Script concordance testing: assessing residents' clinical decision-making skills for infant lumbar punctures

Acad Med. 2014 Jan;89(1):128-35. doi: 10.1097/ACM.0000000000000059.


Purpose: Residents must learn which infants require a lumbar puncture (LP), a clinical decision-making skill (CDMS) difficult to evaluate because of considerable practice variation. The authors created an assessment model of the CDMS to determine when an LP is indicated, taking practice variation into account. The objective was to detect whether script concordance testing (SCT) could measure CDMS competency among residents for performing infant LPs.

Method: In 2011, using a modified Delphi technique, an expert panel of 14 attending physicians constructed 15 case vignettes (each with 2 to 4 SCT questions) that represented various infant LP scenarios. The authors distributed the vignettes to residents at 10 academic pediatric centers within the International Simulation in Pediatric Innovation, Research, and Education Network. They compared SCT scores among residents of different postgraduate years (PGYs), specialties, training in adult medicine, LP experience, and practice within an endemic Lyme disease area.

Results: Of 730 eligible residents, 102 completed 47 SCT questions. They could earn a maximum score of 47. Median SCT scores were significantly higher in PGY-3s compared with PGY-1s (difference: 3.0; 95% confidence interval [CI] 1.0-4.9; effect size d = 0.87). Scores also increased with increasing LP experience (difference: 3.3; 95% CI 1.1-5.5) and with adult medicine training (difference: 2.9; 95% CI 0.6-5.0). Residents in Lyme-endemic areas tended to perform more LPs than those in nonendemic areas.

Conclusions: SCT questions may be useful as an assessment tool to determine CDMS competency among residents for performing infant LPs.

MeSH terms

  • Adult
  • Clinical Competence*
  • Decision Making*
  • Delphi Technique
  • Education, Medical, Graduate / standards*
  • Educational Measurement
  • Female
  • Humans
  • Infant
  • Infant, Newborn
  • Internship and Residency*
  • Male
  • Spinal Puncture / standards*