The Effects of Reflective Pauses on Performance in Simulation Training.

INTRODUCTION: The reflective pause, taking a pause during performance to reflect, is an important practice in simulation-based learning. However, for novice learners, it is a highly complex self-regulatory skill that cannot stand alone without guidance. Using educational theories, we propose how to design cognitive and metacognitive aids to guide learners with the reflective pause and investigate its effects on performance in a simulation training environment. METHODS: These effects are examined in four aspects of performance: cognitive load, primary performance, secondary performance, and encapsulation. Medical students ( N = 72) performed tasks in simulation training for emergency medicine, under 2 conditions: reflection condition ( n = 36) where reflection was prompted and guided, and control condition ( n = 36) without such reflection. RESULTS: The effects of reflective pauses emerged for 2 aspects of performance: cognitive load decreased and secondary performance improved. However, primary performance and encapsulation did not show significant difference. CONCLUSIONS: The results demonstrate that reflective pauses with cognitive and metacognitive aids implemented can enhance some aspects of performance. We suggest that to secure these effects, feedback during reflection and an adaptation period should be provided.

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.

Behind the scenes: Impact of virtual backgrounds in educational videos on visual processing and learning outcomes.

The increasing use of instructional videos in educational settings has emphasized the need for a deeper understanding of their design requirements. This study investigates the impact of virtual backgrounds in educational videos on students' visual information processing and learning outcomes. Participants aged 14-17 (N=47) were randomly assigned to one of three conditions: a video with a neutral, authentic, or off-topic background. Their prior knowledge and working memory capacity (WMC) were measured before watching the video, and eye tracking data was collected during the viewing. Learning outcomes and student experiences were assessed after viewing. The eye tracking data revealed that a neutral background was the least distracting, allowing students to pay better attention to relevant parts of the video. Students found the off-topic background most distracting, but the negative effect on learning outcomes was not statistically significant. In contrast to expectations, no positive effect was observed for the authentic background. Furthermore, WMC had a significant impact on visual information processing and learning outcomes. These findings suggest that educators should consider using neutral backgrounds in educational videos, particularly for learners with lower WMC. Consequently, this research underscores the significance of careful design considerations in the creation of instructional videos.

The medical pause: Importance, processes and training.

Research has shown that taking 'timeouts' in medical practice improves performance and patient safety. However, the benefits of taking timeouts, or pausing, are not sufficiently acknowledged in workplaces and training programmes. To promote this acknowledgement, we suggest a systematic conceptualisation of the medical pause, focusing on its importance, processes and implementation in training programmes. By employing insights from educational and cognitive psychology, we first identified pausing as an important skill to interrupt negative momentum and bolster learning. Subsequently, we categorised constituent cognitive processes for pausing skills into two phases: the decision-making phase (determining when and how to take pauses) and the executive phase (applying relaxation or reflection during pauses). We present a model that describes how relaxation and reflection during pauses can optimise cognitive load in performance. Several strategies to implement pause training in medical curricula are proposed: intertwining pause training with training of primary skills, providing second-order scaffolding through shared control and employing auxiliary tools such as computer-based simulations with a pause function.

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.

Can You Ink While You Blink? Assessing Mental Effort in a Sensor-Based Calligraphy Trainer.

Sensors can monitor physical attributes and record multimodal data in order to provide feedback. The application calligraphy trainer, exploits these affordances in the context of handwriting learning. It records the expert's handwriting performance to compute an expert model. The application then uses the expert model to provide guidance and feedback to the learners. However, new learners can be overwhelmed by the feedback as handwriting learning is a tedious task. This paper presents the pilot study done with the calligraphy trainer to evaluate the mental effort induced by various types of feedback provided by the application. Ten participants, five in the control group and five in the treatment group, who were Ph.D. students in the technology-enhanced learning domain, took part in the study. The participants used the application to learn three characters from the Devanagari script. The results show higher mental effort in the treatment group when all types of feedback are provided simultaneously. The mental efforts for individual feedback were similar to the control group. In conclusion, the feedback provided by the calligraphy trainer does not impose high mental effort and, therefore, the design considerations of the calligraphy trainer can be insightful for multimodal feedback designers.

To guide or to follow? Teaching visual problem solving at the workplace.

Visual problem solving is essential to highly visual and knowledge-intensive professional domains such as clinical pathology, which trainees learn by participating in relevant tasks at the workplace (apprenticeship). Proper guidance of the visual problem solving of apprentices by the master is necessary. Interaction and adaptation to the expertise level of the learner are identified as key ingredients of this guidance. This study focuses on the effect of increased participation of the learner in the task on the interaction and adaptation of the guidance by masters. Thirteen unique dyads consisting of a clinical pathologist (master) and a resident (apprentice) discussed and diagnosed six microscope images. Their dialogues were analysed on their content. The dyads were divided in two groups according to the experience of the apprentice. For each dyad, master and apprentice both operated the microscope for half of the cases. Interaction was operationalised as the equal contribution of both master and apprentice to the dialogue. Adaptation was operationalised as the extent to which the content of the dialogues was adapted to the apprentice's level. The main hypothesis stated that the interaction and adaptation increase when apprentices operate the microscope. Most results confirmed this hypothesis: apprentices contributed more content when participating more and the content of these dialogues better reflected expertise differences of apprentices. Based on these results, it is argued that, for learning visual problem solving in a visual and knowledge-intensive domain, it is not only important to externalise master performance, but also that of the apprentice.

How task demands influence scanpath similarity in a sequential number-search task.

More and more researchers are considering the omnibus eye movement sequence-the scanpath-in their studies of visual and cognitive processing (e.g. Hayes, Petrov, & Sederberg, 2011; Madsen, Larson, Loschky, & Rebello, 2012; Ni et al., 2011; von der Malsburg & Vasishth, 2011). However, it remains unclear how recent methods for comparing scanpaths perform in experiments producing variable scanpaths, and whether these methods supplement more traditional analyses of individual oculomotor statistics. We address this problem for MultiMatch (Jarodzka et al., 2010; Dewhurst et al., 2012), evaluating its performance with a visual search-like task in which participants must fixate a series of target numbers in a prescribed order. This task should produce predictable sequences of fixations and thus provide a testing ground for scanpath measures. Task difficulty was manipulated by making the targets more or less visible through changes in font and the presence of distractors or visual noise. These changes in task demands led to slower search and more fixations. Importantly, they also resulted in a reduction in the between-subjects scanpath similarity, demonstrating that participants' gaze patterns became more heterogenous in terms of saccade length and angle, and fixation position. This implies a divergent strategy or random component to eye-movement behaviour which increases as the task becomes more difficult. Interestingly, the duration of fixations along aligned vectors showed the opposite pattern, becoming more similar between observers in 2 of the 3 difficulty manipulations. This provides important information for vision scientists who may wish to use scanpath metrics to quantify variations in gaze across a spectrum of perceptual and cognitive tasks.

Influence of Coactors on Saccadic and Manual Responses.

Two experiments were conducted to investigate the effects of coaction on saccadic and manual responses. Participants performed the experiments either in a solitary condition or in a group of coactors who performed the same tasks at the same time. In Experiment 1, participants completed a pro- and antisaccade task where they were required to make saccades towards (prosaccades) or away (antisaccades) from a peripheral visual stimulus. In Experiment 2, participants performed a visual discrimination task that required both making a saccade towards a peripheral stimulus and making a manual response in reaction to the stimulus's orientation. The results showed that performance of stimulus-driven responses was independent of the social context, while volitionally controlled responses were delayed by the presence of coactors. These findings are in line with studies assessing the effect of attentional load on saccadic control during dual-task paradigms. In particular, antisaccades - but not prosaccades - were influenced by the type of social context. Additionally, the number of coactors present in the group had a moderating effect on both saccadic and manual responses. The results support an attentional view of social influences.

The challenges of studying visual expertise in medical image diagnosis.

CONTEXT: Visual expertise is the superior visual skill shown when executing domain-specific visual tasks. Understanding visual expertise is important in order to understand how the interpretation of medical images may be best learned and taught. In the context of this article, we focus on the visual skill of medical image diagnosis and, more specifically, on the methodological set-ups routinely used in visual expertise research. METHODS: We offer a critique of commonly used methods and propose three challenges for future research to open up new avenues for studying characteristics of visual expertise in medical image diagnosis. The first challenge addresses theory development. Novel prospects in modelling visual expertise can emerge when we reflect on cognitive and socio-cultural epistemologies in visual expertise research, when we engage in statistical validations of existing theoretical assumptions and when we include social and socio-cultural processes in expertise development. The second challenge addresses the recording and analysis of longitudinal data. If we assume that the development of expertise is a long-term phenomenon, then it follows that future research can engage in advanced statistical modelling of longitudinal expertise data that extends the routine use of cross-sectional material through, for example, animations and dynamic visualisations of developmental data. The third challenge addresses the combination of methods. Alternatives to current practices can integrate qualitative and quantitative approaches in mixed-method designs, embrace relevant yet underused data sources and understand the need for multidisciplinary research teams. CONCLUSION: Embracing alternative epistemological and methodological approaches for studying visual expertise can lead to a more balanced and robust future for understanding superior visual skills in medical image diagnosis as well as other medical fields.

Before your very eyes: the value and limitations of eye tracking in medical education.

CONTEXT: Medicine is a highly visual discipline. Physicians from many specialties constantly use visual information in diagnosis and treatment. However, they are often unable to explain how they use this information. Consequently, it is unclear how to train medical students in this visual processing. Eye tracking is a research technique that may offer answers to these open questions, as it enables researchers to investigate such visual processes directly by measuring eye movements. This may help researchers understand the processes that support or hinder a particular learning outcome. AIM: In this article, we clarify the value and limitations of eye tracking for medical education researchers. For example, eye tracking can clarify how experience with medical images mediates diagnostic performance and how students engage with learning materials. Furthermore, eye tracking can also be used directly for training purposes by displaying eye movements of experts in medical images. CONCLUSIONS: Eye movements reflect cognitive processes, but cognitive processes cannot be directly inferred from eye-tracking data. In order to interpret eye-tracking data properly, theoretical models must always be the basis for designing experiments as well as for analysing and interpreting eye-tracking data. The interpretation of eye-tracking data is further supported by sound experimental design and methodological triangulation.

Systematic viewing in radiology: seeing more, missing less?

To prevent radiologists from overlooking lesions, radiology textbooks recommend "systematic viewing," a technique whereby anatomical areas are inspected in a fixed order. This would ensure complete inspection (full coverage) of the image and, in turn, improve diagnostic performance. To test this assumption, two experiments were performed. Both experiments investigated the relationship between systematic viewing, coverage, and diagnostic performance. Additionally, the first investigated whether systematic viewing increases with expertise; the second investigated whether novices benefit from full-coverage or systematic viewing training. In Experiment 1, 11 students, ten residents, and nine radiologists inspected five chest radiographs. Experiment 2 had 75 students undergo a training in either systematic, full-coverage (without being systematic) or non-systematic viewing. Eye movements and diagnostic performance were measured throughout both experiments. In Experiment 1, no significant correlations were found between systematic viewing and coverage, r = -.10, p = .62, and coverage and performance, r = -.06, p = .74. Experts were significantly more systematic than students F2,25 = 4.35, p = .02. In Experiment 2, significant correlations were found between systematic viewing and coverage, r = -.35, p < .01, but not between coverage and performance, r = .13, p = .31. Participants in the full-coverage training performed worse compared with both other groups, which did not differ between them, F2,71 = 3.95, p = .02. In conclusion, the data question the assumption that systematic viewing leads to increased coverage, and, consequently, to improved performance. Experts inspected cases more systematically, but students did not benefit from systematic viewing training.

Expertise in clinical pathology: combining the visual and cognitive perspective.

Expertise studies in the medical domain often focus on either visual or cognitive aspects of expertise. As a result, characteristics of expert behaviour are often described as either cognitive or visual abilities. This study focuses on both aspects of expertise and analyses them along three overarching constructs: (1) encapsulations, (2) efficiency, and (3) hypothesis testing. This study was carried out among clinical pathologists performing an authentic task: diagnosing microscopic slides. Participants were 13 clinical pathologists (experts), 12 residents in pathology (intermediates), and 13 medical students (novices). They all diagnosed seven cases in a virtual microscope and gave post hoc explanations for their diagnoses. The collected data included eye movements, microscope navigation, and verbal protocols. Results showed that experts used lower magnifications and verbalized their findings as diagnoses. Also, their diagnostic paths were more efficient, including fewer microscope movements and shorter reasoning chains. Experts entered relevant areas later in their diagnostic process, and visited fewer of them. Intermediates used relatively high magnifications and based their diagnoses on specific abnormalities. Also, they took longer to reach their diagnosis and checked more relevant areas. Novices searched in detail, described findings by their appearances, and uttered long reasoning chains. These results indicate that overarching constructs can justly be identified: encapsulations and efficiency are apparent in both visual and cognitive aspects of expertise.

A motivational determinant of facial emotion recognition: regulatory focus affects recognition of emotions in faces.

Two studies examined an unexplored motivational determinant of facial emotion recognition: observer regulatory focus. It was predicted that a promotion focus would enhance facial emotion recognition relative to a prevention focus because the attentional strategies associated with promotion focus enhance performance on well-learned or innate tasks - such as facial emotion recognition. In Study 1, a promotion or a prevention focus was experimentally induced and better facial emotion recognition was observed in a promotion focus compared to a prevention focus. In Study 2, individual differences in chronic regulatory focus were assessed and attention allocation was measured using eye tracking during the facial emotion recognition task. Results indicated that the positive relation between a promotion focus and facial emotion recognition is mediated by shorter fixation duration on the face which reflects a pattern of attention allocation matched to the eager strategy in a promotion focus (i.e., striving to make hits). A prevention focus did not have an impact neither on perceptual processing nor on facial emotion recognition. Taken together, these findings demonstrate important mechanisms and consequences of observer motivational orientation for facial emotion recognition.

Expertise under the microscope: processing histopathological slides.

OBJECTIVES: Although the obvious goal of training in clinical pathology is to bring forth capable diagnosticians, developmental stages and their characteristics are unknown. This study therefore aims to find expertise-related differences in the processing of histopathological slides using a combination of eye tracking data and verbal data. METHODS: Participants in this study were 13 clinical pathologists (experts), 12 pathology residents (intermediates) and 13 medical students (novices). They diagnosed 10 microscopic images of colon tissue for 2 seconds. Eye movements, the given diagnoses, and the vocabulary used in post hoc verbal explanations were registered. Eye movements were analysed according to changes over trial time and the processing of diagnostically relevant areas. The content analysis of verbal data was based on a categorisation system developed from the literature. RESULTS: Although experts and intermediates showed equal levels of diagnostic accuracy, their visual and cognitive processing differed. Whereas experts relied on their first findings and checked the image further for other abnormalities, intermediates tended to double-check their first findings. In their explanations, experts focused on the typicality of the tissue, whereas intermediates mainly mentioned many specific pathologies. Novices looked less often at the relevant areas and were incomplete, incorrect and inconclusive in their explanations. Their diagnostic accuracy was correspondingly poor. CONCLUSIONS: This study indicates that in the case of intermediates and experts, different visual and cognitive strategies can result in equal levels of diagnostic accuracy. Lessons for training underline the relevance of the distinction between normal and abnormal tissue for novices, especially when the mental rotation of 2-D images is required. Intermediates need to be trained to see deviations in abnormalities. Feedback and an educational design that is specific to these developmental stages might improve training.

It depends on how you look at it: scanpath comparison in multiple dimensions with MultiMatch, a vector-based approach.

Eye movement sequences-or scanpaths-vary depending on the stimulus characteristics and the task (Foulsham & Underwood Journal of Vision, 8(2), 6:1-17, 2008; Land, Mennie, & Rusted, Perception, 28, 1311-1328, 1999). Common methods for comparing scanpaths, however, are limited in their ability to capture both the spatial and temporal properties of which a scanpath consists. Here, we validated a new method for scanpath comparison based on geometric vectors, which compares scanpaths over multiple dimensions while retaining positional and sequential information (Jarodzka, Holmqvist, & Nyström, Symposium on Eye-Tracking Research and Applications (pp. 211-218), 2010). "MultiMatch" was tested in two experiments and pitted against ScanMatch (Cristino, Mathôt, Theeuwes, & Gilchrist, Behavior Research Methods, 42, 692-700, 2010), the most comprehensive adaptation of the popular Levenshtein method. In Experiment 1, we used synthetic data, demonstrating the greater sensitivity of MultiMatch to variations in spatial position. In Experiment 2, real eye movement recordings were taken from participants viewing sequences of dots, designed to elicit scanpath pairs with commonalities known to be problematic for algorithms (e.g., when one scanpath is shifted in locus or when fixations fall on either side of an AOI boundary). The results illustrate the advantages of a multidimensional approach, revealing how two scanpaths differ. For instance, if one scanpath is the reverse copy of another, the difference is in the direction but not the positions of fixations; or if a scanpath is scaled down, the difference is in the length of the saccadic vectors but not in the overall shape. As well as having enormous potential for any task in which consistency in eye movements is important (e.g., learning), MultiMatch is particularly relevant for "eye movements to nothing" in mental imagery and embodiment-of-cognition research, where satisfactory scanpath comparison algorithms are lacking.

Visual expertise in paediatric neurology.

BACKGROUND: Visual expertise relies on perceptive as well as cognitive processes. At present, knowledge of these processes when diagnosing clinical cases mainly stems from studies with still pictures. In contrast, patient video cases constitute a dynamic diagnostic challenge that may simulate seeing and diagnosing a patient in person. AIMS: This study investigates visual attention and the concomitant cognitive processes of clinicians diagnosing authentic paediatric video cases. METHODS: A total of 43 clinicians with varying levels of expertise took part in this cross-sectional study. They diagnosed four brief video recordings of children: two with seizures and two with disorders imitating seizures. We used eye tracking to investigate time looking at relevant areas in the video cases and a concurrent think-aloud procedure to explore the associated clinical reasoning processes. RESULTS: More experienced clinicians were more accurate in visual diagnosis and spent more of their time looking at relevant areas. At the same time, they explored data less, yet they built and evaluated more diagnostic hypotheses. CONCLUSIONS: Clinicians of varying expertise analyse patient video cases differently. Clinical teachers should take these differences into account when optimising educational formats with patient video cases.