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

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

Author information

Dr. Chang is assistant professor of pediatrics, Division of Emergency Medicine and Transport, Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, California. Dr. Kessler is assistant professor of pediatrics, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York. Dr. McAninch is assistant professor, Division of Pediatric Emergency Medicine at Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Dr. Fein is assistant professor of pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital at Montefiore affiliated with Albert Einstein College of Medicine, Bronx, New York. Dr. Scherzer is clinical associate professor of pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio. Dr. Seelbach is assistant professor, Department of Pediatrics, University of Kentucky, Lexington, Kentucky. Dr. Zaveri is assistant professor of pediatrics and emergency medicine, Division of Emergency Medicine, Children's National Medical Center and George Washington University, Washington, DC. Dr. Jackson is assistant professor of pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina. Dr. Auerbach is assistant professor of pediatrics, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut. Dr. Mehta is associate professor of pediatrics, Section of Critical Care, Georgia Regents University, Augusta, Georgia. Dr. Van Ittersum is assistant professor of pediatrics, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio. Dr. Pusic is assistant professor of emergency medicine, New York University School of Medicine, New York, New York.



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.


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.


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.


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

[Indexed for MEDLINE]
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