Metacognitive Processes in Radiologic Decision-Making: The Hard-Easy Effect and Temporal Thinking Dynamics

Background Radiologic diagnosis accuracy and efficiency depend on effective metacognitive processes (eg, ongoing confidence monitoring and regulatory decisions). Identifying pitfalls in metacognitive processes is essential for improving diagnostic accuracy and workflow. Purpose To examine how the metacognitive bias termed the hard-easy effect and temporal thinking dynamics manifest in radiologic decision-making and differ with expertise levels. Materials and Methods In this metacognitive analysis, radiologists (at residency year 2 or later) and nonradiology medical professionals reviewed bone radiographs. They determined whether bone lesions were present or absent, which were compared with a reference standard based on CT or MRI findings validated by a panel of two board-certified musculoskeletal radiologists. For each image, participants rated confidence (50% [ie, a guess] to 100%) and recommended the next step (submitting, ordering additional imaging, and consulting a senior colleague). Success, confidence, overconfidence, response time (RT), resolution (confidence-accuracy correlation), efficiency, control sensitivity (confidence-decision correlation), and RT association with confidence were determined. Results Among 28 radiologists and 50 nonradiologists (2806 decisions), the task was challenging, and overconfidence was common (14.73%). Radiologists demonstrated higher success (73.59% [989 of 1344] vs 64.71% [946 of 1462]; P < .001) and confidence (85.12% vs 81.24%; P = .01), less overconfidence (overconfidence of 11.52% vs 16.52%; P = .03), and better resolution (γ = 0.37 vs 0.23; P = .04) than nonradiologists. In both groups, confidence predicted subsequent actions (γ = 0.32 vs 0.53; P = .05). A consistent hard-easy effect emerged: confidence was well-calibrated for easy cases but showed substantial overconfidence for difficult cases (>40%). Fast decisions were accurate and well-calibrated, whereas prolonged deliberation predicted mistakes and increased overconfidence. Lesion-present diagnoses were associated with lower confidence and more deferrals to seniors. Conclusion Metacognitive analysis of radiologic decision-making exposed the hard-easy effect and detrimental temporal dynamics. Although radiologic expertise increased success and confidence in monitoring accuracy, radiologists and nonradiologists were susceptible to overconfidence, particularly in challenging lengthy cases. © RSNA, 2026 Supplemental material is available for this article. See also the article by Krupinski in this issue.