Abstract
Models for diagnostic reasoning in radiology have been based on the observed behaviors of experienced radiologists but have not directly focused on the thought processes of novices as they improve their accuracy of image interpretation. By collecting think-aloud verbal reports, the current study was designed to investigate differences in specific thought processes between medical students (novices) as they learn and radiologists (experts), so that we can better design future instructional environments. Seven medical students and four physicians with radiology training were asked to interpret and diagnose pediatric elbow radiographs where fracture is suspected. After reporting their diagnosis of a case, they were given immediate feedback. Participants were asked to verbalize their thoughts while completing the diagnosis and while they reflected on the provided feedback. The protocol analysis of their verbalizations showed that participants used some combination of four processes to interpret the case: gestalt interpretation, purposeful search, rule application, and reasoning from a prior case. All types of processes except reasoning from a prior case were applied significantly more frequently by experts. Further, gestalt interpretation was used with higher frequency in abnormal cases while purposeful search was used more often for normal cases. Our assessment of processes could help guide the design of instructional environments with well-curated image banks and analytics to facilitate the novice’s journey to expertise in image interpretation.
Highlights
Diagnostic images play an important role in everyday medical practice
We presented a series of pediatric elbow radiographs to seven medical students and three senior radiology residents and one attending-level pediatric radiologist We collected think-aloud verbal reports of participants for each image during their diagnostic process
In this study of novices and experts who participated in a think-aloud study during learning, we identified four main cognitive processes mediating the interpretation of pediatric elbow radiographs
Summary
Diagnostic images play an important role in everyday medical practice. Radiographs, in particular, are one of the most commonly ordered image-based tests (Boutis et al 2019). Since interpretation errors are a potential threat to patient safety (Graber et al 2012) considerable resources are invested in training clinicians to high levels of performance. Development of expertise by bedside exposure to radiograph cases is often insufficient (Dixon 2015; Reeder et al 2004; Ryan et al 2004; Trainor and Krug 2000) and does not offer opportunities for individualized training to master particular weaknesses in diagnostic accuracy. Deliberate practice supports the development of refined mental representations which allow the expert clinician to engage in elaborate reasoning strategies and information processing (Ericsson and Pool 2016). Since radiographs from patients with verified diagnoses can be collected and presented using digital libraries, deliberate practice of radiograph interpretation is possible. Following the diagnosis, the learner can receive feedback on the appropriateness of their response and can learn from errors with every case encounter (Ericsson 2004, 2015)
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