Search

We present an ensemble transfer learning method to predict suicide from Veterans Affairs (VA) electronic medical records (EMR). A diverse set of base models was trained to predict a binary outcome constructed from reported suicide, suicide attempt, and overdose diagnoses with varying choices of study design and prediction methodology. Each model used twenty cross-sectional and 190 longitudinal variables observed in eight time intervals covering 7.5 years prior to the time of prediction. Ensembles of seven base models were created and fine-tuned with ten variables expected to change with study design and outcome definition in order to predict suicide and combined outcome in a prospective cohort. The ensemble models achieved c-statistics of 0.73 on 2-year suicide risk and 0.83 on the combined outcome when predicting on a prospective cohort of [Formula: see text] 4.2 M veterans. The ensembles rely on nonlinear base models trained using a matched retrospective nested case-control (Rcc) study cohort and show good calibration across a diversity of subgroups, including risk strata, age, sex, race, and level of healthcare utilization. In addition, a linear Rcc base model provided a rich set of biological predictors, including indicators of suicide, substance use disorder, mental health diagnoses and treatments, hypoxia and vascular damage, and demographics.

The sense of agency (SoA) represents the everyday experience of control over our actions and their outcomes. We posit a new framework that defines SoA as consisting of three main components: sense of control of self, sense of control of the environment, and the presence of a goal. Across five experiments, we test this framework by altering participants' SoA over their actions and outcomes by manipulating the predictability of each. Results suggest that both actions and outcomes affect participants' SoA. We also report, contrary to previous theoretical predictions, that unpredictable outcomes lead to the lowest SoA as compared to actions. Additionally, results from explicit measures suggest that participants do not discriminate between control over actions and outcomes and that this remains true regardless of experimental design or explicit agency question type. Taken together, these results suggest that both actions and outcomes are vital to the experience of control.

Irrelevant salient distractors can trigger early quitting in visual search, causing observers to miss targets they might otherwise find. Here, we asked whether task-relevant salient cues can produce a similar early quitting effect on the subset of trials where those cues fail to highlight the target. We presented participants with a difficult visual search task and used two cueing conditions. In the high-predictive condition, a salient cue in the form of a red circle highlighted the target most of the time a target was present. In the low-predictive condition, the cue was far less accurate and did not reliably predict the target (i.e., the cue was often a false positive). These were contrasted against a control condition in which no cues were presented. In the high-predictive condition, we found clear evidence of early quitting on trials where the cue was a false positive, as evidenced by both increased miss errors and shorter response times on target absent trials. No such effects were observed with low-predictive cues. Together, these results suggest that salient cues which are false positives can trigger early quitting, though perhaps only when the cues have a high-predictive value. These results have implications for real-world searches, such as medical image screening, where salient cues (referred to as computer-aided detection or CAD) may be used to highlight potentially relevant areas of images but are sometimes inaccurate.

OBJECTIVE: Suicidal behavior is heritable and is a major cause of death worldwide. Two large-scale genome-wide association studies (GWASs) recently discovered and cross-validated genome-wide significant (GWS) loci for suicide attempt (SA). The present study leveraged the genetic cohorts from both studies to conduct the largest GWAS meta-analysis of SA to date. Multi-ancestry and admixture-specific meta-analyses were conducted within groups of significant African, East Asian, and European ancestry admixtures. METHODS: This study comprised 22 cohorts, including 43,871 SA cases and 915,025 ancestry-matched controls. Analytical methods across multi-ancestry and individual ancestry admixtures included inverse variance-weighted fixed-effects meta-analyses, followed by gene, gene-set, tissue-set, and drug-target enrichment, as well as summary-data-based Mendelian randomization with brain expression quantitative trait loci data, phenome-wide genetic correlation, and genetic causal proportion analyses. RESULTS: Multi-ancestry and European ancestry admixture GWAS meta-analyses identified 12 risk loci at p values

Abstract Due to the challenge for intratumoral administration, innate agonists have not made it beyond preclinical studies for efficacy testing in most tumor types. Pancreatic ductal adenocarcinoma (PDAC) has a hostile tumor microenvironment that renders T cells dysfunctional. Innate agonist treatments may serve as a T cell priming mechanism to sensitize PDACs to anti-PD-1 antibody (a-PD-1) treatment. Using a transplant mouse model with spontaneously formed liver metastasis, a genetically engineered KPC mouse model that spontaneously develops PDAC, and a human patient-derived xenograft model, we compared the antitumor efficacy between intrahepatic/intratumoral and intramuscular systemic administration of BMS-986301, a next-generation STING agonist. Flow cytometry, Nanostring, and cytokine assays were used to evaluate local and systemic immune responses. This study demonstrated that administration of STING agonist systemically via intramuscular injection is equivalent to its intratumoral injection in inducing both effector T cell response and antitumor efficacy. Compared to intratumoral administration, T cell exhaustion and immunosuppressive signals induced by systemic administration were attenuated. Nonetheless, either intratumoral or systemic treatment of STING agonist was associated with increased expression of CTLA-4 on tumor-infiltrating T cells. However, the combination of a-PD-1 and anti-CTLA-4 antibody with systemic STING agonist demonstrated the antitumor efficacy in the KPC mouse spontaneous PDAC model. The mouse pancreatic and liver orthotopic model of human patient-derived xenograft reconstituted with PBMC also showed that antitumor and abscopal effects of both intratumoral and intramuscular STING agonist are equivalent. Taken together, this study supports the clinical development of innate agonists via systemic administration for treating PDAC.

An accurate histopathologic diagnosis on surgical biopsy material is necessary for the clinical management of patients and has important implications for research, clinical trial design/enrollment, and public health education. This study used a mixed methods approach to isolate sources of diagnostic error while residents and attending pathologists interpreted digitized breast biopsy slides. Ninety participants, including pathology residents and attending physicians at major United States medical centers reviewed a set of 14 digitized whole-slide images of breast biopsies. Each case had a consensus-defined diagnosis and critical region of interest (cROI) representing the most significant pathology on the slide. Participants were asked to view unmarked digitized slides, draw their participant region of interest (pROI), describe its features, and render a diagnosis. Participants review behavior was tracked using case viewer software and an eye-tracking device. Diagnostic accuracy was calculated in comparison to the consensus diagnosis. We measured the frequency of errors emerging during 4 interpretive phases: (1) detecting the cROI, (2) recognizing its relevance, (3) using the correct terminology to describe findings in the pROI, and (4) making a diagnostic decision. According to eye-tracking data, trainees and attending pathologists were very likely (∼94% of the time) to find the cROI when inspecting a slide. However, trainees were less likely to consider the cROI relevant to their diagnosis. Pathology trainees (41% of cases) were more likely to use incorrect terminology to describe pROI features than attending pathologists (21% of cases). Failure to accurately describe features was the only factor strongly associated with an incorrect diagnosis. Identifying where errors emerge in the interpretive and/or descriptive process and working on building organ-specific feature recognition and verbal fluency in describing those features are critical steps for achieving competency in diagnostic decision making.

Purpose: Digital whole slide imaging allows pathologists to view slides on a computer screen instead of under a microscope. Digital viewing allows for real-time monitoring of pathologists search behavior and neurophysiological responses during the diagnostic process. One particular neurophysiological measure, pupil diameter, could provide a basis for evaluating clinical competence during training or developing tools that support the diagnostic process. Prior research shows that pupil diameter is sensitive to cognitive load and arousal, and it switches between exploration and exploitation of a visual image. Different categories of lesions in pathology pose different levels of challenge, as indicated by diagnostic disagreement among pathologists. If pupil diameter is sensitive to the perceived difficulty in diagnosing biopsies, eye-tracking could potentially be used to identify biopsies that may benefit from a second opinion. Approach: We measured case onset baseline-corrected (phasic) and uncorrected (tonic) pupil diameter in 90 pathologists who each viewed and diagnosed 14 digital breast biopsy cases that cover the diagnostic spectrum from benign to invasive breast cancer. Pupil data were extracted from the beginning of viewing and interpreting of each individual case. After removing 122 trials ( < 10 % ) with poor eye-tracking quality, 1138 trials remained. We used multiple linear regression with robust standard error estimates to account for dependent observations within pathologists. Results: We found a positive association between the magnitude of phasic dilation and subject-centered difficulty ratings and between the magnitude of tonic dilation and untransformed difficulty ratings. When controlling for case diagnostic category, only the tonic-difficulty relationship persisted. Conclusions: Results suggest that tonic pupil dilation may indicate overall arousal differences between pathologists as they interpret biopsy cases and could signal a need for additional training, experience, or automated decision aids. Phasic dilation is sensitive to characteristics of biopsies that tend to elicit higher difficulty ratings and could indicate a need for a second opinion.

Abstract Background Injection drug use (IDU) can increase mortality and morbidity. Therefore, identifying IDU early and initiating harm reduction interventions can benefit individuals at risk. However, extracting IDU behaviors from patients’ electronic health records (EHR) is difficult because there is no other structured data available, such as International Classification of Disease (ICD) codes, and IDU is most often documented in unstructured free-text clinical notes. Although natural language processing can efficiently extract this information from unstructured data, there are no validated tools. Methods To address this gap in clinical information, we design a question-answering (QA) framework to extract information on IDU from clinical notes for use in clinical operations. Our framework involves two main steps: (1) generating a gold-standard QA dataset and (2) developing and testing the QA model. We use 2323 clinical notes of 1145 patients curated from the US Department of Veterans Affairs (VA) Corporate Data Warehouse to construct the gold-standard dataset for developing and evaluating the QA model. We also demonstrate the QA model’s ability to extract IDU-related information from temporally out-of-distribution data. Results Here, we show that for a strict match between gold-standard and predicted answers, the QA model achieves a 51.65% F1 score. For a relaxed match between the gold-standard and predicted answers, the QA model obtains a 78.03% F1 score, along with 85.38% Precision and 79.02% Recall scores. Moreover, the QA model demonstrates consistent performance when subjected to temporally out-of-distribution data. Conclusions Our study introduces a QA framework designed to extract IDU information from clinical notes, aiming to enhance the accurate and efficient detection of people who inject drugs, extract relevant information, and ultimately facilitate informed patient care.

Abstract Background To discover pharmacotherapy prescription patterns and their statistical associations with outcomes through a clinical pathway inference framework applied to real-world data. Methods We apply machine learning steps in our framework using a 2006 to 2020 cohort of veterans with major depressive disorder (MDD). Outpatient antidepressant pharmacy fills, dispensed inpatient antidepressant medications, emergency department visits, self-harm, and all-cause mortality data were extracted from the Department of Veterans Affairs Corporate Data Warehouse. Results Our MDD cohort consisted of 252,179 individuals. During the study period there were 98,417 emergency department visits, 1,016 cases of self-harm, and 1,507 deaths from all causes. The top ten prescription patterns accounted for 69.3% of the data for individuals starting antidepressants at the fluoxetine equivalent of 20-39 mg. Additionally, we found associations between outcomes and dosage change. Conclusions For 252,179 Veterans who served in Iraq and Afghanistan with subsequent MDD noted in their electronic medical records, we documented and described the major pharmacotherapy prescription patterns implemented by Veterans Health Administration providers. Ten patterns accounted for almost 70% of the data. Associations between antidepressant usage and outcomes in observational data may be confounded. The low numbers of adverse events, especially those associated with all-cause mortality, make our calculations imprecise. Furthermore, our outcomes are also indications for both disease and treatment. Despite these limitations, we demonstrate the usefulness of our framework in providing operational insight into clinical practice, and our results underscore the need for increased monitoring during critical points of treatment.

BackgroundMetacognition is a cognitive process that involves self-awareness of thinking, understanding, and performance. This study assesses pathologists' metacognition by examining the association between their diagnostic accuracy and self-reported confidence levels while interpreting skin and breast biopsies.DesignWe studied 187 pathologists from the Melanoma Pathology Study (M-Path) and 115 pathologists from the Breast Pathology Study (B-Path). We measured pathologists' metacognitive ability by examining the area under the curve (AUC), the area under each pathologist's receiver operating characteristic (ROC) curve summarizing the association between confidence and diagnostic accuracy. We investigated possible relationships between this AUC measure, referred to as metacognitive sensitivity, and pathologist attributes. We also assessed whether higher metacognitive sensitivity affected the association between diagnostic accuracy and a secondary diagnostic action such as requesting a second opinion.ResultsWe found no significant associations between pathologist clinical attributes and metacognitive AUC. However, we found that pathologists with higher AUC showed a stronger trend to request secondary diagnostic action for inaccurate diagnoses and not for accurate diagnoses compared with pathologists with lower AUC.LimitationsPathologists reported confidence in specific diagnostic terms, rather than the broader classes into which the diagnostic terms were later grouped to determine accuracy. In addition, while there is no gold standard for the correct diagnosis to determine the accuracy of pathologists' interpretations, our studies achieved a high-quality reference diagnosis by using the consensus diagnosis of 3 experienced pathologists.ConclusionsMetacognition can affect clinical decisions. If pathologists have self-awareness that their diagnosis may be inaccurate, they can request additional tests or second opinions, providing the opportunity to correct inaccurate diagnoses.HighlightsMetacognitive sensitivity varied across pathologists, with most showing higher sensitivity than expected by chance.None of the demographic or clinical characteristics we examined was significantly associated with metacognitive sensitivity.Pathologists with higher metacognitive sensitivity were more likely to request additional tests or second opinions for their inaccurate diagnoses.

Adaptive gain theory proposes that the dynamic shifts between exploration and exploitation control states are modulated by the locus coeruleus-norepinephrine system and reflected in tonic and phasic pupil diameter. This study tested predictions of this theory in the context of a societally important visual search task: the review and interpretation of digital whole slide images of breast biopsies by physicians (pathologists). As these medical images are searched, pathologists encounter difficult visual features and intermittently zoom in to examine features of interest. We propose that tonic and phasic pupil diameter changes during image review may correspond to perceived difficulty and dynamic shifts between exploration and exploitation control states. To examine this possibility, we monitored visual search behavior and tonic and phasic pupil diameter while pathologists (N = 89) interpreted 14 digital images of breast biopsy tissue (1,246 total images reviewed). After viewing the images, pathologists provided a diagnosis and rated the level of difficulty of the image. Analyses of tonic pupil diameter examined whether pupil dilation was associated with pathologists difficulty ratings, diagnostic accuracy, and experience level. To examine phasic pupil diameter, we parsed continuous visual search data into discrete zoom-in and zoom-out events, including shifts from low to high magnification (e.g., 1× to 10×) and the reverse. Analyses examined whether zoom-in and zoom-out events were associated with phasic pupil diameter change. Results demonstrated that tonic pupil diameter was associated with image difficulty ratings and zoom level, and phasic pupil diameter showed constriction upon zoom-in events, and dilation immediately preceding a zoom-out event. Results are interpreted in the context of adaptive gain theory, information gain theory, and the monitoring and assessment of physicians diagnostic interpretive processes.

We present a novel model of prospective memory and fit it to data from a classic experimental paradigm (Einstein & Mc- Daniel, 1990). Our model uses memory for goals (Altmann & Trafton, 2002) and elaboration with spreading activation to show how prospective intentions can be cued by perceptual cues. Our model also suggests how to resolve some of the con- troversies concerning prospective memory and aging.

Abstract We present an ensemble transfer learning method to predict suicide from Veterans Affairs (VA) electronic medical records (EMR). A diverse set of base models was trained to predict a binary outcome constructed from reported suicide, suicide attempt, and overdose diagnoses with varying choices of study design and prediction methodology. Each model used twenty cross-sectional and 190 longitudinal variables observed in eight time intervals covering 7.5 years prior to the time of prediction. Ensembles of seven base models were created and fine-tuned with ten variables expected to change with study design and outcome definition in order to predict suicide and combined outcome in a prospective cohort. The ensemble models achieved c-statistics of 0.73 on 2-year suicide risk and 0.83 on the combined outcome when predicting on a prospective cohort of $$\sim$$ ∼ 4.2 M veterans. The ensembles rely on nonlinear base models trained using a matched retrospective nested case-control (Rcc) study cohort and show good calibration across a diversity of subgroups, including risk strata, age, sex, race, and level of healthcare utilization. In addition, a linear Rcc base model provided a rich set of biological predictors, including indicators of suicide, substance use disorder, mental health diagnoses and treatments, hypoxia and vascular damage, and demographics.

OBJECTIVE: To ensure all patients receiving long-term opioid therapy (LTOT) understand the risks, benefits and treatment alternatives, the Veterans Health Administration (VHA) released a national policy in 2014 to standardize a signature informed consent (SIC) process. We evaluated the impact of this policy on medical follow-up after LTOT initiation, a guideline recommended practice. METHODS: Using VHA administrative data, we identified patients initiating LTOT between May 2013 and May 2016. We used an interrupted time series design to compare the monthly rates of medical follow-up within 30 days and primary care visits within 3 months after LTOT initiation across three periods: 12 months before the policy (Year 1); 12 months after policy release (Year 2); and 12-24 months after policy release, when the SIC process was mandatory (Year 3). RESULTS: Among the 409,895 patients who experienced 758,416 LTOT initiations, medical follow-up within 30 days and primary care engagement within 3 months increased by 4% between Year 1 and Year 3. Compared to Year 1, patients in Year 3 were 1.12 times more likely to have any medical follow-up (95% CI: 1.10, 1.13) and 1.13 times more likely to have a primary care visit (95% CI: 1.12, 1.15). Facilities with a greater proportion of patients receiving SIC had increased medical follow-up (RR: 1.04, 95% CI: 1.01, 1.07) and primary care engagement (RR: 1.06, 95% CI: 1.03, 1.10). CONCLUSION: The VHAs SIC policy is associated with increased medical follow-up among patients initiating LTOT, which may result in improved patient safety and has implications for other healthcare settings.

Although pathologists have their own viewing habits while diagnosing, viewing behaviors leading to the most accurate diagnoses are under-investigated. Digital whole slide imaging has enabled investigators to analyze pathologists visual interpretation of histopathological features using mouse and viewport tracking techniques. In this study, we provide definitions for basic viewing behavior variables and investigate the association of pathologists characteristics and viewing behaviors, and how they relate to diagnostic accuracy when interpreting whole slide images. We use recordings of 32 pathologists actions while interpreting a set of 36 digital whole slide skin biopsy images (5 sets of 36 cases; 180 cases total). These viewport tracking data include the coordinates of a viewport scene on pathologists screens, the magnification level at which that viewport was viewed, as well as a timestamp. We define a set of variables to quantify pathologists viewing behaviors such as zooming, panning, and interacting with a consensus reference panels selected region of interest (ROI). We examine the association of these viewing behaviors with pathologists demographics, clinical characteristics, and diagnostic accuracy using cross-classified multilevel models. Viewing behaviors differ based on clinical experience of the pathologists. Pathologists with a higher caseload of melanocytic skin biopsy cases and pathologists with board certification and/or fellowship training in dermatopathology have lower average zoom and lower variance of zoom levels. Viewing behaviors associated with higher diagnostic accuracy include higher average and variance of zoom levels, a lower magnification percentage (a measure of consecutive zooming behavior), higher total interpretation time, and higher amount of time spent viewing ROIs. Scanning behavior, which refers to panning with a fixed zoom level, has marginally significant positive association with accuracy. Pathologists training, clinical experience, and their exposure to a range of cases are associated with their viewing behaviors, which may contribute to their diagnostic accuracy. Research in computational pathology integrating digital imaging and clinical informatics opens up new avenues for leveraging viewing behaviors in medical education and training, potentially improving patient care and the effectiveness of clinical workflow.

What is the relationship between trust and perceived agency? The present study experimentally investigated the effect of people’s perception of a robot’s compliance (and resistance) to social norms on their evaluation of a robot’s perceived agency, performance trust, and moral trust. Participants reported a norm-conforming robot to have higher perceived agency and a greater sense of trust than a robot that violated social norms. We also found that perceived agency, regardless of how much a robot followed norms, was correlated with trust. We interpret this finding as evidence that as people see a robot as having agency, they trust it more.

Diagnoses of medical images can invite strikingly diverse strategies for image navigation and visual search. In computed tomography screening for lung nodules, distinct strategies, termed scanning and drilling, relate to both radiologists clinical experience and accuracy in lesion detection. Here, we examined associations between search patterns and accuracy for pathologists (N = 92) interpreting a diverse set of breast biopsy images. While changes in depth in volumetric images reveal new structures through movement in the z-plane, in digital pathology changes in depth are associated with increased magnification. Thus, drilling in radiology may be more appropriately termed zooming in pathology. We monitored eye-movements and navigation through digital pathology slides to derive metrics of how quickly the pathologists moved through XY (scanning) and Z (zooming) space. Prior research on eye-movements in depth has categorized clinicians as either scanners or drillers. In contrast, we found that there was no reliable association between a clinicians tendency to scan or zoom while examining digital pathology slides. Thus, in the current work we treated scanning and zooming as continuous predictors rather than categorizing as either a scanner or zoomer. In contrast to prior work in volumetric chest images, we found significant associations between accuracy and scanning rate but not zooming rate. These findings suggest fundamental differences in the relative value of information types and review behaviors across two image formats. Our data suggest that pathologists gather critical information by scanning on a given plane of depth, whereas radiologists drill through depth to interrogate critical features.

Retrospectively obvious events are frequently missed when attention is engaged in another task-a phenomenon known as inattentional blindness. Although the task characteristics that predict inattentional blindness rates are relatively well understood, the observer characteristics that predict inattentional blindness rates are largely unknown. Previously, expert radiologists showed a surprising rate of inattentional blindness to a gorilla photoshopped into a CT scan during lung-cancer screening. However, inattentional blindness rates were higher for a group of naïve observers performing the same task, suggesting that perceptual expertise may provide protection against inattentional blindness. Here, we tested whether expertise in radiology predicts inattentional blindness rates for unexpected abnormalities that were clinically relevant. Fifty radiologists evaluated CT scans for lung cancer. The final case contained a large (9.1 cm) breast mass and lymphadenopathy. When their attention was focused on searching for lung nodules, 66% of radiologists did not detect breast cancer and 30% did not detect lymphadenopathy. In contrast, only 3% and 10% of radiologists (N = 30), respectively, missed these abnormalities in a follow-up study when searching for a broader range of abnormalities. Neither experience, primary task performance, nor search behavior predicted which radiologists missed the unexpected abnormalities. These findings suggest perceptual expertise does not protect against inattentional blindness, even for unexpected stimuli that are within the domain of expertise.

Expert radiologists can quickly extract a basic gist understanding of a medical image following less than a second exposure, leading to above-chance diagnostic classification of images. Most of this work has focused on radiology tasks (such as screening mammography), and it is currently unclear whether this pattern of results and the nature of visual expertise underlying this ability are applicable to pathology, another medical imaging domain demanding visual diagnostic interpretation. To further characterize the detection, localization, and diagnosis of medical images, this study examined eye movements and diagnostic decision-making when pathologists were briefly exposed to digital whole slide images of melanocytic skin biopsies. Twelve resident (N = 5), fellow (N = 5), and attending pathologists (N = 2) with experience interpreting dermatopathology briefly viewed 48 cases presented for 500 ms each, and we tracked their eye movements towards histological abnormalities, their ability to classify images as containing or not containing invasive melanoma, and their ability to localize critical image regions. Results demonstrated rapid shifts of the eyes towards critical abnormalities during image viewing, high diagnostic sensitivity and specificity, and a surprisingly accurate ability to localize critical diagnostic image regions. Furthermore, when pathologists fixated critical regions with their eyes, they were subsequently much more likely to successfully localize that region on an outline of the image. Results are discussed relative to models of medical image interpretation and innovative methods for monitoring and assessing expertise development during medical education and training.

Purpose: Physicians eye movements provide insights into relative reliance on different visual features during medical image review and diagnosis. Current theories posit that increasing expertise is associated with relatively holistic viewing strategies activated early in the image viewing experience. This study examined whether early image viewing behavior is associated with experience level and diagnostic accuracy when pathologists and trainees interpreted breast biopsies. Approach: Ninety-two residents in training and experienced pathologists at nine major U.S. medical centers interpreted digitized whole slide images of breast biopsy cases while eye movements were monitored. The breadth of visual attention and frequency and duration of eye fixations on critical image regions were recorded. We dissociated eye movements occurring early during initial viewing (prior to first zoom) versus later viewing, examining seven viewing behaviors of interest. Results: Residents and faculty pathologists were similarly likely to detect critical image regions during early image viewing, but faculty members showed more and longer duration eye fixations in these regions. Among pathology residents, year of residency predicted increasingly higher odds of fixating on critical image regions during early viewing. No viewing behavior was significantly associated with diagnostic accuracy. Conclusions: Results suggest early detection and recognition of critical image features by experienced pathologists, with relatively directed and efficient search behavior. The results also suggest that the immediate distribution of eye movements over medical images warrants further exploration as a potential metric for the objective monitoring and evaluation of progress during medical training.

In two studies we investigated the effect of resumption practicefollowing an interruption at the same step in a ComputerizedPhysician Order Entry system (CPOE). The results of both studiesshowed that error rate decreased with increasing amounts ofresumption practice. One reason people may have resumed moreaccurately following an interruption is improvement in a generalresumption process. If true, we would expect that participantscould be interrupted at any step in a task and show improvedresumption with increased practice. Instead, our results suggestthat repeatedly resuming from the same step likely producesassociative priming between a specific task, interruption, andstep. The associative priming allowed participants to resumemore successfully with additional interruption practice, but onlyfor that task-interruption-step triplet.

Digital whole slide images are Food and Drug Administration approved for clinical diagnostic use in pathology; however, integration is nascent. Trainees from 9 pathology training programs completed an online survey to ascertain attitudes toward and experiences with whole slide images for pathological interpretations. Respondents (n = 76) reported attending 63 unique medical schools (45 United States, 18 international). While 63% reported medical school exposure to whole slide images, most reported ≤ 5 hours. Those who began training more recently were more likely to report at least some exposure to digital whole slide image training in medical school compared to those who began training earlier: 75% of respondents beginning training in 2017 or 2018 reported exposure to whole slide images compared to 54% for trainees beginning earlier. Trainees exposed to whole slide images in medical school were more likely to agree they were comfortable using whole slide images for interpretation compared to those not exposed (29% vs 12%; P = .06). Most trainees agreed that accurate diagnoses can be made using whole slide images for primary diagnosis (92%; 95% CI: 86-98) and that whole slide images are useful for obtaining second opinions (93%; 95% CI: 88-99). Trainees reporting whole slide image experience during training, compared to those with no experience, were more likely to agree they would use whole slide images in 5 years for primary diagnosis (64% vs 50%; P = .3) and second opinions (86% vs 76%; P = .4). In conclusion, although exposure to whole slide images in medical school has increased, overall exposure is limited. Positive attitudes toward future whole slide image diagnostic use were associated with exposure to this technology during medical training. Curricular integration may promote adoption.

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.

Veterans seeking care in VA medical facilities have high rates of chronic pain, which often co-occur with mental health and substance use disorders, including prescription opioid misuse. The overall goal of the Optimizing Pain Treatment Interventions (OPTI) study was to pilot a 12-week Collaborative Care intervention to improve opioid safety, chronic pain disability, and use of non-pharmacological pain management strategies in veterans in VA primary care. Between November 2014 and January 2017, 100 veteran patients with chronic pain and high-risk prescription opioid use (e.g., high-dose therapy, early refills, etc.) were enrolled and completed an initial one-hour study visit with a primary care provider (PCP) within 4 weeks of enrollment. Study PCPs were guided by a web-based opioid management decision support program and templated notes in the VA electronic medical record. After assessment and education, study PCPs used Shared Decision-Making to formulate a Pain Care Plan aligned with a participant's personal values and goals. After the initial visit, patients randomized to Collaborative Care received one Motivational Interviewing (MI) session with a Care Manager followed by 3 Care Manager-delivered brief telephone MI sessions at 6, 8, and 12 weeks to reinforce Pain Care Plans; patients randomized to an Attention Control condition met with a Care Manager briefly, followed by 3 brief scripted telephone psychoeducation sessions at 6, 8, and 12 weeks. Masked evaluators assessed outcomes at baseline, end of intervention (12 weeks), and after eight weeks of no contact (20 weeks). We present study rationale, detailed methods, preliminary results and lessons learned.

Measurement(s) gaze locations • radiology report • abnormality localizations • chest localization (lung and heart) • abnormality presence Technology Type(s) eye tracking device • Microphone Device • User Interface Device Sample Characteristic - Organism Homo sapiens

Prior research has shown that interruptions lead to a variety of performance costs. However, these costs are heterogenous and poorly understood. Under some circumstances, interruptions lead to large decreases in accuracy on the primary task, whereas in others task duration increases, but task accuracy is unaffected. Presently, the underlying cause of these costs is unclear. The Memory for Goals model suggests that interruptions interfere with the ability to represent the current goal of the primary task. Here, we test the idea that working memory (WM) may play a critical role in representing the current goal and thus may underlie the observed costs associated with interruption. In two experiments, we utilized laboratory-based visual search tasks, which differed in their WM demands, in order to assess how this difference influenced the observed interruption costs. Interruptions led to more severe performance costs when the target of the search changed on each trial. When the search target was consistent across trials, the cost of interruption was greatly reduced. This suggests that the WM demands associated with the primary task play an important role in determining the performance costs of interruption. Our findings suggest that it is important for research to consider the cognitive processes a task engages in order to predict the nature of the adverse effects of interruption in applied settings such as radiology.

Tigran Avoundjian,1 Lara Troszak,1,2 Jennifer Cohen,3,4 Mary Beth Foglia,3,5 Jodie Trafton,1,6,7 Amanda Midboe1,2 1Center for Innovation to Implementation, Va Palo Alto Health Care System, Palo Alto, CA, USA; 2School of Medicine, Stanford University, Stanford, CA, USA; 3National Center for Ethics in Health Care, Veterans Affairs, Seattle, WA, USA; 4Department of Epidemiology, University of Washington, Seattle, WA, USA; 5Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA; 6Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, CA, USA; 7VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USACorrespondence: Tigran Avoundjian, Center for Innovation to Implementation, 745 Willow Road, Menlo Park, CA, 94205, USA, Fax +206-296-4803, Email tavoun@uw.eduObjective: To ensure all patients receiving long-term opioid therapy (LTOT) understand the risks, benefits and treatment alternatives, the Veterans Health Administration (VHA) released a national policy in 2014 to standardize a signature informed consent (SIC) process. We evaluated the impact of this policy on medical follow-up after LTOT initiation, a guideline recommended practice.Methods: Using VHA administrative data, we identified patients initiating LTOT between May 2013 and May 2016. We used an interrupted time series design to compare the monthly rates of medical follow-up within 30 days and primary care visits within 3 months after LTOT initiation across three periods: 12 months before the policy (Year 1); 12 months after policy release (Year 2); and 12– 24 months after policy release, when the SIC process was mandatory (Year 3).Results: Among the 409,895 patients who experienced 758,416 LTOT initiations, medical follow-up within 30 days and primary care engagement within 3 months increased by 4% between Year 1 and Year 3. Compared to Year 1, patients in Year 3 were 1.12 times more likely to have any medical follow-up (95% CI: 1.10, 1.13) and 1.13 times more likely to have a primary care visit (95% CI: 1.12, 1.15). Facilities with a greater proportion of patients receiving SIC had increased medical follow-up (RR: 1.04, 95% CI: 1.01, 1.07) and primary care engagement (RR: 1.06, 95% CI: 1.03, 1.10).Conclusion: The VHA’s SIC policy is associated with increased medical follow-up among patients initiating LTOT, which may result in improved patient safety and has implications for other healthcare settings.Keywords: chronic pain, opioid therapy, informed consent, care engagement

Adaptive gain theory proposes that the dynamic shifts between exploration and exploitation control states are modulated by the locus coeruleus-norepinephrine system and reflected in tonic and phasic pupil diameter. This study tested predictions of this theory in the context of a societally important visual search task: the review and interpretation of digital whole slide images of breast biopsies by physicians (pathologists). As these medical images are searched, pathologists encounter difficult visual features and intermittently zoom in to examine features of interest. We propose that tonic and phasic pupil diameter changes during image review may correspond to perceived difficulty and dynamic shifts between exploration and exploitation control states. To examine this possibility, we monitored visual search behavior and tonic and phasic pupil diameter while pathologists (N = 89) interpreted 14 digital images of breast biopsy tissue (1,246 total images reviewed). After viewing the images, pathologists provided a diagnosis and rated the level of difficulty of the image. Analyses of tonic pupil diameter examined whether pupil dilation was associated with pathologists’ difficulty ratings, diagnostic accuracy, and experience level. To examine phasic pupil diameter, we parsed continuous visual search data into discrete zoom-in and zoom-out events, including shifts from low to high magnification (e.g., 1× to 10×) and the reverse. Analyses examined whether zoom-in and zoom-out events were associated with phasic pupil diameter change. Results demonstrated that tonic pupil diameter was associated with image difficulty ratings and zoom level, and phasic pupil diameter showed constriction upon zoom-in events, and dilation immediately preceding a zoom-out event. Results are interpreted in the context of adaptive gain theory, information gain theory, and the monitoring and assessment of physicians’ diagnostic interpretive processes.

Past research has found that interruptions change therelationship between confidence and accuracy. However, it isunclear how interruptions affect confidence-accuracycalibration. In this study, we used a rule-based proceduraltask called UNRAVEL and compared confidence-accuracycalibration between interrupted and uninterrupted trials.Results showed that participants were better calibrated in theinterruption condition than in the no interruption condition.We interpret this novel effect as a result of changes in thevalidity of internal cues for confidence between conditions.Specifically, we explore response time as one potentialmediating factor.

Drift diffusion models of decision-making offer some of themost robust predictions of response time for a number ofmemory manipulations. Some drift diffusion models havebeen extended to explain confidence judgments. Many ofthese models assume that confidence judgments areindependent and are not systematically related to other taskitems. In this paper the authors report a relationship betweenconfidence judgments in procedural tasks and how theMemory for Goals model would explain this relationship.

Navigational tools are relied on to traverse unfamiliar grounds, but their use may come at a cost to situational awareness and spatial memory due to increased cognitive load. In order to test for a cost-benefit trade off in navigational cues, we implemented a variety of navigation cues known to facilitate target search and spatial knowledge acquisition of an urban virtual environment viewed through an HTC VIVE Pro as a simulation of cues that would be possible using Augmented Reality (AR). We used a Detection Response Task (DRT) during the navigation task to measure cognitive load and situational awareness. Participants searched for targets in the city with access to a map that did or did not have a “you are here” indicator showing the viewer’s location as they moved. In addition, navigational beacons were also present or absent in the environment as well as a compass and street name indicator. Participants searched for three separate target objects and then returned back to their starting location in the virtual world. After returning home, as a measure of spatial knowledge acquisition, they pointed toward each target from the home location and pointed to home and to the other targets from each target location. Results showed that the navigational cues aided spatial knowledge without increasing cognitive load as assessed with the DRT. Pointing error was lowest when all navigational cues were present during navigation and when pointing was done from home to the target objects. Participants who received the “you are here” indicator on their map consulted the map more often, but without detrimental effects for the acquisition of spatial knowledge compared to a map with no indicator. Taken together, the results suggest that navigational cues can help with spatial learning during navigation without additional costs to situational awareness.

Abstract Prior research has shown that interruptions lead to a variety of performance costs. However, these costs are heterogenous and poorly understood. Under some circumstances, interruptions lead to large decreases in accuracy on the primary task, whereas in others task duration increases, but task accuracy is unaffected. Presently, the underlying cause of these costs is unclear. The Memory for Goals model suggests that interruptions interfere with the ability to represent the current goal of the primary task. Here, we test the idea that working memory (WM) may play a critical role in representing the current goal and thus may underlie the observed costs associated with interruption. In two experiments, we utilized laboratory-based visual search tasks, which differed in their WM demands, in order to assess how this difference influenced the observed interruption costs. Interruptions led to more severe performance costs when the target of the search changed on each trial. When the search target was consistent across trials, the cost of interruption was greatly reduced. This suggests that the WM demands associated with the primary task play an important role in determining the performance costs of interruption. Our findings suggest that it is important for research to consider the cognitive processes a task engages in order to predict the nature of the adverse effects of interruption in applied settings such as radiology.