holmqvist kenneth editions bol ), Models of working memory: mechanisms of active maintenance and executive control, (pp. These include lung x-rays, histology slides, and skin lesions. Here we consider one individual difference that warrants more consideration in the domains of medical image interpretation and decision-making: working-memory capacity. As we noted above, medical training frequently involves explicit feedback by instructors on exams and worked examples. Eye tracking in human-computer interaction and usability research.
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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. https://doi.org/10.3758/PBR.16.5.850. In this manner, the task demands working-memory storage (to memorize the words) while also processing distracting arithmetic problems. A review of eye tracking for understanding and improving diagnostic interpretation. You better look again. Consistent with this line of thinking, Manning and colleagues found that false-positives when examining chest radiographs were typically associated with longer cumulative dwell time than true-positives (Manning et al., 2006). Broadly speaking, these include visual search and pattern matching, hypothesis generation and testing, and reasoning and problem-solving. Privitera, C. M., Renninger, L. W., Carney, T., Klein, S., & Aguilar, M. (2010). Journal of Experimental Psychology: Learning Memory and Cognition, 24, 15211543. European Journal of Paediatric Neurology, 16, 161166. 
Sox, H. C., Blatt, M. A., Higgins, M. C., & Marton, K. I. Eye trackers provide several measures of visual behavior that are relevant for understanding the interpretive process; these are categorically referred to as movement measures, position measures, numerosity measures, and latency measures (Holmqvist et al., 2011). 2537).
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Aggarwal, R., & Darzi, A. Cambridge: Cambridge University Press. Liversedge, S. P., & Findlay, J. M. (2000). Task-evoked pupillary responses, processing load, and the structure of processing resources. You look lost: understanding uncertainty and representational flexibility in navigation. If the clinician has disconfirmed one of several hypotheses but has not confirmed a single hypothesis, the cyclical process continues; the process also continues under conditions of uncertainty when no given hypotheses have been ruled in or out (Kassirer, Kopelman, & Wong, 1991). This result suggests that novices can indeed leverage anothers eye movements to more effectively guide their own search behavior. 
Geller, B. M., Nelson, H. D., Carney, P. A., Weaver, D. L., Onega, T., Allison, K. H., Elmore, J. G. (2014). Gur, D., Sumkin, J. H., Rockette, H. E., Ganott, M., Hakim, C., Hardesty, L., Wallace, L. (2004). Eye movements during scene viewing: an overview. Under the assumption that increased fixation durations indicate successful recognition, if a participant fixates on a particular region for longer than a given threshold then any subsequent diagnostic error must be due to failed decision-making. Ledley, R. S., & Lusted, L. B. https://doi.org/10.1111/j.1469-8986.2008.00681.x. Cognitive Technology, 9, 2629. More recently, Berbaum and colleagues demonstrated that satisfaction of search alone may not adequately describe the search process (Berbaum et al., 2015; Krupinski, Berbaum, Schartz, Caldwell, & Madsen, 2017). It is also important to keep in mind that several diagnoses fall on a spectrum with categorical delineations, with the goal of identifying the highest diagnostic category present in a given image. ), The Cambridge handbook of situated cognition. Opening the black box of clinical skills assessment via observation: a conceptual model. One possible method for facilitating this progression is by showing students video-based playbacks of expert eye movements, a method called eye-movement modeling examples (EMMEs (Jarodzka et al., 2012)). https://doi.org/10.1111/j.1553-2712.2008.00148.x. Manage cookies/Do not sell my data we use in the preference centre. eye retinitis pigmentosa tracking omega vector amazing borderline background disorder personality nui galway freeimages laboratory psychology (2010). https://doi.org/10.3758/PBR.17.5.718. (2008). Applied Cognitive Psychology, 4, 261272. On the other hand, this approach could introduce bias in the second physician and unintentionally increase agreement; if the first physician arrived at an incorrect interpretation, such agreement could be detrimental, demonstrating the importance of continuing research in this regard (Gandomkar, Tay, Brennan, Kozuch, & Mello-Thoms, 2018). Thus, in both search and decision-making there appear to be critical roles for working-memory capacity in predicting clinician performance. Just say no: how are visual searches terminated when there is no target present? Jarodzka, H., Van Gog, T., Dorr, M., Scheiter, K., & Gerjets, P. (2013). Human Performance, 10, 7183. Medical Teacher, 29, 642647. Medical Teacher, 38, 8895. https://doi.org/10.1097/00001888-199910000-00065. A short history of image perception in medical radiology. Analysis of eye gaze: do novice surgeons look at the same location as expert surgeons during a laparoscopic operation? Experimental Brain Research, 196, 475481. Continued innovations in software for integrating dynamic visual scenes and eye movements will enable this type of research: for instance techniques that parse dynamic video stimuli based on navigation behavior (pause, rewind, play) to identify critical video frames (Yu, Ma, Nahrstedt, & Zhang, 2003). Visual search of mammographic images: influence of lesion subtlety. Current Biology, 20, 121124. Visual skills in airport-security screening. The intrinsic value of visual information affects saccade velocities. (2014). Carmody, D. P., Nodine, C. F., & Kundel, H. L. (1980). Educational Psychology Review, 23(4), 523552. Treisman, A., & Gelade, G. (1980). Biological Psychology, 121, 6273. A taxonomy of errors in multiple-target visual search. OMeara, P., Munro, G., Williams, B., Cooper, S., Bogossian, F., Ross, L., McClounan, M. (2015). Science, 130, 921. https://doi.org/10.1016/S0001-6918(03)00033-7. Educational milestone development in the first 7 specialties to enter the next accreditation system. The impact of speed and bias on the cognitive processes of experts and novices in medical image decision-making. Other methods such as think-aloud protocols and feature annotation may prove especially valuable to complement eye tracking in these situations: when a diagnostician recognizes a feature, they either say it aloud (e.g., I see cell proliferation) or annotate the feature with a text input (Pinnock, Young, Spence, & Henning, 2015). Gaze behavior among experts and trainees during optic disc examination: does how we look affect what we see? (1992). A theory of individual differences in task and contextual performance. https://doi.org/10.1093/acprof:oso/9780198524793.001.0001. van der Gijp, A., Ravesloot, C. J., Jarodzka, H., van der Schaaf, M. F., van der Schaaf, I. C., van Schaik, J. P. J., & ten Cate, T. 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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. Google Scholar.
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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. Furthermore, second opinions can also induce diagnostic disagreements among expert clinicians and necessitate time and expense for resolving disagreement and reaching a consensus diagnosis. Holmqvist, K., Nystrm, M., & Mulvey, F. (2012). Steciuk, H., & Zwierno, T. (2015). These explicit feature recognitions can then be assessed for their accuracy and predictive value toward accurate diagnosis. (1988). New York: Elsevier. alibris methodology Thus, the premise is that educators can use eye tracking to demonstrate, train, and assess gaze patterns during medical education, possibly accelerating the transition from novice to expert. Patel, V. L., Arocha, J., & Zhang, J. Bruny, T. T., & Gardony, A. L. (2017). Part of 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). Educational strategies in curriculum development: the SPICES model. Medical image interpretation is a highly complex skill that influences not only diagnostic interpretations but also patient quality of life and survivability. Studies in Health Technology and Informatics, 210, 9094. Educational Psychology Review, 21, 113140. Thus, while viewing an experts behavior may prove advantageous in certain conditions, future research must isolate the parameters that may dictate its success and balance the potential trade-off between guiding eye movements and potentially biasing interpretation. Third, well-organized expert eye movements can help an observer recognize relations within and between images, helping them discriminate similar features and possibly promote transfer to novel cases (Kieras & Bovair, 1984). This proposal has not been examined with diagnosticians inspecting medical images, though it suggests that physicians with higher working memory capacity may show higher performance when searching for multiple features, offering an interesting avenue for future research. Research 4, 7 (2019). (2010). Cookies policy. Beatty, J. Inhibition of return to successively stimulated locations in a sequential visual search paradigm. In P. Robbins, & M. Aydede (Eds. The authors suggest that detecting a target during search may not induce search termination, but rather change response thresholds during a multiple-target search. As noted previously, we distinguish education from training by noting that training involves active practice of knowledge and skills, with or without feedback (Kern, Thomas, & Hughes, 1998). Bruny, T. T., Carney, P. A., Allison, K. H., Shapiro, L. G., Weaver, D. L., & Elmore, J. G. (2014). 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). Most existing research in this regard leverages the well-established finding that experts move their eyes differently from novices (Bruny et al., 2014; Gegenfurtner, Lehtinen, & Slj, 2011; Krupinski, 2005; Krupinski et al., 2006; Kundel et al., 2008; Lesgold et al., 1988). https://doi.org/10.1007/s00221-009-1879-1. Los Altos: Morgan Kaufmann. Some of the earliest research using eye tracking during medical image interpretation was done during x-ray film inspection (Kundel & Nodine, 1978). In both cases, cueing a trainee with expert eye movements not only gets them to fixate in a desired region, but also seems to help them understand expert intent, behave more like an expert, and develop a more accurate diagnostic interpretation. eye tracking cognitive lab psychology exeter research software Journal of Graduate Medical Education, 7, 334337. Mason, L., Pluchino, P., & Tornatora, M. C. (2015). Velichkovsky, B. M. (1995). (1959). Vision Research, 45, 33913401. 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). Thus, some research suggests that passively viewing an experts eye gaze can be advantageous to medical education. ), Eye guidance in reading and scene perception, (pp. https://doi.org/10.1111/medu.12054. https://doi.org/10.1016/j.acra.2017.03.021. Patel, V. L., & Groen, G. J. Studies in the medical domain have provided more nuanced understandings of visual interpretation and diagnostic decision-making in diverse medical specialties including radiology, pathology, pediatrics, surgery, and emergency medicine (Al-Moteri, Symmons, Plummer, & Cooper, 2017; Blondon & Lovis, 2015; van der Gijp et al., 2017). As opposed to a novice passively viewing expert eye-gaze behavior, some studies have examined eye gaze as a training tool. Matsumoto, H., Terao, Y., Yugeta, A., Fukuda, H., Emoto, M., Furubayashi, T., Ugawa, Y. https://doi.org/10.1016/j.biopsycho.2016.10.002. McCarley, J. S., Kramer, A. F., Wickens, C. D., Vidoni, E. D., & Boot, W. R. (2004). https://doi.org/10.1111/j.1365-2869.2006.00504.x. This active maintenance of previously detected features may deplete working memory resources that could otherwise be used to search for lower-salience and prevalence targets. Characterizing the development of visual search experience in pathology residents viewing whole slide images. This is because a strategic shift of attention toward a particular feature is evident in oculomotor processes, for instance with longer fixations, regardless of whether recognition has proceeded accurately (Heekeren, Marrett, & Ungerleider, 2008). B. H., Yu, E., & van Merrienboer, J. J. G. (2015). B. Varying target prevalence reveals two dissociable decision criteria in visual search. McCarley, J. S., & Carruth, D. (2004). Second, it is worth pointing out that some research has suggested that people may intentionally alter their patterns of eye movements if they know that their eye movements are being monitored or that videos of their eye movements will be replayed to others (Neider, Chen, Dickinson, Brennan, & Zelinsky, 2010; Velichkovsky, 1995). Research with neurologists and pathologists has demonstrated that novice diagnosticians, such as medical residents, tend to detect features with high visual salience sooner and more often than experienced diagnosticians; this focus on highly salient visual features can be at the cost of neglecting the detection of critical features with relatively low visual salience (Bruny et al., 2014; Matsumoto et al., 2011). Though the concept of CBME has been around for several decades, formal frameworks for competency training and assessment have been more recently developed by CanMEDS, the Outcome Project of the US Accreditation Council for Graduate Medical Education (ACGME), and the Scottish Doctor (Frank & Danoff, 2007; Nasca, Philibert, Brigham, & Flynn, 2012; Simpson et al., 2002; Swing, 2007). Blink before and after you think: Blinks occur prior to and following cognitive load indexed by pupillary responses. 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. Science, 283(5401), 549554. Balslev, T., Jarodzka, H., Holmqvist, K., De Grave, W., Muijtjens, A. M. M., Eika, B., Scherpbier, A. J. J. 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). Why did I miss the diagnosis? Google Scholar. https://doi.org/10.1007/s10648-011-9174-7. Thus, most of our understanding of how image interpretation and diagnostic accuracy and efficiency emerge during professional development is restricted to insights from cross-sectional designs. Characterizing diagnostic search patterns in digital breast pathology: scanners and drillers. Cambridge: Cambridge University Press.
All authors read and approved the final manuscript. https://doi.org/10.1068/p090339. Before describing these, it is important to realize that the eye is constantly moving between points of fixation. In The nature of expertise, (pp. This research leverages several phenomena from the cognitive and instructional sciences.
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