Award Date


Degree Type


Degree Name

Doctor of Philosophy (PhD)


Educational Psychology & Higher Education

First Committee Member

Alice Corkill

Second Committee Member

Lisa Bendixen

Third Committee Member

Harsha Perera

Fourth Committee Member

Merrill Landers

Number of Pages



A hallmark of clinician decision making is the ability to know when to make quick decisions and when decision making should be slowed to account for complicating factors. Throughout the physician training process, multiple choice test items are used to assess student knowledge however, these items do not assess the process used by a student to arrive at the answer choice. If an important characteristic of decisions in clinical practice is timing, then decision timing could be an important consideration for medical school assessments. The purpose of this study, therefore, is to investigate factors that may affect the amount of time a student takes to consider a test item when first presented with the item. Based on decision making theory, factors are at the student-level (current knowledge, prior knowledge, and thinking disposition), item-level (item difficulty), and student-by-item-level (response) should have an effect on the amount of time a student views a question on the first encounter.

The present study employed student testing data generated by second-year medical students during a 154-question high-stakes exam. First-view time of each item was derived from computer-based snapshot files and used as the dependent variable. A multilevel mixed model was specified to describe the effect of response, item difficulty, and student thinking disposition on first-view time. As predicted, students spent less time on first encounter for items which were ultimately answered correctly. However, for the easy items answered incorrectly, students spent the same amount of time as difficult items answered incorrectly. In addition, students who were more analytical in their thinking disposition displayed less difference in first-time view between correct and incorrect responses. These results are interpreted using the theoretical framework of the three-stage dual process model of decision making proposed by Pennycook, Fugelsang, and Koheler (2015).


Assessments; Clinical decision making; Dual-process theory; Medical education; Multiple choice tests; Response time


Cognitive Psychology | Education | Educational Assessment, Evaluation, and Research

File Format


Degree Grantor

University of Nevada, Las Vegas




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