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AbstractWe examined how the ability to detect lung nodules in chest x-ray inspection is reflected in experience-related differences in visual search and decision-making, and whether the eyetracking metric time-to-first hit showed systematic decreases across expertise levels in medical image perception. Observers with a range of medical expertise undertook a freeresponse nodule detection task and decision-making improved with expertise, however, the time-to-first fixate a nodule showed only a non-significant trend to decrease with expertise.Surprisingly, naïve and expert observers both allocated less visual attention at nodule locations compared to 1 st and 3 rd year radiography students. This similarity in visual attention at nodules but not in decision-making was explained by the fact that naïve observers were more likely than experts to fixate and make errors on distracter regions. Time-to-first hit has been linked to expert performance in mammography, but in chest x-ray inspection, this metric was not sufficiently sensitive to demonstrate clear linear improvements across expertise groups. This brings into question the use of this stand-alone metric as an indirect measure of rapid initial holistic processing.