1. The script concordance test as a measure of clinical reasoning: a national validation study Nouh et al The American Journal of Surgery 2012; 203: 530-534

2. SCT-Clinical Reasoning national validation study SCT- prior single center study, differentiated between Jr and Sr SR To determine validity and reliability, administered on a national level Test given to 202 Residents - 9 Gen Surg programs across Canada SCT distinguishes intra-operative decision making skills of Jr. vs Sr. gen surgical residents

3. SCT Based on script theory from cognitive psychology Uses authentic clinical scenarios to compare a trainees judgment skills with those of experts SCT scores- intended to reflect respondents competence, interpreting clinical data under conditions of uncertainty

4. Script Theory Elements Clinical encounter: –perceiving features of situation – assessing relevant hypotheses –checking for sx & signs that confirm or refute hypotheses –Using related knowledge to guide investigations + Rx Charlin et al Med Educ 2007: 41,1178-1184

5. Script Theory Elements Provides explanations for how events are processed Fields of computer science and psychology Organization of experiences in script-like formations –Referred to in future –Understand same or similar new situations

6. SCT A Practical + Reliable Instrument 2004 Radiology 2006 Surgery 2009 Radiation oncology Neurology Pediatric emerg med 2011 Dermatology ENT Preclinical med students 2012 Geriatrics

7. SCT Example If you are considering the following investigation... and then you find...you would consider the proposed investigation to be... A V/Q scan to R/O pulmonary embolism CXR Shows areas of collapse much less useful slightly less useful neither less nor more useful slightly more useful much more useful

8. SCT- Natl Study Methods Res level of training: post grad yrs 1-5 Jr = R1-2 Sr= R3,4,5 Test development: 9 prgrm dir; scenario,2- 6(?)s Ans key: 5 pt scale, ranging from (-2), comp contra-ind to (+2), comp indic 153 (?)s

9. SCT- Natl Study Methods Scoring Every choice sel by expert Credit 22 Gen Sur experts took test Credit for each answer was transformed proportionally to get a max score of 1 for the modal experts choice on each item Stat analysis

10. SCT- Natl Study Methods Results Scores progressively from R1to R4 with a dip in R5 Test differentiated R1+2 from R3+4+5 Site of training had sig effect on scores

11. Discussion Limitations –No observed drop in variability from R1 to R5 –Choice of scale unsettled –Scores depend on cohort of experts –Influence of generalist vs subspecialist –Item production –Setting of passing scores Advantages –Ease of administration; online –Reliable; valid (?)