Bernard Charlin

Scripts and Medical Diagnostic Knowledge: Theory and Applications for Clinical Reasoning Instruction and Research

Medical diagnosis is a categorization task that allows physicians to make predictions about features of clinical situations and to determine appropriate course of action. The script concept, which first arose in cognitive psychology, provides a theoretical framework to explain how medical diagnostic knowledge can be structured for diagnostic problem solving. The main characteristics of the script concept are pre-stored knowledge, values acceptable or not acceptable for each illness attribute, and default values. Scripts are networks of knowledge adapted to goals of clinical tasks. The authors describe how scripts are used in diagnostic tasks, how the script concept fits within the clinical reasoning literature, how it contrasts with competing theories of clinical reasoning, how educators can help students build and refine scripts, and how scripts can be used to assess clinical competence.

Scripts and clinical reasoning

Context  Each clinical encounter represents an amazing series of psychological events: perceiving the features of the situation; quickly accessing relevant hypotheses; checking for signs and symptoms that confirm or rule out competing hypotheses, and using related knowledge to guide appropriate investigations and treatment.

The many faces of problem-based learning: a framework for understanding and comparison

There is much literature on problem-based learning (PBL), both within and outside medical education. The literature addresses such questions as what is PBL and how does it work, and many examples are given; yet it is often difficult to determine from these descriptions whether the educational approach being described is actually PBL. The goal of this article is to provide planners and/or assessors of PBL curricula with a framework that would facilitate analyses of this educational approach. We propose to categorize educational activities as PBL or non-PBL according to three core principles: (1) the problem acts as a stimulus for learning; (2) it is an educational approach, not an isolated instructional technique, and (3) it is a student-centered approach, and four criteria concerning their effect on student learning: (1) active processing of information; (2) activation of prior knowledge; (3) meaningful context; and (4) opportunities for elaboration/organization of knowledge). Beyond this, PBL curricula v...

Script Concordance Tests: Guidelines for Construction

BackgroundSCT is used to assess clinical reasoning in ambiguous or uncertain situations. It allows testing on real-life situations that are not adequately measured with current tests. It probes the multiple judgments that are made in the clinical reasoning process. Scoring reflects the degree of concordance of these judgments to those of a panel of reference experts.MethodSCT is an item format that is gaining acceptance in education in the health professions. However, there are no detailed guidelines on item writing, test scoring or test optimization.ResultsThe item format is described and the steps for preparing and administering reliable and valid SCTs are presented.ConclusionSCTs probe examinees on a specific clinical reasoning task: data interpretation, a crucial step in the clinical reasoning process. It is inferred that a high degree of concordance corresponds to optimal use of information in the context of these specific tasks and therefore provides an indication of clinical reasoning quality.

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory

Abstract Context. Clinical reasoning plays a major role in the ability of doctors to make diagnoses and decisions. It is considered as the physicians most critical competence, and has been widely studied by physicians, educationalists, psychologists and sociologists. Since the 1970s, many theories about clinical reasoning in medicine have been put forward. Purpose. This paper aims at exploring a comprehensive approach: the “dual-process theory”, a model developed by cognitive psychologists over the last few years. Discussion. After 40 years of sometimes contradictory studies on clinical reasoning, the dual-process theory gives us many answers on how doctors think while making diagnoses and decisions. It highlights the importance of physicians’ intuition and the high level of interaction between analytical and non-analytical processes. However, it has not received much attention in the medical education literature. The implications of dual-process models of reasoning in terms of medical education will be discussed.

Standardized Assessment of Reasoning in Contexts of Uncertainty The Script Concordance Approach

Current written tools of assessment are mostly measuring the capacity to solve well-defined problems by the application of rules and principles, while the essence of expertise in the professions lies in the capacity to solve illdefined problems, that is, reasoning in contexts of uncertainty. The purpose of this study is to describe an approach that allows assessing ill-defined problems and to present and discuss research findings related to this approach. The tool has been used up to now mainly in medicine, however it can be applied in all health professions. The approach is based on three principles: (a) examinees are faced with a challenging authenticsituation in which several options are relevant; (b) the response format is a Likert-type scale that reflects the way information is processed in problem-solving situations, according to the script theory; and (c) scoring is based on the aggregate scoring method to take into account the variability of reasoning processes among experts. Research findings suggest that the approach permits one to reliably discriminate examinees across their level of experience, and so in very different domains. It makes it possible to measure skills or domains that were up to now difficult to measure.

Varying conceptions of competence : an analysis of how health sciences educators define competence

Medical Education 2012: 46: 357–365

Measurement of clinical reflective capacity early in training as a predictor of clinical reasoning performance at the end of residency: an experimental study on the script concordance test

The script concordance (SC) test was conceived to measure knowledge organization, the presence of links between items of knowledge which allow for interpretation of data in clinical decision making situations. Earlier studies have shown that the SC test has good psychometric qualities and overcomes some of the limitations of simulation clinical testing. This study explores the predictive validity of the test.

Assessment in the context of uncertainty: how many members are needed on the panel of reference of a script concordance test?

Purpose  The script concordance test (SCT) assesses clinical reasoning in the context of uncertainty. Because there is no single correct answer, scoring is based on a comparison of answers provided by examinees with those provided by members of a panel of reference made up of experienced practitioners. This study aims to determine how many members are needed on the panel to obtain reliable scores to compare against the scores of examinees.

Script concordance testing: a review of published validity evidence

Medical Education 2011: 45: 329–338