SDN Article: SJTs for Health Professions Admissions in the United States and Canada: A Research Review

Started by Emil Chuck, PhD
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Emil Chuck, PhD

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Abstract: Situational Judgment Tests (SJTs) are a cornerstone of holistic admissions in U.S. and Canadian medical and health professions programs, designed to assess crucial non-academic professional characteristics alongside traditional cognitive metrics. The two primary instruments utilized are the Computer-Based Assessment for Sampling Personal Characteristics (Casper, Acuity Insights), an open-response test, and the AAMC PREview Professional Readiness Exam, a fixed-response test. Research consistently demonstrates that SJTs measure important professional competencies, such as empathy, ethics, collaboration, and resilience. They offer incremental predictive validity for non-academic performance later in training, specifically signaling “non-academic risk.” However, there is significant debate over their ability to mitigate demographic bias. While the AAMC reports that its fixed-response PREview exam exhibits smaller group differences compared to academic metrics, independent studies concerning the constructed-response Casper test have repeatedly identified significant performance disparities where underrepresented in medicine (URiM) applicants, including Black and Hispanic candidates, and International Medical Graduates (IMGs) score significantly lower than their counterparts. Given the post-2023 U.S. Supreme Court ruling restricting race-conscious admissions, the equitable implementation of these ostensibly “race-neutral” SJTs remains a critical area of scrutiny.

Introduction and Purpose of Situational Judgment Tests​


Medical education institutions rely heavily on traditional academic metrics, such as the Medical College Admission Test (MCAT) and undergraduate Grade Point Average (GPA), which effectively predict academic success early in the curriculum (Ellison et al., 2024). However, these cognitive measures fail to adequately assess the non-academic personal and professional attributes essential for effective clinical practice (Patterson et al., 2016; AAMC, n.d.). SJTs were adopted to provide a standardized, scalable method for assessing vital non-cognitive traits such as empathy, collaboration, and professionalism, aligning with the contemporary emphasis on holistic review (Patterson et al., 2016; AAMC, n.d.). The skills measured generally fall into two broad areas: relational skills (e.g., communication, empathy) and personal accountability (e.g., ethical responsibility, resilience, and self-improvement) (AAMC, n.d.).

Structural and Methodological Differences​


The two primary SJTs used in North American medical and health professions admissions, Casper and the AAMC PREview Exam, use fundamentally different designs:

  1. AAMC PREview Professional Readiness Exam (Fixed-Response): The PREview exam uses a text-based, fixed-response format. Examinees read scenarios based on real-world medical situations and rate the effectiveness of four to eight possible responses using a four-point scale (AAMC, n.d.). The exam includes 186 total items (AAMC, n.d.). Scoring relies on aligning the examinee’s ratings with consensus ratings established by medical education subject matter experts, with full or half credit awarded for close alignment (AAMC, n.d.). This standardized format is intended to create a “level playing field” by ensuring that every examinee provides consistent information, unlike interviews or essays, where response content and length vary (AAMC, 2026). The PREview exam measures two broad skill areas: relational skills and personal accountability (AAMC, 2026). However, service orientation and oral communication skills are not assessed (Fraser et al., 2025)
  2. Computer-Based Assessment for Sampling Personal Characteristics (Casper) (Open-Response): Casper, developed at McMaster University in Canada (McMaster, 2022), employs an open-response format and often uses video-stem scenarios (Rosales et al., 2024). The test typically consists of 12 sections, where applicants generate their own typed or video-recorded solutions to three follow-up questions within a strict five-minute time frame (Gustafson et al., 2023; Rosales et al., 2024). Scenarios often focus on transferable skills such as ethical decision-making and collaboration, rather than strictly on medical knowledge (McMaster, 2022). Responses are scored by multiple human raters using a 9-point Likert scale (1 = unsatisfactory to 9 = superb) (Gustafson et al., 2023).

Program Usage in the United States and Canada​


SJTs are widely utilized across medical and health professional education programs in North America.

  • Casper Usage: Casper has expanded substantially, having been licensed by Altus Assessments (McMaster, 2022). It is currently being used at nearly 400 university medical schools and health sciences programs in Canada, the U.S., and Australia (McMaster, 2022). Specifically regarding U.S. programs, a review of the Casper website indicated that 22 US medical schools and osteopathic schools use the exam (Gustafson et al., 2023). The exam is also being marketed and piloted as a screening tool for residency applicants, including a pilot involving 22 residency programs across four specialties during one match cycle (Rosales et al., 2024; Moore et al., 2024).
  • PREview Usage: The AAMC PREview exam is open to MD- and DO-granting medical schools and other postgraduate degree programs in the health professions (AAMC, n.d.). The AAMC has conducted longitudinal validity studies with partner schools (Ellison et al., 2024; AAMC, n.d.). Every spring, the AAMC lists programs that require or recommend PREview scores as part of the application profile among US applicants; as of 2025, no Canadian programs required PREview.

Predictive Validity and Demographic Gaps​

Predictive Validity


SJTs demonstrate value by predicting outcomes distinct from those predicted by academic performance. One study showed that Casper’s design to include video responses predicted interview performance (Robb et al., 2025). Casper scores show a moderate predictive correlation with performance on sections of Canadian national licensure examinations assessing personal and professional characteristics years after admission (Dore et al., 2017). The University of Colorado’s Physician Assistant Program also shows a strong association between a Casper result (z-score) and the likelihood of a student committing a professionalism infraction (Sivahop et al., 2025)

The AAMC’s research confirms that while GPA and MCAT scores strongly predict academic risk (academic dismissal), PREview scores offer a strong signal of non-academic risk (termination for non-academic reasons/professionalism issues) (Royal et al., 2025). Furthermore, scores from a prototype version of the PREview exam correlated with faculty ratings of professional behaviors, providing unique information relative to MCAT scores and GPAs (AAMC, 2023). However, PREview results do not have predictive validity with Multiple Mini Interview (MMI) performance, suggesting that PREview may emphasize other competencies than the investigating school’s MMI (Ellison et al., 2024).

Demographic Performance Gaps


Studies remain divided on whether SJT design can mitigate bias more effectively than cognitive-based tests.

  • Casper Disparities: Independent cohort studies have found significant disparities in Casper scores across racial and ethnic groups.
    • A study of applicants at a U.S. medical school found that Black or African-American, Native American or Alaskan Native, and Hispanic applicants had significantly lower Casper scores than other applicants (Gustafson et al., 2023).
    • Purdue University College of Veterinary Medicine’s handling of Casper scores may have excluded first-generation, male, URM, and international applicants (Raghavan et al., 2025).
    • An anesthesiology residency study found that White candidates scored significantly higher than Black and Hispanic candidates (Rosales et al., 2024).
    • The largest published Graduate Medical Education dataset for an SJT (ophthalmology residency applicants) found that URiM applicants scored 17 percentile points lower, and International Medical Graduates (IMGs) scored 32 percentile points lower than their non-URiM and domestic counterparts on Casper (Moore et al., 2024). This latter study noted that the magnitude of bias in Casper against the URiM and IMG groups was even greater than that observed in standardized academic exams such as Step 1 and Step 2 (Moore et al., 2024).
  • PREview Disparities: The AAMC’s data from early administrations of the PREview exam indicated that group differences were small between White examinees and Black or Hispanic examinees, and these differences were smaller than those observed with traditional academic assessments (Ellison et al., 2024). The AAMC contends that the notable overlap in scores supports the objective of assessing examinees equitably across different ethnic groups (Ellison et al., 2024).

    Icahn School of Medicine at Mount Sinai investigated whether PREview scores, which they did not consider in admissions decisions, correlated with their admissions committee’s decisions on applicants. They found that low PREview scores were more common among applicants from lower socioeconomic status and first-generation backgrounds. Furthermore, lower PREview scores were associated with a lower likelihood of receiving an interview invitation. Finally, PREview scores did not show a strong correlation with post-interview committee evaluations. The investigators concluded that PREview scores did not show a strong alignment with their admissions committee decisions (Catlett et al., 2026)

SJTs: Research on the Applicant Experience​


Learn how students perceive SJTs in this breakdown of the Situational Judgment Test Experience section of the Fall 2024 HPSA/SDN Applicant Experience Survey.

Response Format and Bias Mechanisms​


The structural format is likely to influence these discrepancies. Open-response formats, such as Casper, inherently exhibit greater content variability, offering more nuance in how assessors evaluate individual responses (Iqbal et al., 2025). Research suggests that while scoring primarily relies on demonstrating competencies, providing justification, and considering various perspectives, assessors also take into account construct-irrelevant linguistic factors (Iqbal et al., 2025). The requirement for quick, typed answers may place significant cognitive load on non-native English speakers, potentially affecting their performance, even when their ethical reasoning is sound (Iqbal et al., 2025).

Coaching and Preparation​


SJTs claim to be generally resistant to explicit coaching, especially the open-response format of Casper, which requires deeper processing than closed-response formats (Acuity Insights, 2021). Internal research by the Casper administrator suggests that participation in commercial third-party test preparation accounts for only about 2% of the overall variance in scores (Acuity Insights, 2021). However, preparation programs explicitly designed for URiMs are highly effective. A Casper Preparation Program (CPP) successfully increased participants’ self-perceived competence and confidence, with 51% of URiM students who participated scoring in the highest quartile on the actual Casper test (Mahmood et al., 2023).

Post-Affirmative Action Context​


The role of SJTs has intensified following the 2023 U.S. Supreme Court ruling that prohibited the use of race-conscious admissions (Nguyen et al., 2025). SJTs are viewed as race-neutral tools intended to support holistic review (AAMC, n.d.). Despite this intended purpose, recent AAMC data show that matriculants from all historically underrepresented groups in U.S. MD-granting schools declined in 2024 compared to 2023, with Black or African American matriculants declining 11.6% and Hispanic, Latino, or of Spanish Origin matriculants declining 10.8% (AAMC, 2025). This decline, reflecting an emergent disparity in acceptance rates for URiM applicants relative to Asian and White applicants, emphasizes the need for continuous research to ensure that SJTs do not inadvertently perpetuate existing inequities (Nguyen et al., 2025).

AAMC Professional Competencies Update for 2026​


‘Self-awareness” and “Understanding Others” replaced “Cultural Awareness” and “Cultural Humility” in the 2026-2027 application cycle, likely in response to political sensitivity concerning an emphasis on race or ethnicity (AAMC, 2026). The AAMC’s Anatomy of an Applicant workbook has been updated to reflect this change, but it is unclear how the PREview exam will be revised to assess these attributes.

Frequently Asked Questions​

Q: What specific professional skills do SJTs measure?
A: SJTs assess key professional attributes generally divided into relational skills (e.g., communication, empathy, collaboration) and personal accountability (e.g., ethical responsibility, resilience, and continuous self-improvement) (AAMC, n.d.).

Q: How many programs use Casper?
A: Casper is widely used, accounting for over 95% of applicants to Canadian and U.S. medical schools (McMaster, 2022). A review of the Casper website indicated that 22 U.S. medical schools and osteopathic schools use the exam (Gustafson et al., 2023). It is also used by nearly 400 total medical and health sciences programs globally (McMaster, 2022).

Q: Do SJTs successfully mitigate racial and ethnic bias in admissions?
A: Evidence is mixed. The fixed-response AAMC PREview exam reports small demographic-group differences that are smaller than those observed in traditional academic measures (Ellison et al., 2024). However, the open-response Casper test consistently shows significantly lower scores for Underrepresented in Medicine (URiM) applicants and International Medical Graduates (IMGs) compared to their majority counterparts (Moore et al., 2024; Gustafson et al., 2023).

Q: What predictive value do SJTs offer?
A: SJTs predict non-academic outcomes years after admission, showing moderate correlation with professional characteristics assessed on national licensure exams (Dore et al., 2017). The AAMC reports that PREview scores are strong signals of non-academic termination risk in medical school (Royal et al., 2025).

Q: Can preparation improve SJT scores?
A: While commercial prep courses account for only a minimal variance (Acuity Insights, 2021), dedicated pathway programs for URiM students have been highly effective, with 51% of participants scoring in the highest quartile of the Casper test (Mahmood et al., 2023).

Bibliography​


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AAMC. (n.d.). About the AAMC PREview® Exam | Students & Residents.

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AAMC. (January 13, 2026). AAMC PREview Testing Year Update for Prehealth Advisors (webinar).

AAMC. (accessed April 6, 2026). The Premed Competencies for Entering Medical Students.

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Catlett, J. L., II, Sarfo, E. K., Maysonet, J., Parkas, V., & Swartz, T. H. (2026). Validity and equity of the AAMC PREview situational judgment test in U.S. medical school admissions. Medical Teacher, 1–9. https://doi.org/10.1080/0142159X.2026.2621963

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Disclosure of AI assistance​


The literature review was initially conducted with the help of NotebookLM/Google (accessed December 23, 2025) and Elicit.ai basic (December 24, 2025). With the help of Claude/Anthropic, the analysis reports provided the basis for this review. The abstract and first draft were written with the assistance of Gemini (a Chrome extension).

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