A passing glance? Differences in eye tracking and gaze patterns between trainees and experts reading plain film bunion radiographs

Cognitive and behavioral markers for human detection error in AI-assisted bridge inspection

Integrating Artificial Intelligence (AI) and drone technology into bridge inspections offers numerous advantages, including increased efficiency and enhanced safety. However, it is essential to recognize that this integration changes the cognitive ergonomics of the inspection task. Gaining a deeper understanding of how humans process information and behave when collaborating with drones and AI systems is necessary for designing and implementing effective AI-assisted inspection drones. To further understand human-drone-AI intricate dynamics, an experiment was conducted in which participants' biometric and behavioral data were collected during a simulated drone-enabled bridge inspection under two conditions: with an 80% accurate AI assistance and with no AI assistance. Results indicate that cognitive and behavioral factors, including vigilance, cognitive processing intensity, gaze patterns, and visual scanning efficiency can influence inspectors' performance respectively in either condition. This highlights the importance of designing inspection protocols, drones and AI systems based on a comprehensive understanding of the cognitive processes required in each condition to prevent cognitive overload and minimize errors. We also remark on the visual scanning and gaze patterns associated with a higher chance of missing critical information in each condition, insights that inspectors can use to enhance their inspection performance.

Selective processing of clinical information related to correct and incorrect diagnoses: An eye-tracking experiment

INTRODUCTION

Diagnostic errors are often attributed to erroneous selection and interpretation of patients' clinical information, due to either cognitive biases or knowledge deficits. However, whether the selection or processing of clinical information differs between correct and incorrect diagnoses in written clinical cases remains unclear. We hypothesised that residents would spend more time processing clinical information that was relevant to their final diagnosis, regardless of whether their diagnosis was correct.

METHODS

In this within-subjects eye-tracking experiment, 19 internal or emergency medicine residents diagnosed 12 written cases. Half the cases contained a correct diagnostic suggestion and the others an incorrect suggestion. We measured how often (i.e. number of fixations) and how long (i.e. dwell time) residents attended to clinical information relevant for either suggestion. Additionally, we measured confidence and time to diagnose in each case.

RESULTS

Residents looked longer and more often at clinical information relevant for the correct diagnostic suggestion if they received an incorrect suggestion and were able to revise this suggestion to the correct diagnosis (dwell time: M: 6.3 seconds, SD: 5.1 seconds; compared to an average of 4 seconds in other conditions; number of fixations: M: 25 fixations, SD: 20; compared to an average of 16-17 fixations). Accordingly, time to diagnose was longer in cases with an incorrect diagnostic suggestion (M: 86 seconds, SD: 47 seconds; compared to an average of 70 seconds in other conditions). Confidence (range: 64%-67%) did not differ depending on residents' accuracy or the diagnostic suggestion.

DISCUSSION

Selectivity in information processing was not directly associated with an increase in diagnostic errors but rather seemed related to recognising and revising a biased suggestion in favour of the correct diagnosis. This could indicate an important role for case-specific knowledge in avoiding biases and diagnostic errors. Future research should examine information processing for other types of clinical information.

Enhancing Imaging Anatomy Competency: Integrating Digital Imaging and Communications in Medicine (DICOM) Viewers Into the Anatomy Lab Experience

INTRODUCTION

Radiologic interpretation is a skill necessary for all physicians to provide quality care for their patients. However, some medical students are not exposed to Digital Imaging and Communications in Medicine (DICOM) imaging manipulation until their third year during clinical rotations. The objective of this study is to evaluate how medical students exposed to DICOM manipulation perform on identifying anatomical structures compared to students who were not exposed.

METHODS

This was a cross-sectional cohort study with 19 medical student participants organized into a test and control group. The test group consisted of first-year students who had been exposed to a new imaging anatomy curriculum (n = 9). The control group consisted of second-year students who had not had this experience (n = 10). The outcomes measured included quiz performance, self-reported confidence levels, and eye-tracking data.

RESULTS

Students in the test group performed better on the quiz compared to students in the control group (p = 0.03). Confidence between the test and control groups was not significantly different (p = 0.16), though a moderate to large effect size difference was noted (Hedges' g = 0.75). Saccade peak velocity and fixation duration between the groups were not significantly different (p = 0.29, p = 0.77), though a moderate effect size improvement was noted in saccade peak velocity for the test group (Hedges' g = 0.49).

CONCLUSION

The results from this study suggest that the early introduction of DICOM imaging into a medical school curriculum does impact students' performance when asked to identify anatomical structures on a standardized quiz.

First understand the context and then look at the graph - the effect of attentional guidance on cognitive linear graph processing?

PURPOSE

Many studies have investigated the effect of signaling on graph processing, but not the effect of a question's timing as attentional guidance (AG). We investigated how the AG, task level, and visual load affect graph processing, among university students.

DESIGN

We developed a graph processing task. The AG process created by displaying the question before the graph was displayed. We used behavioral measures and observation duration of eye movements to evaluate graph processing.

FINDINGS

AG has more significant impact on graph processing than the cognitive load of the graph. This means that understanding the context before looking at the graph is important to graph processing. In addition, AG influencing was seen mainly in process duration, rather than on decision-making accuracy.

ORIGINALITY

The results have important implications both for teachers and students how to develop interpretations of visual information into CONCLUSIONS: These results are discussed broadly in the article.

An interactive eye-tracking system for measuring radiologists' visual fixations in volumetric CT images: Implementation and initial eye-tracking accuracy validation

PURPOSE

Eye-tracking approaches have been used to understand the visual search process in radiology. However, previous eye-tracking work in computer tomography (CT) has been limited largely to single cross-sectional images or video playback of the reconstructed volume, which do not accurately reflect radiologists' visual search activities and their interactivity with three-dimensional image data at a computer workstation (e.g., scroll, pan, and zoom) for visual evaluation of diagnostic imaging targets. We have developed a platform that integrates eye-tracking hardware with in-house-developed reader workstation software to allow monitoring of the visual search process and reader-image interactions in clinically relevant reader tasks. The purpose of this work is to validate the spatial accuracy of eye-tracking data using this platform for different eye-tracking data acquisition modes.

METHODS

An eye-tracker was integrated with a previously developed workstation designed for reader performance studies. The integrated system captured real-time eye movement and workstation events at 1000 Hz sampling frequency. The eye-tracker was operated either in head-stabilized mode or in free-movement mode. In head-stabilized mode, the reader positioned their head on a manufacturer-provided chinrest. In free-movement mode, a biofeedback tool emitted an audio cue when the head position was outside the data collection range (general biofeedback) or outside a narrower range of positions near the calibration position (strict biofeedback). Four radiologists and one resident were invited to participate in three studies to determine eye-tracking spatial accuracy under three constraint conditions: head-stabilized mode (i.e., with use of a chin rest), free movement with general biofeedback, and free movement with strict biofeedback. Study 1 evaluated the impact of head stabilization versus general or strict biofeedback using a cross-hair target prior to the integration of the eye-tracker with the image viewing workstation. In Study 2, after integration of the eye-tracker and reader workstation, readers were asked to fixate on targets that were randomly distributed within a volumetric digital phantom. In Study 3, readers used the integrated system to scroll through volumetric patient CT angiographic images while fixating on the centerline of designated blood vessels (from the left coronary artery to dorsalis pedis artery). Spatial accuracy was quantified as the offset between the center of the intended target and the detected fixation using units of image pixels and the degree of visual angle.

RESULTS

The three head position constraint conditions yielded comparable accuracy in the studies using digital phantoms. For Study 1 involving the digital crosshairs, the median ± the standard deviation of offset values among readers were 15.2 ± 7.0 image pixels with the chinrest, 14.2 ± 3.6 image pixels with strict biofeedback, and 19.1 ± 6.5 image pixels with general biofeedback. For Study 2 using the random dot phantom, the median ± standard deviation offset values were 16.7 ± 28.8 pixels with use of a chinrest, 16.5 ± 24.6 pixels using strict biofeedback, and 18.0 ± 22.4 pixels using general biofeedback, which translated to a visual angle of about 0.8° for all three conditions. We found no obvious association between eye-tracking accuracy and target size or view time. In Study 3 viewing patient images, use of the chinrest and strict biofeedback demonstrated comparable accuracy, while the use of general biofeedback demonstrated a slightly worse accuracy. The median ± standard deviation of offset values were 14.8 ± 11.4 pixels with use of a chinrest, 21.0 ± 16.2 pixels using strict biofeedback, and 29.7 ± 20.9 image pixels using general biofeedback. These corresponded to visual angles ranging from 0.7° to 1.3°.

CONCLUSIONS

An integrated eye-tracker system to assess reader eye movement and interactive viewing in relation to imaging targets demonstrated reasonable spatial accuracy for assessment of visual fixation. The head-free movement condition with audio biofeedback performed similarly to head-stabilized mode.

Differences in echocardiography interpretation techniques among trainees and expert readers

Background

Trainees learn transthoracic echocardiogram (TTE) interpretation through independently completing and reviewing selected portions of the study with experts. The diagnostic accuracy of novice TTE interpretation is known to be low and schema for reading TTEs systematically are lacking. The purpose of our study is to identify techniques experts use while reading TTEs which could be used to more effectively teach novice readers.

Methods

We performed a prospective qualitative case study to observe how experts and trainees interpret TTEs in an academic institution using a concurrent think aloud (CTA) method. Three TTEs of intermediate complexity were given to 3 advanced imaging fellows, 3 first year fellows and 3 expert TTE readers Participants filled out a report while reading and described aloud their thought processes. Sessions were video and audiotaped for analysis.

Results

Experts and advanced fellows used specific techniques that novices did not including: previewing studies, reviewing multiple images simultaneously, having flexibility in image review order and disease coding, and saving hardest elements to code for the end. Direct observation of TTE reading informed trainee inefficiencies and was a well-received educational tool.

Conclusions

In this single centered study we identified several unique approaches experts use to interpret TTEs which may be teachable to novices. Although limited in generalizability the findings of this study suggests that a more systematic approach to TTE interpretation, using techniques found in experts, might be of significant value for trainees. Further study is needed to evaluate teaching practices at other institutions and to assess whether implementation of these techniques by novices improves can improve their diagnostic accuracy and efficiency of reading at an earlier stage in their training.

Statistical modeling of dynamic eye-tracking experiments: Relative importance of visual stimulus elements for gaze behavior in the multi-group case

This paper presents a model that allows group comparisons of gaze behavior while watching dynamic video stimuli. The model is based on the approach of Coutrot and Guyader (2017) and allows linear combinations of feature maps to form a master saliency map. The feature maps in the model are, for example, the dynamically salient contents of a video stimulus or predetermined areas of interest. The model takes into account temporal aspects of the stimuli, which is a crucial difference to other common models. The multi-group extension of the model introduced here allows to obtain relative importance plots, which visualize the effect of a specific feature of a stimulus on the attention and visual behavior for two or more experimental groups. These plots are interpretable summaries of data with high spatial and temporal resolution. This approach differs from many common methods for comparing gaze behavior between natural groups, which usually only include single-dimensional features such as the duration of fixation on a particular part of the stimulus. The method is illustrated by contrasting a sample of a group of persons with particularly high cognitive abilities (high achievement on IQ tests) with a control group on a psycholinguistic task on the conceptualization of motion events. In the example, we find no substantive differences in relative importance, but more exploratory gaze behavior in the highly gifted group. The code, videos, and eye-tracking data we used for this study are available online.

Differences in Gaze Fixation Location and Duration Between Resident and Fellowship Sonographers Interpreting a Focused Assessment With Sonography in Trauma

OBJECTIVES

We quantified the gaze fixation duration of resident and fellowship sonographers interpreting a prerecorded focused assessment with sonography in trauma (FAST). We hypothesized that all sonographers would fixate on each relevant anatomic relationship but that the duration of fixation would differ.

METHODS

We conducted a cross-sectional study collecting and analyzing the gaze fixations of a convenience sample of current resident and fellowship sonographers. All sonographers viewed a standardized FAST video, and their gaze fixations were recorded using a Tobii X3-120 eye-tracking bar. Gaze fixations over nine anatomic regions of interest (ROIs) were identified. These were assessed for normality and analyzed using the Wilcoxon rank sum test at an alpha of 0.05 and Bonferroni correction p value of <0.0034. The chi-square test and Pearson's correlation were performed to assess statistical association.

RESULTS

The gaze fixation recordings of 24 resident and eight fellowship sonographers were suitable for analysis. Fourteen of the 24 resident sonographers viewed all ROIs in the FAST, whereas all eight fellowship sonographers viewed each of the nine relevant ROIs. Five ROIs were identified over which at least one resident sonographer did not have a gaze fixation. No statistically significant difference was identified between groups. Resident sonographers gaze fixated over the left upper quadrant (LUQ) splenorenal interface for a median (interquartile range) of 10.64 (9.73-11.60) seconds. The fellowship group viewed the same ROI for 8.43 (6.64-8.95) seconds (p < 0.003). All participants viewed this ROI. No other ROIs had a statistical difference.

CONCLUSION

Five ROIs were identified that were not visually interrogated by all resident sonographers. Only 14 of 24 resident sonographers visually interrogated every area in the FAST, whereas all fellowship sonographers interrogated every ROI. A statistically significant difference was found in gaze fixation duration between resident and fellowship sonographers in one ROI. Further study is required for gaze fixation assessment to become a tool for the interpretation component of point-of-care ultrasound.

The Radiologist's Gaze: Mapping Three-Dimensional Visual Search in Computed Tomography of the Abdomen and Pelvis

A radiologist's search pattern can directly influence patient management. A missed finding is a missed opportunity for intervention. Multiple studies have attempted to describe and quantify search patterns but have mainly focused on chest radiographs and chest CTs. Here, we describe and quantify the visual search patterns of 17 radiologists as they scroll through 6 CTs of the abdomen and pelvis. Search pattern tracings varied among individuals and remained relatively consistent per individual between cases. Attendings and trainees had similar eye metric statistics with respect to time to first fixation (TTFF), number of fixations in the region of interest (ROI), fixation duration in ROI, mean saccadic amplitude, or total number of fixations. Attendings had fewer numbers of fixations per second versus trainees (p < 0.001), suggesting efficiency due to expertise. In those cases that were accurately interpreted, TTFF was shorter (p = 0.04), the number of fixations per second and number of fixations in ROI were higher (p = 0.04, p = 0.02, respectively), and fixation duration in ROI was increased (p = 0.02). We subsequently categorized radiologists as "scanners" or "drillers" by both qualitative and quantitative methods and found no differences in accuracy with most radiologists being categorized as "drillers." This study describes visual search patterns of radiologists in interpretation of CTs of the abdomen and pelvis to better approach future endeavors in determining the effects of manipulations such as fatigue, interruptions, and computer-aided detection.

A comparison of visual identification of dental radiographic and nonradiographic images using eye tracking technology

OBJECTIVES

Eye tracking has been used in medical radiology to understand observers' gaze patterns during radiological diagnosis. This study examines the visual identification ability of junior hospital dental officers (JHDOs) and dental surgery assistants (DSAs) in radiographic and nonradiographic images using eye tracking technology and examines if there is a correlation.

MATERIAL AND METHODS

Nine JHDOs and nine DSAs examined six radiographic images and 16 nonradiographic images using eye tracking. The areas of interest (AOIs) of the radiographic images were rated as easy, medium, and hard, and the nonradiographic images were categorized as pattern recognition, face recognition, and image comparison. The participants were required to identify and locate the AOIs. Data analysis of the two domains, entire slide and AOI, was conducted by evaluating the eye tracking metrics (ETM) and the performance outcomes. ETM consisted of six parameters, and performance outcomes consisted of four parameters.

RESULTS

No significant differences were observed for ETMs for JHDOs and DSAs for both radiographic and nonradiographic images. The JHDOs showed significantly higher percentage in identifying AOIs than DSAs for all the radiographic images (72.7% vs. 36.4%, p = .004) and for the easy categorization of radiographic AOIs (85.7% vs. 42.9%, p = .012). JHDOs with higher correct identification percentage in face recognition had a shorter dwell time in AOIs.

CONCLUSIONS

Although no significant relation was observed between radiographic and nonradiographic images, there were some evidence that visual recognition skills may impact certain attributes of the visual search pattern in radiographic images.

A review of eye tracking for understanding and improving diagnostic interpretation

Inspecting digital imaging for primary diagnosis introduces perceptual and cognitive demands for physicians tasked with interpreting visual medical information and arriving at appropriate diagnoses and treatment decisions. The process of medical interpretation and diagnosis involves a complex interplay between visual perception and multiple cognitive processes, including memory retrieval, problem-solving, and decision-making. Eye-tracking technologies are becoming increasingly available in the consumer and research markets and provide novel opportunities to learn more about the interpretive process, including differences between novices and experts, how heuristics and biases shape visual perception and decision-making, and the mechanisms underlying misinterpretation and misdiagnosis. The present review provides an overview of eye-tracking technology, the perceptual and cognitive processes involved in medical interpretation, how eye tracking has been employed to understand medical interpretation and promote medical education and training, and some of the promises and challenges for future applications of this technology.

The Holistic Processing Account of Visual Expertise in Medical Image Perception: A Review

In the field of medical image perception, the holistic processing perspective contends that experts can rapidly extract global information about the image, which can be used to guide their subsequent search of the image (Swensson, 1980; Nodine and Kundel, 1987; Kundel et al., 2007). In this review, we discuss the empirical evidence supporting three different predictions that can be derived from the holistic processing perspective: Expertise in medical image perception is domain-specific, experts use parafoveal and/or peripheral vision to process large regions of the image in parallel, and experts benefit from a rapid initial glimpse of an image. In addition, we discuss a pivotal recent study (Litchfield and Donovan, 2016) that seems to contradict the assumption that experts benefit from a rapid initial glimpse of the image. To reconcile this finding with the existing literature, we suggest that global processing may serve multiple functions that extend beyond the initial glimpse of the image. Finally, we discuss future research directions, and we highlight the connections between the holistic processing account and similar theoretical perspectives and findings from other domains of visual expertise.

How visual search relates to visual diagnostic performance: a narrative systematic review of eye-tracking research in radiology

Eye tracking research has been conducted for decades to gain understanding of visual diagnosis such as in radiology. For educational purposes, it is important to identify visual search patterns that are related to high perceptual performance and to identify effective teaching strategies. This review of eye-tracking literature in the radiology domain aims to identify visual search patterns associated with high perceptual performance. Databases PubMed, EMBASE, ERIC, PsycINFO, Scopus and Web of Science were searched using 'visual perception' OR 'eye tracking' AND 'radiology' and synonyms. Two authors independently screened search results and included eye tracking studies concerning visual skills in radiology published between January 1, 1994 and July 31, 2015. Two authors independently assessed study quality with the Medical Education Research Study Quality Instrument, and extracted study data with respect to design, participant and task characteristics, and variables. A thematic analysis was conducted to extract and arrange study results, and a textual narrative synthesis was applied for data integration and interpretation. The search resulted in 22 relevant full-text articles. Thematic analysis resulted in six themes that informed the relation between visual search and level of expertise: (1) time on task, (2) eye movement characteristics of experts, (3) differences in visual attention, (4) visual search patterns, (5) search patterns in cross sectional stack imaging, and (6) teaching visual search strategies. Expert search was found to be characterized by a global-focal search pattern, which represents an initial global impression, followed by a detailed, focal search-to-find mode. Specific task-related search patterns, like drilling through CT scans and systematic search in chest X-rays, were found to be related to high expert levels. One study investigated teaching of visual search strategies, and did not find a significant effect on perceptual performance. Eye tracking literature in radiology indicates several search patterns are related to high levels of expertise, but teaching novices to search as an expert may not be effective. Experimental research is needed to find out which search strategies can improve image perception in learners.

Accuracy is in the eyes of the pathologist: The visual interpretive process and diagnostic accuracy with digital whole slide images

Digital whole slide imaging is an increasingly common medium in pathology, with application to education, telemedicine, and rendering second opinions. It has also made it possible to use eye tracking devices to explore the dynamic visual inspection and interpretation of histopathological features of tissue while pathologists review cases. Using whole slide images, the present study examined how a pathologist's diagnosis is influenced by fixed case-level factors, their prior clinical experience, and their patterns of visual inspection. Participating pathologists interpreted one of two test sets, each containing 12 digital whole slide images of breast biopsy specimens. Cases represented four diagnostic categories as determined via expert consensus: benign without atypia, atypia, ductal carcinoma in situ (DCIS), and invasive cancer. Each case included one or more regions of interest (ROIs) previously determined as of critical diagnostic importance. During pathologist interpretation we tracked eye movements, viewer tool behavior (zooming, panning), and interpretation time. Models were built using logistic and linear regression with generalized estimating equations, testing whether variables at the level of the pathologists, cases, and visual interpretive behavior would independently and/or interactively predict diagnostic accuracy and efficiency. Diagnostic accuracy varied as a function of case consensus diagnosis, replicating earlier research. As would be expected, benign cases tended to elicit false positives, and atypia, DCIS, and invasive cases tended to elicit false negatives. Pathologist experience levels, case consensus diagnosis, case difficulty, eye fixation durations, and the extent to which pathologists' eyes fixated within versus outside of diagnostic ROIs, all independently or interactively predicted diagnostic accuracy. Higher zooming behavior predicted a tendency to over-interpret benign and atypia cases, but not DCIS cases. Efficiency was not predicted by pathologist- or visual search-level variables. Results provide new insights into the medical interpretive process and demonstrate the complex interactions between pathologists and cases that guide diagnostic decision-making. Implications for training, clinical practice, and computer-aided decision aids are considered.

Impact of Patient Photographs on Radiologists' Visual Search of Chest Radiographs

RATIONALE AND OBJECTIVES

To increase detection of mislabeled medical imaging studies, evidence shows it may be useful to include patient photographs during interpretation. This study examined how inclusion of photographs impacts visual search.

MATERIALS AND METHODS

Ten radiologists participated. Average age was 43.00 years and average years Board-certified was 9.70, with 2 residents, 1 general, 2 abdominal, 4 cardiothoracic, and 1 pediatric radiologist. They viewed 21 portable chest radiographs with and without a simultaneously acquired photograph of the patient while visual search was recorded. Their task was to note placement of lines and tubes.

RESULTS

Presence of the photograph reduced the number of fixations (chest radiograph only mean 98.68; chest with photograph present 80.81; photograph 10.59; p < 0.0001) and total dwell (chest radiograph only mean 30.84 seconds; chest radiograph with photograph present 25.68; photograph 3.93; p < 0.0001) on the chest radiograph as a result of periodically looking at the photograph. Overall viewing time did not increase with addition of the photograph because time not spent on the radiograph was spent on the photograph. On average, readers scanned from the radiograph to the photographs about four times during search. Men and non-cardiothoracic radiologists spent significantly more time scanning all the images, including the photographs. Average preference for having photographs was 6.10 on a 0-10 scale, and neck and chest were preferred as areas to include in the photograph.

CONCLUSION

Photographs may help with certain image interpretation tasks and may help personalize the reading experience for radiologists without increasing interpretation time.

Gaze entropy reflects surgical task load

BACKGROUND

Task (over-)load imposed on surgeons is a main contributing factor to surgical errors. Recent research has shown that gaze metrics represent a valid and objective index to asses operator task load in non-surgical scenarios. Thus, gaze metrics have the potential to improve workplace safety by providing accurate measurements of task load variations. However, the direct relationship between gaze metrics and surgical task load has not been investigated yet. We studied the effects of surgical task complexity on the gaze metrics of surgical trainees.

METHODS

We recorded the eye movements of 18 surgical residents, using a mobile eye tracker system, during the performance of three high-fidelity virtual simulations of laparoscopic exercises of increasing complexity level: Clip Applying exercise, Cutting Big exercise, and Translocation of Objects exercise. We also measured performance accuracy and subjective rating of complexity.

RESULTS

Gaze entropy and velocity linearly increased with increased task complexity: Visual exploration pattern became less stereotyped (i.e., more random) and faster during the more complex exercises. Residents performed better the Clip Applying exercise and the Cutting Big exercise than the Translocation of Objects exercise and their perceived task complexity differed accordingly.

CONCLUSIONS

Our data show that gaze metrics are a valid and reliable surgical task load index. These findings have potential impacts to improve patient safety by providing accurate measurements of surgeon task (over-)load and might provide future indices to assess residents' learning curves, independently of expensive virtual simulators or time-consuming expert evaluation.