title: Pupil diameter changes reflect difficulty and diagnostic accuracy during medical image interpretation.
abstract: No automated methods exist to objectively monitor and evaluate the diagnostic process while physicians review computerized medical images. The present study tested whether using eye tracking to monitor tonic and phasic pupil dynamics may prove valuable in tracking interpretive difficulty and predicting diagnostic accuracy.
  
  
  
  Pathologists interpreted digitized breast biopsies varying in diagnosis and rated difficulty, while pupil diameter was monitored. Tonic diameter was recorded during the entire duration of interpretation, and phasic diameter was examined when the eyes fixated on a pre-determined diagnostic region during inspection.
  
  
  
  Tonic pupil diameter was higher with increasing rated difficulty levels of cases. Phasic diameter was interactively influenced by case difficulty and the eventual agreement with consensus diagnosis. More difficult cases produced increases in pupil diameter, but only when the pathologists' diagnoses were ultimately correct. All results were robust after adjusting for the potential impact of screen brightness on pupil diameter.
  
  
  
  Results contribute new understandings of the diagnostic process, theoretical positions regarding locus coeruleus-norepinephrine system function, and suggest novel approaches to monitoring, evaluating, and guiding medical image interpretation.
authors.affiliation: Center for Applied Brain and Cognitive Sciences, 200 Boston Ave, Suite 3000, Medford, 02155, MA, USA. tbruny01@tufts.edu.|Department of Psychology, Tufts University, 490 Boston Ave, Medford, 02155, MA, USA. tbruny01@tufts.edu.
authors.forename: Tad T
authors.initials: TT
authors.lastname: Brunyé
authors.affiliation: Center for Applied Brain and Cognitive Sciences, 200 Boston Ave, Suite 3000, Medford, 02155, MA, USA.|Department of Psychology, Tufts University, 490 Boston Ave, Medford, 02155, MA, USA.
authors.forename: Marianna D
authors.initials: MD
authors.lastname: Eddy
authors.affiliation: Department of Computer Science and Engineering, University of Washington, Seattle, 98104, WA, USA.
authors.forename: Ezgi
authors.initials: E
authors.lastname: Mercan
authors.affiliation: Department of Pathology, Stanford University School of Medicine, Palo Alto, 94305, CA, USA.
authors.forename: Kimberly H
authors.initials: KH
authors.lastname: Allison
authors.affiliation: Department of Pathology and UVM Cancer Center, University of Vermont, Burlington, 05401, VT, USA.
authors.forename: Donald L
authors.initials: DL
authors.lastname: Weaver
authors.affiliation: Department of Medicine, University of Washington, Seattle, 98104, WA, USA.
authors.forename: Joann G
authors.initials: JG
authors.lastname: Elmore
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000000981:diagnostic imaging; D000066491:Clinical Decision-Making; D005260:Female; D006801:Humans; D008125:Locus Coeruleus / Q000502:physiology*; D008875:Middle Aged; D009638:Norepinephrine / Q000502:physiology*; D010820:Physicians; D011680:Pupil / Q000502:physiology*
chemical_list: D009638:Norepinephrine
keywords: Decision making; Diagnosis; Locus coeruleus; Medical image interpretation; Pupil diameter