Teaching through their eyes: effects on optometry teachers' adaptivity and students' learning when teachers see students' gaze.

Adaptive teacher support fosters effective learning in one-to-one teaching sessions, which are a common way of learning complex visual tasks in the health sciences. Adaptive support is tailored to student needs, and this is difficult in complex visual tasks as visual problem-solving processes are covert and thus cannot be directly observed by the teacher. Eye-tracking apparatus can measure covert processes and make them visible in gaze displays: visualizations of where a student looks while executing a task. We investigate whether live dynamic gaze displays help teachers in being more adaptive to students' needs when teaching optical coherence tomography interpretation in one-to-one teaching sessions and whether this fosters learning. Forty-nine students and 10 teachers participated in a one-to-one teaching session in clinical optometry. In the control condition, teachers saw the learning task of the student and could discuss it with them, whereas in the gaze-display condition, teachers could additionally see where the student looked. After the 15-minute teaching session, a test was administered to examine achievement. Furthermore, students filled in the 'questionnaire on teacher support adaptivity', and teachers rated how adaptive their support was. Bayesian analyses provide some initial evidence that students did not experience support to be more adaptive in the gaze-display condition versus the control condition, nor were their post-test scores higher. Teachers rated their provided support as being more adaptive in the gaze-display versus the control condition. Further research could investigate if live dynamic gaze displays impact adaptive teaching when used over longer periods or with more teacher training.

The effects of gaze-display feedback on medical students' self-monitoring and learning in radiology.

Self-monitoring is essential for effectively regulating learning, but difficult in visual diagnostic tasks such as radiograph interpretation. Eye-tracking technology can visualize viewing behavior in gaze displays, thereby providing information about visual search and decision-making. We hypothesized that individually adaptive gaze-display feedback improves posttest performance and self-monitoring of medical students who learn to detect nodules in radiographs. We investigated the effects of: (1) Search displays, showing which part of the image was searched by the participant; and (2) Decision displays, showing which parts of the image received prolonged attention in 78 medical students. After a pretest and instruction, participants practiced identifying nodules in 16 cases under search-display, decision-display, or no feedback conditions (n = 26 per condition). A 10-case posttest, without feedback, was administered to assess learning outcomes. After each case, participants provided self-monitoring and confidence judgments. Afterward, participants reported on self-efficacy, perceived competence, feedback use, and perceived usefulness of the feedback. Bayesian analyses showed no benefits of gaze displays for post-test performance, monitoring accuracy (absolute difference between participants' estimated and their actual test performance), completeness of viewing behavior, self-efficacy, and perceived competence. Participants receiving search-displays reported greater feedback utilization than participants receiving decision-displays, and also found the feedback more useful when the gaze data displayed was precise and accurate. As the completeness of search was not related to posttest performance, search displays might not have been sufficiently informative to improve self-monitoring. Information from decision displays was rarely used to inform self-monitoring. Further research should address if and when gaze displays can support learning.

Teaching medical students to apply deliberate reflection.

PURPOSE: Deliberate reflection on initial diagnosis has been found to repair diagnostic errors. We investigated the effectiveness of teaching students to use deliberate reflection on future cases and whether their usage would depend on their perception of case difficulty. METHOD: One-hundred-nineteen medical students solved cases either with deliberate-reflection or without instructions to reflect. One week later, all participants solved six cases, each with two equally likely diagnoses, but some symptoms in the case were associated with only one of the diagnoses (discriminating features). Participants provided one diagnosis and subsequently wrote down everything they remembered from it. After the first three cases, they were told that the next three would be difficult cases. Reflection was measured by the proportion of discriminating features recalled (overall; related to their provided diagnosis; related to alternative diagnosis). RESULTS: The deliberate-reflection condition recalled more features for the alternative diagnosis than the control condition (p = .013) regardless of described difficulty. They also recalled more features related to their provided diagnosis on the first three cases (p = .004), but on the last three cases (described as difficult), there was no difference. CONCLUSION: Learning deliberate reflection helped students engage in more reflective reasoning when solving future cases.

Disentangling the effects of message content and message sharer on students' views of political misinformation.

A consistent finding in fake news research is that people are more likely to believe content in favor of their political views. Unclear, however, is whether this political bias is moderated by contextual effects, such as politicians sharing content on their social media accounts. The present study investigated how both message content and sharer affect views of political misinformation. Participants (N = 164) evaluated eight news messages. Message content (pro-left/pro-right misinformation) and sharer (left-wing/right-wing/unknown politician) were manipulated within subjects. As expected, participants agreed more with concordant misinformation (aligned with their political orientation) and perceived it as more accurate than discordant misinformation. There was an additional, smaller effect of politician: Participants agreed more with discordant misinformation when shared by a politician representing their political viewpoint than when shared by others. Furthermore, left-oriented participants' agreement with concordant misinformation was hardly affected by message sharer, whereas right-oriented participants' agreement with concordant misinformation was-unexpectedly-positively affected by the left-wing politician. Irrespective of their political orientation, participants perceived misinformation from the left-wing politician as more accurate than misinformation from other politicians. Our findings suggest that both message content and sharer affect views of misinformation and interact in doing so, which is important for designing interventions on recognizing misinformation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Did You Get That? Predicting Learners' Comprehension of a Video Lecture from Visualizations of Their Gaze Data.

In online lectures, unlike in face-to-face lectures, teachers lack access to (nonverbal) cues to check if their students are still "with them" and comprehend the lecture. The increasing availability of low-cost eye-trackers provides a promising solution. These devices measure unobtrusively where students look and can visualize these data to teachers. These visualizations might inform teachers about students' level of "with-me-ness" (i.e., do students look at the information that the teacher is currently talking about) and comprehension of the lecture, provided that (1) gaze measures of "with-me-ness" are related to comprehension, (2) people not trained in eye-tracking can predict students' comprehension from gaze visualizations, (3) we understand how different visualization techniques impact this prediction. We addressed these issues in two studies. In Study 1, 36 students watched a video lecture while being eye-tracked. The extent to which students looked at relevant information and the extent to which they looked at the same location as the teacher both correlated with students' comprehension (score on an open question) of the lecture. In Study 2, 50 participants watched visualizations of students' gaze (from Study 1), using six visualization techniques (dynamic and static versions of scanpaths, heatmaps, and focus maps) and were asked to predict students' posttest performance and to rate their ease of prediction. We found that people can use gaze visualizations to predict learners' comprehension above chance level, with minor differences between visualization techniques. Further research should investigate if teachers can act on the information provided by gaze visualizations and thereby improve students' learning.

Learning deliberate reflection in medical diagnosis: does learning-by-teaching help?

Deliberate reflection has been found to foster diagnostic accuracy on complex cases or under circumstances that tend to induce cognitive bias. However, it is unclear whether the procedure can also be learned and thereby autonomously applied when diagnosing future cases without instructions to reflect. We investigated whether general practice residents would learn the deliberate reflection procedure through 'learning-by-teaching' and apply it to diagnose new cases. The study was a two-phase experiment. In the learning phase, 56 general-practice residents were randomly assigned to one of two conditions. They either (1) studied examples of deliberate reflection and then explained the procedure to a fictitious peer on video; or (2) solved cases without reflection (control). In the test phase, one to three weeks later, all participants diagnosed new cases while thinking aloud. The analysis of the test phase showed no significant differences between the conditions on any of the outcome measures (diagnostic accuracy, p = .263; time to diagnose, p = .598; mental effort ratings, p = .544; confidence ratings, p = .710; proportion of contradiction units (i.e. measure of deliberate reflection), p = .544). In contrast to findings on learning-by-teaching from other domains, teaching deliberate reflection to a fictitious peer, did not increase reflective reasoning when diagnosing future cases. Potential explanations that future research might address are that either residents in the experimental condition did not apply the learned deliberate reflection procedure in the test phase, or residents in the control condition also engaged in reflection.

When closeness is effortful: Teachers' physiological activation undermines positive effects of their closeness on student emotions.

BACKGROUND: Student perceptions of teachers' interpersonal closeness positively affect their emotions. If closeness is, however, effortful for the teacher (i.e., emotional labour, signalling less genuine closeness), this may undermine these positive effects. We tested this assumption by using student reports and external observations of teacher closeness and ambulant measures of teacher heart rate, to gauge teachers' physiological effort connected to being close during class. AIMS: We investigated the association between teachers' physiological effort connected to closeness and students' lesson-focused emotions. SAMPLE: 75 teachers and their students (N = 1645) participated during one real-life lesson. METHODS: Teacher interpersonal closeness was continuously coded based on a video recording and teachers' heart rate was measured continuously as an indicator of physiological effort. Students reported their emotions and perception of teacher closeness at the end of the lesson. RESULTS: Multilevel models with student emotions as DVs and students' perceptions of teacher warmth (L1 predictor) and teachers' physiological effort when being close (i.e., an intra-individual cross-correlation, L2 predictor) were tested. As expected, students reported more positive and less negative emotions when they perceived more teacher closeness. The physiological effort connected to being close was not directly associated with student emotions; however, such effort moderated the effect of perceived closeness, especially with regard to negative student emotions (i.e., cross-level interactions). The more effortful teacher closeness was, the less closeness protected students from negative emotions. CONCLUSIONS: In line with extant research on faking enjoyment and emotional labour, students seemed to be affected when teacher closeness was physiologically effortful, and overall positive effects of teacher closeness were undermined.

Vocabulary Learning During Reading: Benefits of Contextual Inferences Versus Retrieval Opportunities.

Retrieval practice of isolated words (e.g., with flashcards) enhances foreign vocabulary learning. However, vocabulary is often encountered in context. We investigated whether retrieval opportunities also enhance contextualized word learning. In two within-subjects experiments, participants encoded 24 foreign words and then read a story to further strengthen word knowledge. The story contained eight target words in a retrieval context, which required participants to recall word meaning from memory to understand the text (e.g., "She borrowed a knyga"), and eight target words in an inference context from which meaning could be inferred (e.g., "She read a knyga" [book]). After 1 to 2 days, a posttest measured word retention. Reading the words in either the retrieval or inference context increased retention, compared to control words not included in the story. Moreover, in Experiment 1, retention was significantly higher in the inference than in the retrieval condition. In Experiment 2, in which encoding before reading was more extensive and feedback was available, no differences in retention were found between the inference and retrieval + feedback condition (both increased retention, compared to control words). Overall, the findings suggest that the benefits of retrieval may be less pronounced during incidental, contextualized learning than during intentional exercises and that retrieval success must be considered when adding retrieval opportunities to contextualized learning. Under low retrieval success, the better comprehension afforded by an informative context may outweigh the benefits of retrieval opportunities (Exp.1). Yet even when retrieval success was enhanced and feedback was added (Exp. 2), retrieval opportunities were only as beneficial as exposure to rich contextual information.

Improving medical residents' self-assessment of their diagnostic accuracy: does feedback help?

When physicians do not estimate their diagnostic accuracy correctly, i.e. show inaccurate diagnostic calibration, diagnostic errors or overtesting can occur. A previous study showed that physicians' diagnostic calibration for easy cases improved, after they received feedback on their previous diagnoses. We investigated whether diagnostic calibration would also improve from this feedback when cases were more difficult. Sixty-nine general-practice residents were randomly assigned to one of two conditions. In the feedback condition, they diagnosed a case, rated their confidence in their diagnosis, their invested mental effort, and case complexity, and then were shown the correct diagnosis (feedback). This was repeated for 12 cases. Participants in the control condition did the same without receiving feedback. We analysed calibration in terms of (1) absolute accuracy (absolute difference between diagnostic accuracy and confidence), and (2) bias (confidence minus diagnostic calibration). There was no difference between the conditions in the measurements of calibration (absolute accuracy, p = .204; bias, p = .176). Post-hoc analyses showed that on correctly diagnosed cases (on which participants are either accurate or underconfident), calibration in the feedback condition was less accurate than in the control condition, p = .013. This study shows that feedback on diagnostic performance did not improve physicians' calibration for more difficult cases. One explanation could be that participants were confronted with their mistakes and thereafter lowered their confidence ratings even if cases were diagnosed correctly. This shows how difficult it is to improve diagnostic calibration, which is important to prevent diagnostic errors or maltreatment.

Recognizing biased reasoning: Conflict detection during decision-making and decision-evaluation.

Although it is well established that our thinking can often be biased, the precise cognitive mechanisms underlying these biases are still debated. The present study builds on recent research showing that biased reasoners often seem aware that their reasoning is incorrect; they show signs of conflict detection. One important shortcoming in this research is that the conflict detection effect has only been studied with classic problem-solving tasks, requiring people to make a decision themselves. However, in many reasoning situations people are confronted with decisions already made by others. Therefore, the present study (N = 159) investigated whether conflict detection occurs not only during reasoning on problem-solving tasks (i.e., decision-making), but also on vignette tasks, requiring participants to evaluate decisions made by others. We analyzed participants' conflict detection sensitivity on confidence and response time measures. Results showed that conflict detection occurred during both decision-making and decision-evaluation, as indicated by a decreased confidence. The response time index appeared to be a less reliable measure of conflict detection on the novel tasks. These findings are very relevant for studying reasoning in contexts in which recognizing reasoning errors is important; for instance, in education where teachers have to give feedback on students' reasoning.

Development of Attention and Accuracy in Learning a Categorization Task.

Being able to categorize objects as similar or different is an essential skill. An important aspect of learning to categorize is learning to attend to relevant features (i.e., features that determine category membership) and ignore irrelevant features of the to-be-categorized objects. Feature variability across objects of different categories is informative, because it allows inferring the rules underlying category membership. In this study, participants learned to categorize fictitious creatures (i.e., aliens). We measured attention to the aliens during learning using eye-tracking and calculated the attentional focus as the ratio of attention to relevant versus irrelevant features. As expected, participants' categorization accuracy improved with practice; however, in contrast to our expectations, their attentional focus did not improve with practice. When computing the attentional focus, attention to the aliens' eyes was disregarded, because while eyes attract a lot of attention, they did not vary across aliens (non-informative feature). Yet, an explorative analysis of attention to eyes suggested that participants' attentional focus did become somewhat more efficient in that over time they learned to ignore the eyes. Results are discussed in the context of the need for instructional methods to improve attentional focus in learning to categorize.

How Experts Adapt Their Gaze Behavior When Modeling a Task to Novices.

Domain experts regularly teach novice students how to perform a task. This often requires them to adjust their behavior to the less knowledgeable audience and, hence, to behave in a more didactic manner. Eye movement modeling examples (EMMEs) are a contemporary educational tool for displaying experts' (natural or didactic) problem-solving behavior as well as their eye movements to learners. While research on expert-novice communication mainly focused on experts' changes in explicit, verbal communication behavior, it is as yet unclear whether and how exactly experts adjust their nonverbal behavior. This study first investigated whether and how experts change their eye movements and mouse clicks (that are displayed in EMMEs) when they perform a task naturally versus teach a task didactically. Programming experts and novices initially debugged short computer codes in a natural manner. We first characterized experts' natural problem-solving behavior by contrasting it with that of novices. Then, we explored the changes in experts' behavior when being subsequently instructed to model their task solution didactically. Experts became more similar to novices on measures associated with experts' automatized processes (i.e., shorter fixation durations, fewer transitions between code and output per click on the run button when behaving didactically). This adaptation might make it easier for novices to follow or imitate the expert behavior. In contrast, experts became less similar to novices for measures associated with more strategic behavior (i.e., code reading linearity, clicks on run button) when behaving didactically.

Teachers' Emotional Exhaustion: Associations With Their Typical Use of and Implicit Attitudes Toward Emotion Regulation Strategies.

Teaching is an emotionally challenging profession, sometimes resulting in high levels of teacher stress, burnout, and attrition. It has often been claimed that certain emotion regulation strategies can lower teachers' feelings of burnout. The use of cognitive reappraisal (i.e., cognitively changing the emotional impact of a situation) has generally been associated with positive outcomes, whereas using expressive suppression (i.e., inhibiting emotional responses) usually has negative consequences. The present study investigated the association between teachers' typical use of these two emotion regulation strategies (i.e., cognitive reappraisal and expressive suppression) and their feelings of emotional exhaustion. Because there is evidence that regulating emotions could involve higher costs when regulation goes against individual preferences, we also explored the potentially moderating effect of teachers' implicit attitudes toward emotion regulation versus emotion expression on the association between typical use of emotion regulation strategies and teachers' emotional exhaustion with an Implicit Association Test (IAT). We included the interpersonal teacher-student relationship (in terms of teacher agency and communion), teacher experience, and teacher gender as covariates in our analyses. Participants were 94 teachers in secondary education, vocational education, and teacher training for secondary education. Replicating findings from prior studies, hierarchical regression analyses showed that typical use of cognitive reappraisal, but not expressive suppression, was significantly related to lower levels of teachers' emotional exhaustion. Teachers' implicit attitudes toward emotion regulation versus emotion expression moderated the relationship between the use of emotion regulation strategies and emotional exhaustion, but only in a subsample with more experienced teachers. Teachers who showed more interpersonal agency in class and had more years of teaching experience reported lower levels of emotional exhaustion. Interpersonal communion and gender were not directly associated with feelings of exhaustion. Implications for teacher training and suggestions for future research are discussed.

Co-thought gesturing supports more complex problem solving in subjects with lower visual working-memory capacity.

During silent problem solving, hand gestures arise that have no communicative intent. The role of such co-thought gestures in cognition has been understudied in cognitive research as compared to co-speech gestures. We investigated whether gesticulation during silent problem solving supported subsequent performance in a Tower of Hanoi problem-solving task, in relation to visual working-memory capacity and task complexity. Seventy-six participants were assigned to either an instructed gesture condition or a condition that allowed them to gesture, but without explicit instructions to do so. This resulted in three gesture groups: (1) non-gesturing; (2) spontaneous gesturing; (3) instructed gesturing. In line with the embedded/extended cognition perspective on gesture, gesturing benefited complex problem-solving performance for participants with a lower visual working-memory capacity, but not for participants with a lower spatial working-memory capacity.

Fostering novice students' diagnostic ability: the value of guiding deliberate reflection.

BACKGROUND: Deliberate reflection when practising the diagnosis of clinical cases has been shown to develop medical students' diagnostic competence. Adding guidance by cueing reflection or providing modelling of reflection increased the benefits of reflection for advanced (Years 5-6) students. The present study investigated whether we could replicate and extend these findings by comparing the effects of free, cued and modelled reflection on novice students' diagnostic competence. METHODS: A total of 80 third-year medical students participated in a two-phase experiment. In the learning phase, students diagnosed nine clinical cases under one of three conditions: free reflection; cued reflection, and modelled reflection. Two weeks later, all students diagnosed four new examples of the diseases studied in the learning phase and four cases of non-studied related diseases ('adjacent diseases'). The main outcome measurements were diagnostic accuracy scores (range 0-1) on studied and adjacent diseases. RESULTS: For studied diseases, there was a significant effect of experimental condition on diagnostic accuracy (p < 0.02), with the cued-reflection group (mean = 0.58, standard deviation [SD] = 0.23) performing significantly better than the free-reflection group (mean = 0.41, SD = 0.20; p < 0.02). The cued-reflection and modelled-reflection groups (mean = 0.54, SD = 0.22) did not differ in diagnostic accuracy (p > 0.05), nor did the modelled-reflection group perform better than the free-reflection group (p > 0.05). For adjacent diseases, the three groups scored extremely low, without significant differences in performance (p > 0.05). Cued reflection and free reflection were rated as requiring similar effort (p > 0.05) and both were more demanding than studying examples of reflection (both p < 0.001) in the learning phase. CONCLUSIONS: Simply cueing novice students' reflection to focus it on relevant diseases was sufficient to increase diagnostic performance relative to reflection without any guidance. Cued reflection and studying examples of reflection appear to be equally useful approaches for teaching clinical diagnosis to novice students. Students found studying examples of reflection required less effort but cued reflection will certainly demand much less investment from teachers.

Cognitive load theory for training health professionals in the workplace: A BEME review of studies among diverse professions: BEME Guide No. 53.

AIM: Cognitive load theory (CLT) is of increasing interest to health professions education researchers. CLT has intuitive applicability to workplace settings, yet how CLT should inform teaching, learning, and research in health professions workplaces is unclear. METHOD: To map the existing literature, we performed a scoping review of studies involving cognitive load, mental effort and/or mental workload in professional workplace settings within and outside of the health professions. We included actual and simulated workplaces and workplace tasks. RESULT: Searching eight databases, we identified 4571 citations, of which 116 met inclusion criteria. Studies were most often quantitative. Methods to measure cognitive load included psychometric, physiologic, and secondary task approaches. Few covariates of cognitive load or performance were studied. Overall cognitive load and intrinsic load were consistently negatively associated with the level of experience and performance. Studies consistently found distractions and other aspects of workplace environments as contributing to extraneous load. Studies outside the health professions documented similar findings to those within the health professions, supporting relevance of CLT to workplace learning. CONCLUSION: The authors discuss implications for workplace teaching, curricular design, learning environment, and metacognition. To advance workplace learning, the authors suggest future CLT research should address higher-level questions and integrate other learning frameworks.

Training self-assessment and task-selection skills to foster self-regulated learning: Do trained skills transfer across domains?

Students' ability to accurately self-assess their performance and select a suitable subsequent learning task in response is imperative for effective self-regulated learning. Video modeling examples have proven effective for training self-assessment and task-selection skills, and-importantly-such training fostered self-regulated learning outcomes. It is unclear, however, whether trained skills would transfer across domains. We investigated whether skills acquired from training with either a specific, algorithmic task-selection rule or a more general heuristic task-selection rule in biology would transfer to self-regulated learning in math. A manipulation check performed after the training confirmed that both algorithmic and heuristic training improved task-selection skills on the biology problems compared with the control condition. However, we found no evidence that students subsequently applied the acquired skills during self-regulated learning in math. Future research should investigate how to support transfer of task-selection skills across domains.

What Am I Looking at? Interpreting Dynamic and Static Gaze Displays.

Displays of eye movements may convey information about cognitive processes but require interpretation. We investigated whether participants were able to interpret displays of their own or others' eye movements. In Experiments 1 and 2, participants observed an image under three different viewing instructions. Then they were shown static or dynamic gaze displays and had to judge whether it was their own or someone else's eye movements and what instruction was reflected. Participants were capable of recognizing the instruction reflected in their own and someone else's gaze display. Instruction recognition was better for dynamic displays, and only this condition yielded above chance performance in recognizing the display as one's own or another person's (Experiments 1 and 2). Experiment 3 revealed that order information in the gaze displays facilitated instruction recognition when transitions between fixated regions distinguish one viewing instruction from another. Implications of these findings are discussed.

Fostering clinical reasoning in physiotherapy: comparing the effects of concept map study and concept map completion after example study in novice and advanced learners.

BACKGROUND: Health profession learners can foster clinical reasoning by studying worked examples presenting fully worked out solutions to a clinical problem. It is possible to improve the learning effect of these worked examples by combining them with other learning activities based on concept maps. This study investigated which combinaison of activities, worked examples study with concept map completion or worked examples study with concept map study, fosters more meaningful learning of intervention knowledge in physiotherapy students. Moreover, this study compared the learning effects of these learning activity combinations between novice and advanced learners. METHODS: Sixty-one second-year physiotherapy students participated in the study which included a pre-test phase, a 130-min guided-learning phase and a four-week self-study phase. During the guided and self-study learning sessions, participants had to study three written worked examples presenting the clinical reasoning for selecting electrotherapeutic currents to treat patients with motor deficits. After each example, participants engaged in either concept map completion or concept map study depending on which learning condition they were randomly allocated to. Students participated in an immediate post-test at the end of the guided-learning phase and a delayed post-test at the end of the self-study phase. Post-tests assessed the understanding of principles governing the domain of knowledge to be learned (conceptual knowledge) and the ability to solve new problems that have similar (i.e., near transfer) or different (i.e., far transfer) solution rationales as problems previously studied in the examples. RESULTS: Learners engaged in concept map completion outperformed those engaged in concept map study on near transfer (p = .010) and far transfer (p < .001) performance. There was a significant interaction effect of learners' prior ability and learning condition on conceptual knowledge but not on near and far transfer performance. CONCLUSIONS: Worked examples study combined with concept map completion led to greater transfer performance than worked examples study combined with concept map study for both novice and advanced learners. Concept map completion might give learners better insight into what they have and have not yet learned, allowing them to focus on those aspects during subsequent example study.

Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment.

BACKGROUND: Literature suggests that patients who display disruptive behaviours in the consulting room fuel negative emotions in doctors. These emotions, in turn, are said to cause diagnostic errors. Evidence substantiating this claim is however lacking. The purpose of the present experiment was to study the effect of such difficult patients' behaviours on doctors' diagnostic performance. METHODS: We created six vignettes in which patients were depicted as difficult (displaying distressing behaviours) or neutral. Three clinical cases were deemed to be diagnostically simple and three deemed diagnostically complex. Sixty-three family practice residents were asked to evaluate the vignettes and make the patient's diagnosis quickly and then through deliberate reflection. In addition, amount of time needed to arrive at a diagnosis was measured. Finally, the participants rated the patient's likability. RESULTS: Mean diagnostic accuracy scores (range 0-1) were significantly lower for difficult than for neutral patients (0.54 vs 0.64; p=0.017). Overall diagnostic accuracy was higher for simple than for complex cases. Deliberate reflection upon the case improved initial diagnostic, regardless of case complexity and of patient behaviours (0.60 vs 0.68, p=0.002). Amount of time needed to diagnose the case was similar regardless of the patient's behaviour. Finally, average likability ratings were lower for difficult than for neutral-patient cases. CONCLUSIONS: Disruptive behaviours displayed by patients seem to induce doctors to make diagnostic errors. Interestingly, the confrontation with difficult patients does however not cause the doctor to spend less time on such case. Time can therefore not be considered an intermediary between the way the patient is perceived, his or her likability and diagnostic performance.