MCQ’s 1: MCQ’s 1: Construction of an MCQConstruction of an MCQ

MCQ Check-listMCQ Check-list

This presentation will focus on:This presentation will focus on: Why we write themWhy we write them What type is bestWhat type is best What flaws are to be avoidedWhat flaws are to be avoided What content to testWhat content to test How to construct itHow to construct it

Why do we test?Why do we test?

Formative assessment Formative assessment Communicate to the students what material is Communicate to the students what material is

importantimportant Identify areas of deficiency in need of Identify areas of deficiency in need of

remediation or further learningremediation or further learning Summative assessmentSummative assessment

Determine final gradesDetermine final grades Make promotion decisionsMake promotion decisions

BothBoth Motivate students to studyMotivate students to study Identify areas where the course/curriculum is Identify areas where the course/curriculum is

weakweak

What Should Be Tested?What Should Be Tested?

Exam content should match course Exam content should match course objectivesobjectives

Important topics should be weighted Important topics should be weighted more heavily than less important more heavily than less important topicstopics

The testing time devoted to each The testing time devoted to each topic should reflect the relative topic should reflect the relative importance of the topicsimportance of the topics

What Should Be Tested?What Should Be Tested?

Sampling - Performance on the sample Sampling - Performance on the sample provides a basis for estimating provides a basis for estimating achievement in the broader domain achievement in the broader domain that is actually of interestthat is actually of interest

Questions sample: Questions sample: TOPICS – eg MCC presentationsTOPICS – eg MCC presentations SKILLS – eg Course Objectives – SKILLS – eg Course Objectives –

determining diagnosis, next step in determining diagnosis, next step in management, etc.management, etc.

Anatomy of an MCQ ItemAnatomy of an MCQ Item

StemStem Lead-inLead-in OptionsOptions

One correct answerOne correct answer DistractorsDistractors

Types of MCQ’sTypes of MCQ’s

True/False familyTrue/False family Assess recall of isolated factsAssess recall of isolated facts

Stems must be clear and unambiguousStems must be clear and unambiguous Options must be absolutely true or false or Options must be absolutely true or false or

examinee must decide examinee must decide how truehow true options are options are

Generally not recommended – usually Generally not recommended – usually have subtle flawshave subtle flaws

Types of MCQ’s: True/FalseTypes of MCQ’s: True/False

Which of the following statements is true regarding Which of the following statements is true regarding contraception?contraception?

A)A) oral contraceptives should not be initiated until oral contraceptives should not be initiated until six weeks after therapeutic abortion to avoid the six weeks after therapeutic abortion to avoid the risk of hypercoagulabilityrisk of hypercoagulability

B)B) an intrauterine device can provide good an intrauterine device can provide good contraceptive protection 5 years after insertioncontraceptive protection 5 years after insertion

C)C) oral contraceptives should not be prescribed to oral contraceptives should not be prescribed to individuals under the age of 15 without parental individuals under the age of 15 without parental consentconsent

D)D) lesbian women do not require counseling about lesbian women do not require counseling about contraception or sexually transmitted diseasescontraception or sexually transmitted diseases

E)E) oral contraceptives should not be prescribed for oral contraceptives should not be prescribed for women overwomen over the age of 35the age of 35

Types of MCQ’sTypes of MCQ’s

One-Best-Answer family (A type)One-Best-Answer family (A type) Options may be diagrammed:Options may be diagrammed:

D C A E BD C A E B

Correct answer is the Correct answer is the most likelymost likely correct correct Better application of knowledge, Better application of knowledge,

integration, synthesis and judgmentintegration, synthesis and judgment

Least correct Most correct

Types of MCQ’s: Types of MCQ’s: One-Best-Answer familyOne-Best-Answer family

A 24 year old university student came to see you A 24 year old university student came to see you because she is missing several days of school each because she is missing several days of school each month because of severe dysmenorrhea month because of severe dysmenorrhea unresponsive to the OCP and NSAIDS. She also unresponsive to the OCP and NSAIDS. She also complains of deep dyspareunia and has a tender complains of deep dyspareunia and has a tender uterosacral nodule on pelvic examination. Which uterosacral nodule on pelvic examination. Which one of the following conditions is most likely one of the following conditions is most likely responsible for her symptoms?responsible for her symptoms?

A)A) Chronic pelvic inflammatory diseaseChronic pelvic inflammatory diseaseB)B) EndometriosisEndometriosisC)C) AdenomyosisAdenomyosisD)D) FibroidsFibroids

What to test?What to test?

Items can be classified byItems can be classified by cognitive processescognitive processes required to answer the question:required to answer the question:

Recall Recall (Memory)– tests knowledge of isolated (Memory)– tests knowledge of isolated factsfacts

InterpretationInterpretation (Comprehension)– review (Comprehension)– review information to reach conclusion, eg diagnosisinformation to reach conclusion, eg diagnosis

Problem solvingProblem solving (Reasoning) – situation (Reasoning) – situation requires action, eg next step in managementrequires action, eg next step in management Process depends on background of Process depends on background of

traineetrainee

What to test?What to test?

Simpler classification based on taskSimpler classification based on task:: Application of knowledgeApplication of knowledge item item ****

Reach conclusionsReach conclusions Make predictionsMake predictions Select course of actionSelect course of action

Recall Recall itemitem Test knowledge of isolated factsTest knowledge of isolated facts

What to test?What to test?

Test application of knowledge using Test application of knowledge using clinical vignettesclinical vignettes Adds ‘face-validity’Adds ‘face-validity’ Usually selects more important, less trivialUsually selects more important, less trivial Identifies student who’ve memorized but Identifies student who’ve memorized but

do not understanddo not understand

BUT experience in patient care should BUT experience in patient care should not be necessarynot be necessary

What to test - summaryWhat to test - summary

Focus item on Focus item on key conceptskey concepts and principles and principles that are essential information (without that are essential information (without access to references) for all examinees to access to references) for all examinees to understandunderstand

Test material that is Test material that is relevantrelevant to learning in to learning in pre-clinical courses and beyondpre-clinical courses and beyond

AvoidAvoid items that items that onlyonly require require recall of recall of isolated factsisolated facts

Avoid esotericAvoid esoteric or interesting topics that or interesting topics that are not essentialare not essential

What to test - summaryWhat to test - summary

Test application of knowledge using Test application of knowledge using clinical vignettesclinical vignettes to pose medical to pose medical decisions in patient care situationsdecisions in patient care situations

Focus items on Focus items on common or common or potentially catastrophic problemspotentially catastrophic problems

Pose clinical decisions that would be Pose clinical decisions that would be expected of a successful examinee expected of a successful examinee ie Avoid clinical situations that would be ie Avoid clinical situations that would be

handled by a (sub)specialisthandled by a (sub)specialist

Anatomy of an MCQ ItemAnatomy of an MCQ Item

StemStem Lead-inLead-in OptionsOptions

One correct answerOne correct answer DistractorsDistractors

Writing the QuestionsWriting the Questions

Construct stem –include all Construct stem –include all necessary information to arrive at necessary information to arrive at the right answerthe right answer

Choose lead-in – pose a clear Choose lead-in – pose a clear questionquestion

Choose distractorsChoose distractors

Stem*Stem*

Usually a clinical scenario Usually a clinical scenario Clear, unambiguousClear, unambiguous Should be long relative to optionsShould be long relative to options Includes all pertinent informationIncludes all pertinent information

Patient’s age/genderPatient’s age/gender Clinical settingClinical setting ComplaintComplaint Other important info – history, physical Other important info – history, physical

findings, test resultsfindings, test results

Lead-in*Lead-in*

Follows stemFollows stem In the form of a questionIn the form of a question Should relate to the stemShould relate to the stem Should be answerable without looking Should be answerable without looking

at optionsat options ““Cover the Options test”Cover the Options test”

Should clearly communicate the Should clearly communicate the learning objective learning objective

DistractorsDistractors

Each should be selected by some, Each should be selected by some, therefore all plausible, none therefore all plausible, none obviously incorrectobviously incorrect

3 or 4 choices3 or 4 choices Common misconceptionsCommon misconceptions Faulty reasoningFaulty reasoning

DistractorsDistractors

Homogeneous in content to the correct answerHomogeneous in content to the correct answer Should be in same category as correct Should be in same category as correct

answer– diagnosis, treatment, diagnostic testanswer– diagnosis, treatment, diagnostic test Clearly incorrect or inferior to the correct Clearly incorrect or inferior to the correct

answeranswer Plausible and attractive to the uninformedPlausible and attractive to the uninformed Similar to the correct answer in construction Similar to the correct answer in construction

and length and length Grammatically consistent and logically Grammatically consistent and logically

compatible with the stemcompatible with the stem

General Guidelines for Item General Guidelines for Item ConstructionConstruction Include as much of the item as possible in Include as much of the item as possible in

the stems: Long stems, short optionsthe stems: Long stems, short options Avoid negatively phrased items (Avoid negatively phrased items (exceptexcept or or

notnot in the lead-in). If you must, use only in the lead-in). If you must, use only with short optionswith short options

Avoid writing questions of the form:Avoid writing questions of the form: Which of the following statements is correct?Which of the following statements is correct? Each of the following statements is correct Each of the following statements is correct

EXCEPTEXCEPT Unfocussed Unfocussed Heterogeneous optionsHeterogeneous options

““Top-down” versus “Bottom-Top-down” versus “Bottom-up”up”

Top-DownTop-Down Knowledge or recall question Knowledge or recall question Cite a disease and then ask what Cite a disease and then ask what

patient findings are expectedpatient findings are expected Structured like textbooksStructured like textbooks

Clinically backwardClinically backward

““Top-down” versus “Bottom-Top-down” versus “Bottom-up”up”

Bottom-upBottom-up Application of knowledgeApplication of knowledge Gives findings and asks examinee to Gives findings and asks examinee to

indicate the diseaseindicate the disease Examinees need to be able to Examinees need to be able to

synthesize information from several synthesize information from several pages of a textbook (or notes) to pages of a textbook (or notes) to answer these questionsanswer these questions

Clinically realisticClinically realistic

Basic Rules for MCQ’s (A type)*Basic Rules for MCQ’s (A type)*

Focus item on important conceptFocus item on important concept Item should assess application of Item should assess application of

knowledge, not recall of an isolated factknowledge, not recall of an isolated fact Stem must pose clear question – ‘Cover Stem must pose clear question – ‘Cover

the options’ testthe options’ test All distractors should be homogeneousAll distractors should be homogeneous Avoid technical item flawsAvoid technical item flaws

ReferenceReference

Constructing Written Test Questions Constructing Written Test Questions For the Basic and Clinical SciencesFor the Basic and Clinical Sciences Case & Swanson, NBME 1996Case & Swanson, NBME 1996

Basic Rules for MCQ’s (A type)*Basic Rules for MCQ’s (A type)*

Focus item on important conceptFocus item on important concept Item should assess application of Item should assess application of

knowledge, not recall of an isolated factknowledge, not recall of an isolated fact Stem must pose clear question – ‘Cover Stem must pose clear question – ‘Cover

the options’ testthe options’ test All distractors should be homogeneousAll distractors should be homogeneous Avoid technical item flawsAvoid technical item flaws

One last step…One last step…

Get a colleague to read over your Get a colleague to read over your questions questions Detects more than one right answerDetects more than one right answer Discovers the ‘what am I thinking?’ Discovers the ‘what am I thinking?’

questionquestion Identifies not enough information in the Identifies not enough information in the

stemstem ……