in medical simulation. PLoS One, 8, 64366. https://doi.org/10.1371/journal.pone.0064366. Biological Psychology, 121, 6273. Studies of eye movements and visual search in radiology. https://doi.org/10.1207/s15327043hup1002_1. Can think aloud be used to teach and assess clinical reasoning in graduate medical education? Kane, M. J., & Engle, R. W. (2003). Nasca, T. J., Philibert, I., Brigham, T., & Flynn, T. C. (2012). https://doi.org/10.4300/JGME-05-01-33. Google Scholar. Elstein, A. S., Shulman, L. S., & Sprafka, S. A. Kogan, J. R., Conforti, L., Bernabeo, E., Iobst, W., & Holmboe, E. (2011). 311342). To further differentiate errors of recognition versus decision-making, Kundel and Nodine distinguished trials where the radiologist fixated within 2.8 of a nodule for greater than or less than 600 ms. Center for Applied Brain and Cognitive Sciences, Tufts University, 200 Boston Ave., Suite 3000, Medford, MA, 02155, USA, Department of Psychology, University of Utah, 380 1530 E, Salt Lake City, UT, 84112, USA, Department of Pathology and University of Vermont Cancer Center, University of Vermont, 111 Colchester Ave., Burlington, VT, 05401, USA, Department of Medicine, David Geffen School of Medicine at UCLA, University of California at Los Angeles, 10833 Le Conte Ave., Los Angeles, CA, 90095, USA, You can also search for this author in New England Journal of Medicine, 366, 10511056. https://doi.org/10.1093/cercor/bhi007.

), The handbook of medical image perception and techniques, (pp. If the fixation occurred for less than 600 ms this was considered a recognition error, and if greater than 600 ms it was considered a decision error. Cain, M. S., Vul, E., Clark, K., & Mitroff, S. R. (2012). NeuroImage, 104, 7988. Psychonomic Bulletin and Review, 16, 850856. Furthermore, tonic pupil diameter increases can indicate a higher mental workload involved in a decision-making task (Mandrick, Peysakhovich, Rmy, Lepron, & Causse, 2016).

Furthermore, second opinions can also induce diagnostic disagreements among expert clinicians and necessitate time and expense for resolving disagreement and reaching a consensus diagnosis.

Feedback-giving behaviour in performance evaluations during clinical clerkships. There are also cases where images that are usually navigated (panned, zoomed) are artificially restricted, increasing the risk that results are no longer relevant to routine clinical practice. Problem solving and situated cognition. https://doi.org/10.1146/annurev.neuro.28.061604.135709. How people learn: brain, mind, experience, and school. Once a diagnostician finds one target, there is no guarantee that it is the critical feature that will assist in rendering an appropriate diagnosis. Oxford: Oxford University Press. Steciuk, H., & Zwierno, T. (2015). Eye trackers are designed to track eye gaze as a series of fixations and saccades; in other words, they are designed to track foveal attention. eye tracking psychology heat map eyes mapping advertisements advertising Impact of introducing a diagnostic scheme to medical students in a problem based learning curriculum. Some research demonstrates that individual differences in working memory capacity predict hypothesis generation and verification processes in a task involving customer order predictions (Dougherty & Hunter, 2003). https://doi.org/10.1037/a0030726. 592597). Barnett, S. M., & Ceci, S. J. You look lost: understanding uncertainty and representational flexibility in navigation. Cognition, 106, 894912.

Gaze dwell times on acute trauma injuries missed because of satisfaction of search. Medical Teacher, 40(1), 6269.

Saccadic eye movements and cognition. Towards a framework for attention cueing in instructional animations: guidelines for research and design. Journal of Thoracic Imaging, 30, 130138. New England Journal of Medicine, 355, 26952696. Seeing or doing?

Sprinfield: C. C. Thomas. https://doi.org/10.1016/S0364-0213(84)80003-8. The intrinsic value of visual information affects saccade velocities. An example of near-transfer might be a pathologist learning the features and rules for diagnosing DCIS on one case or from text-book examples, and transferring that knowledge and skill to a biopsy with similar features that clearly indicate DCIS (Roads, Xu, Robinson, & Tanaka, 2018). (1997). In other words, their eye movements increasingly resemble those of experts as they progress through training. Lecture Notes in Computer Science, 8077, 3748. The ACGME outcome project: retrospective and prospective. Experimental Psychology, 53, 117122. Cerebral Cortex, 15, 12431249.

https://doi.org/10.1016/j.ijpsycho.2017.07.008. Eye tracking is an innovative tool that is becoming increasingly commonplace in medical research and holds the potential to revolutionize trainee and clinician experiences. https://doi.org/10.1109/TPAMI.2009.30. But there are few methods for providing feedback regarding the dynamic interpretive process; for instance, how a microscope was panned and zoomed, which features were inspected, and precisely where in the process difficulties may have arisen (Bok et al., 2013; 2016; Kogan, Conforti, Bernabeo, Iobst, & Holmboe, 2011; Wald, Davis, Reis, Monroe, & Borkan, 2009). https://doi.org/10.4324/9781315169781. The reliable involvement of these processes has made them of interest as targets for both clinical research and the design of educational interventions to improve diagnostic decision-making (Crowley, Naus, Stewart, & Friedman, 2003; Custers, 2015; Nabil et al., 2013). As evidence for relatively implicit attention guidance, novice lung x-ray interpretation can improve when they receive implicit cueing based on an experts eye movements (Ball & Litchfield, 2017). The content is solely the responsibility of the authors and does not necessarily represent the views of the National Cancer Institute or the National Institutes of Health. The main function of examining a visual image and recognizing features is to develop and test diagnostic hypotheses (Sox, Blatt, Higgins, & Marton, 1988). Eye tracking could thus augment traditional text annotations to allow consultative physicians to see the case through the eyes of the other physician, possibly reducing disagreement or facilitating consensus through shared understanding. Models of working memory: an introduction. Localization of diagnostically relevant regions of interest in whole slide images: a comparative study.

Eye tracking is a critical tool for recognizing and quantifying attention toward distracting image regions and has been instrumental in identifying this source of search failure among relatively novice diagnosticians. Varying target prevalence reveals two dissociable decision criteria in visual search. In R. S. Michalski, J. G. Carbonell, & T. M. Mitchell (Eds. The former was considered a failure to disembed the nodule from the background noise (despite fixating on it), and the latter was considered a successful recognition of a nodule without appropriately mapping it to diagnostic criteria. These early studies suggest that eye tracking can be a valuable tool for helping dissociate putative sources of error during medical image interpretation (i.e., search, recognition, and decision-making), given that high-resolution foveal vision appears to be critical for diagnostic interpretation. https://doi.org/10.1016/j.acra.2005.03.068. empathy pain faces children frontiersin In each of these cases, methods were evaluated and implemented for integrating CBME, including new standards for curriculum, teaching, and assessment.

This phenomenon was originally coined satisfaction of search, when radiologists would become satisfied with their interpretation of a medical image after identifying one lesion, at the expense of identifying a second more important lesion (Berbaum et al., 1990; Smith, 1967). A taxonomy of errors in multiple-target visual search. Richstone, L., Schwartz, M. J., Seideman, C., Cadeddu, J., Marshall, S., & Kavoussi, L. R. (2010). https://doi.org/10.1037/a0020082. Thus, eye tracking appears to be a valuable tool for augmenting qualitative feedback of trainee performance with concrete examples and guidance to help them attend to appropriate features and incorporate them into diagnoses. https://doi.org/10.1016/B978-044451020-4/50031-1. Nabil, N. M., Guemei, A. https://doi.org/10.1016/j.ergon.2004.06.004. Here we consider one individual difference that warrants more consideration in the domains of medical image interpretation and decision-making: working-memory capacity. https://doi.org/10.1037/0033-2909.124.3.372. Over the past four decades since this original research, eye tracking has been expanded to understanding diagnostic interpretation in several medical specializations, including radiology, breast pathology, general surgery, neurology, emergency medicine, anesthesiology, ophthalmology, and cardiology (Balslev et al., 2012; Berbaum et al., 2001; Bruny et al., 2014; Giovinco et al., 2015; Henneman et al., 2008; Jungk, Thull, Hoeft, & Rau, 2000; Krupinski et al., 2006; Kundel, Nodine, Krupinski, & Mello-Thoms, 2008; Matsumoto et al., 2011; ONeill et al., 2011; Sibbald, de Bruin, Yu, & van Merrienboer, 2015; Wood, Batt, Appelboam, Harris, & Wilson, 2014).

Wolfe, J. M., & Van Wert, M. J. Sox, H. C., Blatt, M. A., Higgins, M. C., & Marton, K. I. Eye-movement modeling of integrative reading of an illustrated text: effects on processing and learning. Charting the road to competence: developmental milestones for internal medicine residency training. Variable feedback experiments testing a sampled data model for eye tracking movements. https://doi.org/10.1002/acp.2350040404. For example, a radiologist failing to fixate a lung nodule (Manning, Ethell, Donovan, & Crawford, 2006), a pathologist failing to fixate large nucleoli in pleomorphic cells (Bruny, Mercan, Weaver, & Elmore, 2017), or a neuro-radiologist failing to fixate a cerebral infarction (Matsumoto et al., 2011). Specifically, expert cueing can help a novice calibrate the relevance and importance of a region (Litchfield et al., 2010), which can be complemented by an experts verbal narration. B., Tabbers, H. K., Rikers, R. M. J. P., & Paas, F. (2009). https://doi.org/10.1126/science.130.3366.9. https://doi.org/10.1523/JNEUROSCI.0582-14.2014.

Neural and psychophysiological correlates of human performance under stress and high mental workload. https://doi.org/10.1016/j.cedpsych.2015.01.004. Annals of Surgery, 252(1), 177182. (2018). In this task, radiologists search chest x-ray films for evidence of lung nodules; Kundel and Nodine were interested in whether radiologists were making errors of visual search versus errors of recognition and/or decision-making. https://doi.org/10.1007/s00464-011-2143-x. (2006). (2015). Eye tracking has the potential to revolutionize clinical practice and medical education, with far-reaching implications for the development of automated competency assessments (Bond et al., 2014; Krupinski, Graham, & Weinstein, 2013; Richstone et al., 2010; Tien et al., 2014), advanced clinical tutorials (e.g., watching an experts eye movements over an image; (Khan et al., 2012; OMeara et al., 2015)), biologically inspired artificial intelligence to enhance computer-aided diagnosis (Buettner, 2013; Young & Stark, 1963), and the automated detection and mitigation of emergent interpretive errors during the diagnostic process (Ratwani & Trafton, 2011; Tourassi, Mazurowski, Harrawood, & Krupinski, 2010; Voisin, Pinto, Morin-Ducote, Hudson, & Tourassi, 2013). Eye tracking: a comprehensive guide to methods and measures.

Tien, T., Pucher, P. H., Sodergren, M. H., Sriskandarajah, K., Yang, G. Z., & Darzi, A. Aston-Jones, G., & Cohen, J. D. (2005). 317327). Recognition is an example of attentional mechanisms working together to dynamically guide attention toward features that may be of diagnostic relevance and mapping them to stored knowledge. Think-aloud technique and protocol analysis in clinical decision-making research. Funke, G., Greenlee, E., Carter, M., Dukes, A., Brown, R., & Menke, L. (2016). Manning, D., Ethell, S., Donovan, T., & Crawford, T. (2006).

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(2012). 382391). In that study, eye movements were tracked in emergency medicine residents during objective structured clinical examinations in a simulation environment. However, having an earlier physicians interpretation available during diagnosis may unintentionally bias the second physicians diagnostic process. In The minds eye: cognitive and applied aspects of eye movement research, (pp. In this study, a participating pathologist is inspecting a digital breast biopsy (Bruny, Mercan, et al., 2017). The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. In this method, individual fixation durations are parsed into two categories using a quantitative threshold. Some of the earliest research using eye tracking during medical image interpretation was done during x-ray film inspection (Kundel & Nodine, 1978). Opening the black box of clinical skills assessment via observation: a conceptual model. https://doi.org/10.1111/j.1365-2869.2006.00504.x. Microsaccades are very small saccades that are less than 1 of visual arc and occur very frequently during fixations (about two to three times per second) (Martinez-Conde, Otero-Millan, & MacKnik, 2013). The risk is that after finding a single target a diagnostician may terminate search prematurely and fail to detect a target with higher value for a correct diagnosis. Journal of Neuroscience, 34, 1369313700. Analysis of mental workload during en-route air traffic control task execution based on eye-tracking technique.

Frontiers in Human Neuroscience, 9, 526. https://doi.org/10.3389/fnhum.2015.00526. (2002). Second, watching expert eye movements can help observers recognize and learn organizational strategies for viewing and interpreting visual images, understand the experts intent, identify the organizational structure of the images, and better organize perceived information into mental schemas (Becchio, Sartori, Bulgheroni, & Castiello, 2008; Jarodzka et al., 2013; Lobmaier, Fischer, & Schwaninger, 2006). Reasoning foundations of medical diagnosis. Determinants of saccade latency. More research is needed to understand whether EMMEs promote only near-transfer, or whether multiple EMME experiences can promote relatively far-transfer by promoting perceptual differentiation of features, accurate feature recognition, and more accurate and efficient mapping of features to candidate diagnoses.

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