To Operate or Not to Operate? A Script Concordance Study of Resident Preoperative Decision-Making

Deciding when to operate is crucial to surgery but difficult to teach. Script concordance testing (SCT) can assess clinical reasoning for uncertain scenarios. We aimed to assess trainee preoperative decision-making using SCT and evaluate resident answer certainty.

We created five clinical scenarios (appendicitis, gallbladder pathology, inguinal hernia, small bowel obstruction, necrotizing pancreatitis) and used SCT to evaluate preoperative decision-making. Each scenario had four management questions and asked how certain the resident was in their answer. The grading rubric was created from faculty surgeon responses, and the SCT was administered to general surgery residents. Overall mean score, topic scores, junior versus senior resident scores, and concordance between score and resident reported answer certainty was assessed. Certainty differences based on resident level and gender were determined.

Sixty residents participated (95.5% response rate). The overall mean score was 66.3%. Scores were highest for appendicitis (72.8%) and lowest for necrotizing pancreatitis (56.3%). Senior residents scored significantly higher overall than junior residents (68.7% versus 63.9%, P = 0.033) and reported significantly greater confidence (63.3% versus 30.0% confident, P = 0.004). There was no significant difference in confidence based on gender (P = 0.47). Residents were most often concordantly certain for questions on appendicitis, gallbladder pathology, and inguinal hernia, but most often discordantly certain for small-bowel obstruction and necrotizing pancreatitis.

SCT can evaluate preoperative decision-making and distinguish between junior and senior residents. Discordance between resident scores and reported certainty demonstrates a significant need for ongoing education regarding preoperative decision-making.