Assessing clinical reasoning in airway related cases among anesthesiology fellow residents using Script Concordance Test (SCT)

Figures & data

Table 1. An example of an airway management vignette with Script Concordance Test (SCT) items.

A four-year old patient with ASA 1 without airway difficulty came to the hospital with a foreign body (a coin) in the esophagus. Extraction was done intraoperatively using an endoscopic probe. Induction and intubation were done without any difficulty. However, during intraoperative, oxygen desaturated gradually until 85%.
If you were thinking of …	Then you found on clinical presentation/investigation …	The hypothesis becomes …
1. Endotracheal tube dislodge	End-tidal CO2 (ETCO2) can still be read with an unchanged wave, but the value was around 25 mmHg (previously it was 38–40 mmHg)	−2, −1, 0, +1, +2
2. Change the ventilator mode to the manual bagging mode	The breathing circuit and connector were well connected, but the bellow progressively fell.	−2, −1, 0, +1, +2
3. Open draping immediately, extubate, and re-intubate	SpO2 was still not increased, ETCO2 decreased further, and there was an air leak sound from the oral	−2, −1, 0, +1, +2

Where: −2: ruled out or almost ruled out; −1: less probable; 0: neither less nor more probable; +1: more probable; +2: certain or almost certain

Table 2. Demographic of anesthesia fellow residents.

	Junior residents n = 27	Intermediate residents n = 29		Senior residents n = 43
Age	29.7 ± 1.9		29.9 ± 3.0	32.3 ± 2.7
Sex
Male	51.8%		68.9%	62.7%
Female	48.2%		31.1%	37.3%

Table 3. SCT results and subgroup analysis.

	Junior residents n = 27	Intermediate residents n = 29	Senior residents n = 43	Expert n = 10	p-value
SCT result	59.3 (46.1–72.8)	64.7 (39.9–74.9)	67.5 (50.6–78.3)	79.6 (78.4–84.8)	< 0.001^a
Assessment	63.7 ± 9.74	66.7 ± 14.1	73.5 ± 11.1	86.3 ± 7.4	< 0.001^b
Investigation	51.8 ± 13.5	58.5 ± 11.6	59.8 ± 9.3	76.4 ± 7.4	< 0.001^c
Management	58.5 ± 9.9	62.7 ± 9.8	66.7 ± 7.2	80.3 ± 3.5	< 0.001^d

^aKruskal-Wallis

^bANOVA

^cANOVA

^dANOVA

Table 4. Survey of SCT on clinical reasoning assessment.

	Junior residents	Intermediate residents	Senior residents	Expert n = 10
	n = 27	n = 29	n = 43
Very Agree	10/37.0%	12/41.4%	12/27.9%	3/30.0%
Agree	11/40.7%	13/44.8%	25/58.1%	6/50.0%
Neutral	5/18.5%	3/10.3%	5/11.6%	0/0.0%
Disagree	1/3.7%	1/3.4%	1/2.3%	1/10.0%

Table 5. Survey of fidelity, reliability and clarity of SCT.

	Junior residents n = 27	Intermediate residents n = 29	Senior residents n = 43	Expert n = 10
Fidelity (agree/neutral)	88.9%/11.1%	100%/0%	95.3%/4.7%	100%/0%
Reliability (agree/disagree)	77.7%/3.7%	86.2%/3.4%	86%/2.3%	90%/10%
Clarity (agree/disagree)	59.2%/11.1%	62%/0%	55.9%/14%	70%/0%