Table 6.

The overall divisions of the qualitative action codes. A description of each action code and representative examples from the transcripts are provided.

Divisions	Number	Action code	Description of code	Examples
Anatomical identification	AC1	Identify imaging plane	Describes the imaging plain of the presented image	“So this means another axial image”; “so we’re sagittal”
	AC2	Identify anatomical structures	Describe what they are seeing in the image at the time of the initial assessment; names the organs that they see in the image	“stomach, spleen,” “small bowel, and bottom tip of the liver”;
				“spine, vertebrae, kidneys”;
				“left renal vein”
	AC3	Nonverbalization	No dialogue while doing task	Silence; often noted in transcripts as pauses or lapsed time
	AC4	Emphasizes substructures of organs	The identification of these substructures is important to their understanding of the image location	“I can see the rugae in the stomach”; “medial limb of the right adrenal gland”;
				“third segment of the duodenum crossing over.”
	AC5	Physical contact with the mannequin	This action simulates action similar to a physical examination	Palpation of the mannequin to localize or define the location of the anatomy, similar to a physical examination
	AC6	Uses an external landmark to describe location	Uses landmarks on the external surface of the body to describe the anatomic location	“It’s above the umbilicus”;
				“I want to be near the epigastric region”; “midclavicular”; “use bottom rib to signify where liver edge is located
	AC7	Shape, size or amount of organ	Describes the size or shape of the organ or structure. It becomes of some importance to identifying the organ location	“so the liver is quite a bit larger”; “larger slice of liver”;
				“liver took up more of the screen”
	AC8	Expresses the importance of adjacent anatomy	Uses the adjacent anatomy to describe the location of the anatomy (presence or absence of anatomy/organs). This relationship of the anatomy is important in their localization.	“So level of like the lowest ribs with—you can still see part of the liver”; “And so, they’re just, like, easy to see how they related to the anatomy around them
	AC9	Location within an organ	Describes a nonanatomic terminology location within an organ to localize where the image is in the organ	“biggest part of the liver”; “upper like third-ish or like the lower third (when describing a kidney)”; “superior/inferior pole of the kidney”; “lower part of the liver”
	AC10	Use of incorrect terminology	Describes anatomic findings using nonmedical or nonanatomic terms	“stomach bubble”; “air fields” (when describing lungs); “Belly button” “bunch of bowel”; “big lung window”; “gastric bubble”; north and south rather than superior and inferior; describing structures by color, black and white, contrast rather than the organ.
	AC11	Use of descriptive cues (nonanatomic)	Describe structure by its color	“And then there are these three little dots in the duodenum, and so I matched up those”; “I was seeing if…this little, black blob—if that’s similar to that one”; “liver shadowing”; “This time, I think it’s more contrast in color.”
Localization and reasoning	AC12	Identify location within the body (initial)	Describes the location of where organs/structures are in the body	“this is pretty high, I see the stomach”; this is on the right-hand side”; “Well I knew it was right, because his liver was there”; “it’s above the umbilicus”
	AC13	Reasoning why used certain organs/structures to localize (initially)	Using key organs or structures to identify the location of the image	“So I’m well medial to the iliac crest. So again that would bring it in here rather than being out here”; “And the pancreas is up pretty high, so I would say, like, I don’t know—there-ish?”; “The relationship, yeah, because knowing the psoas I know that it has to be a little more medial because if I go too far lateral, it’s going to be the quadratus lumborum because I’ve come out of the psoas.”
	AC14	Compared with expected cued target	Compared with the target goal and where they placed the probe	“I’m too high”, “I’m too low”; “I’m too far to the right”
Strategies for matching	AC15	Elements or reasoning for fine tuning using small structures (matching up image)	Using structures that have narrow zones (vessels, loop of bowel) of change to adjust the location and match images	“Well, it’s thinner in the superior/inferior dimension. So it’s hard to—things that are thicker are harder to fine tune like that”;” Because it was the tiniest structure that I could use that was precise, like as opposed to like a triangular piece of the liver or, you know, kidneys you can’t really, you know, they’re kind of look the same for a period of time, and so I was using the renal vein”; “Yeah, you want—vascular structures are going to be helpful. You see that that’s what I’ve been going after, because they’re relatively unchanging”; “I was just looking at the way the crescents (of the lungs) looked.”; “so I was looking at the loop of small bowel that goes across the middle of the image”; “looking at the shape of the bone here and seeing what, you know, sort of the shape of the iliac crest”
	AC16	Elements for reasoning remains at organ level (matching up images)	Using the size and shape of a larger organ (liver, spleen, kidney) to adjust location	“I was focusing in on like the smaller organ and the spleen because I felt like I could match that up better than using the liver which is larger. So it’s the size of the spleen is what I was using on that one.”
	AC17	Reasoning for matching up that is not anatomic	Using nonanatomic references to match up images; matches colors or patterns	“The air and the fluid level in the stomach is what I was matching it up on”; “looking for patterns, like seeing this kind of swirl part of the kidney or looking for that dark spot there that looks similar to the test image or the initial image and looking for the bowel gas patterns”
	AC18	Trial and error for matching and refining the matching of anatomy	Makes movements in search of specific anatomy	“going to keep moving down until I see the kidneys”; “And then I was, like, getting positive reinforcement from the image as I was moving down that it was adjusting more to the correct one.”
Experience and confidence cues	AC19	Uncertainty in anatomy	Uncertain what structure they are seeing in the image	“looks like a large vessel. I don’t know if that’s the aorta or not, but pretty close to midline. Puts me on the left side. Slightly in the left side. But it could be the IVC, in which case I would be on the right and I really don’t know.”“ I’m not sure what that black is (in reference to the lungs)”; “I think that’s the pancreas”
	AC20	Misinterpretation of anatomy	Called the presented anatomy the wrong structure; don’t know what the structure is; not knowing where anatomy is on mannequin (internal or external)	Referring to anatomy that is not present, i.e., I think that’s the pancreas (there is not pancreas in the image); Referring to the duodenum as the pancreas; referred to anatomy in the image that was not present in the image (i.e., Gall bladder’s presence when it was not present); “He doesn’t have a belly button” (but it really does have one)
	AC21	Compare at case level/prior cases	Compares the current image with a prior case—either appearing similar or in relationship to another case within the simulation session	“I’m just a little higher than the last one”; “So I’m going to go a little bit lower than I did the last time”; “this is similar to the first one”; “this is like where I had initially put my probe because I saw too much of the liver”; “So I used the basis of what I had to move the last time”; “I know it’s higher that the last one”; “Kind of looks like the first one you showed me”
	AC22	Localizes by the absence of a structure	The absence of a structure becomes an important way of localization	“I know that I’m on the right side because I don’t see the heart”; “so we’re not seeing much spine”; “I don’t see the kidneys yet”; “I’m not midline because I don’t see the vertebrae”
	AC23	Certainty of knowledge (positive)	Statements about their confidence in what they are doing (affirmative statements; sure about their decision)	“It’s experience now, I mean—”; “I am not sure how I know, but I just know”; “I’m correct”
	AC24	Uncertainty of knowledge (negative)	Statements about their lack of confidence in what they are doing (uncertainty; not completely sure)	“Then I guess here”; “I’m not used to really trying to determine where on the body the pancreas is”; “I guess”; “I’m not very familiar with this one”; “I really don’t know”
	AC25	Direction to anatomy	Vocalization of direction to move to locate desired anatomy (correction to initial localization)	“we’re down at the very edge of the liver, kidneys so I got to go farther inferior”; “So I need to go move toward where there’s more volume of the liver.”; “The liver was too big, so I knew it was too high.”
	AC26	Incorporation of past experience	Relates how they approach the case using reference from their own past experience outside of this simulation event	“It’s a pattern I have in my head. So I suppose it is a concept that I’ve developed over years, you know”; “from experience looking at lots, thousands of CTs of the belly”; “No. I’m afraid now I think CT. I always, even in ultrasound, start with the axial plane because I think CT”; “Like this reminds me of when like you scroll down on the CT chest too low and you start seeing the liver.”
	AC27	Define spatial anatomy for themselves	Their explanation of how they are able to localize the image in space	“I have a very good 3-D picture in my head of where it’s supposed to be”; “So I visualize where it should be physically in space and where I have to interact with the body’s surface to get there”; “Yeah, I’m just picturing the anatomy of the organs in the abdomen. So, yeah”; “I don’t have a good sense of the 3-D how the three pelvis would change, so I’m like having to do little testing for that.”
	AC28	Unreliable anatomy	Explains why some anatomy is less reliable to use for localizing	“between studies, they vary so much because you have peristalsis going on all the time. So bowel is really…bowel is too variable.”
	AC29	Verbalizes difficulty	When localization of the area or plane of imaging is more difficult to assess	“Sagittal is always more difficult”; “Yep. And actually midline is the hardest anyways”; “I don’t have a good sense of the 3D how the three pelvis would change, so I’m like having to do little testing for that.”
	AC30	Realization of anatomic cues that they missed	Retrospect realization that there was key anatomy that could have helped guide their anatomic location	“I guess and the belly button— you see exactly the belly button. [CHUCKLING] That one should have helped me”; “Well, no. I should have seen that. I didn’t look at the umbilicus. That was stupid”; “Again, you got to look at all pictures of the image.”