Writing MCQs

Liz NormanMassey University

Why worry about item writing flaws?

• Affect 36-65% of questions • 10-15% are serious enough to influence pass-

fail decisions • high-achieving students were more likely than

borderline students to be penalised by flawed items.

• reducing item flaws does improve the performance of MCQs

Avoiding irrelevant difficulty

Focus on one thing per Q

• One thing• Something important – common or catastrophic• Application not recall• Something that would happen in real life• NOT something tricky or overly complex

Avoid double options

2-year-old male neutered Border Collie is presented with the following history and neurologic signs: …….. Which one of the following neuroanatomic localizations and diagnoses is CORRECT?

A. Left C1-C5 myelopathy, intervertebral disk rupture

B. Right C6-T2 myelopathy, fibrocartilagenous embolism

C. Right C1-C5 myelopathy, intervertebral disk rupture

D. Left C1-C5 myelopathy, fibrocartilagenous embolism

Keep options short

Iris prolapse is a common sequel to penetrating corneal wounds or ruptured corneal ulcers. Which of the following steps is NOT appropriate for the treatment of iris prolapse?

A. primary closure of the corneal laceration with 8-0 vicryl and treatment with topical antibiotics to control infection.

B. placement of a nictitans flap and treatment with systemic antibiotics to control infection.

C. placement of a corneal graft with an overlying conjunctival pedicle graft and treatment with systemic antibiotics to control infection.

A 7-year-old mare has had intermittent signs of moderately severe colic for the past 48 hours. Heart rate is 56 beats/min. Hydration, acid-base balance, and electrolyte parameters are near normal. On rectal examination, the left dorsal and ventral colon feels distended and is felt coursing in a dorsocranial direction. The spleen is displaced caudomedially. Which of the following is the most likely diagnosis?

A. Cecocolic intussusception or cecal inversion

B. Displacement of the left colon over the nephrosplenic ligament

C. Ileocecal intussusception

D. Infarction of the large colon

E. Volvulus of the large colon and the cecum

Pose a clear task

Chyle is :-

A. The semifluid mass which empties from the stomach into the duodenum.

B. The lymph containing fat droplets found in the lacteals of the small intestine.

C. The contents of the gall bladder.

D. The rounded piece of chewed food which passes down the oesophagus when the animal swallows.

Make all distractors plausible and homogenous

Which of the following statements regarding hepatic encephalopathy is true?

A. Patients typically present with asymmetrical neurological deficits

B. The most effective and appropriate anticonvulsant to use for a patient that is seizuring due to hepatic encephalopathy is phenobarbital

C. Abdominal radiographs of dogs with portosystemic shunts will often show an enlarged liver

D. Cats with portosystemic shunts often exhibit ptyalism as a clinical sign

E. An appropriate treatment for hepatic encephalopathy is intravenous neomycin

Include only ONE best answer

Which of the following is true?

A. Bananas are green

B. Motorbikes are faster than cars

C. Boys are taller than girls

Include only ONE best answer

Leastcorrect

Mostcorrect

D E AC B

Avoid none of the above

Which of the following is true regarding ligament injuries?

A. Ligament injuries are appropriately referred to as “strains” or “sprains”.

B. Surgical intervention is indicated for treatment of second-degree sprains with demonstrable instability.

C. The elastic nature of ligaments allows 30% elongation before permanent deformation.

D. Following surgical repair of ligaments, immobilization via ESF or external coaptation is contraindicated, as range of motion is critical to successful repair.

E. None of the above.

Avoid negative framing

Which of the following statements is false regarding arthrotomies?

A. When detachment of a ligament is necessary, this should be performed by osteotomy of the bony origin rather than transection of the ligament.

B. Complete closure of the synovium is necessary to prevent synovial fluid leakage into subcutaneous tissue.

C. Surgical removal of osteophytes is often followed by their relatively rapid regrowth, and has questionable value.

D. Monofilament absorbable suture material has a lower risk for long term infection than does braided nonabsorbable suture.

E. None of the above.

Three options are enough

• Most 4- and 5-option MCQs actually function as 3-option anyway

• 3 options questions:– discriminate as well or better– question difficulty changes but this can be

compensated for– reliability is as good or better– may allow more questions per testing time –

increasing reliability and validity– reduces exposure to “incorrect” options

But what about guessing?

• Possible significance not been borne out empirically: – multiple studies and meta-analysis– across many disciplines including medicine and nursing

• Would be detectable in post-test analysis if it happened

• Probability modelling doesn’t apply because guessing is not truly random

• Students do not do substantially better on tests using three-option formats.

3 options is enough – but sometimes you do need more

A horse suffering from an acute intestinal accident is MOST likely to have

A. primary respiratory acidosis

B. primary respiratory alkalosis

C. primary metabolic alkalosis

D. primary metabolic acidosis

Avoiding irrelevant ease“testwiseness”

Flaws to watch out for include

• Grammatical cues: – one or more distractors don’t follow grammatically from

the stem

• Logical cues: – a subset of the options are collectively exhaustive

• Absolute and vague terms: – terms such as “always”, “never” or “all” used in options.– terms such as “usually” and “frequently” used in

options.

Flaws to watch out for include

• Long correct answer: – correct answer is longer, more specific, or more

complete than other options

• Word repeats: – a word or phrase is included in the stem and in the

correct answer

• Convergence: – the correct answer includes the most elements in

common with the other options

Flaws to watch out for include

• Numeric data not stated consistently• Options are in an illogical order• Stems (lead-ins) are tricky or unnecessarily

complicated

Eurodollars refers to dollar deposits when the depository bank is located in

a) Europe.

b) Europe, and the Caribbean.

c) Outside the United States.

d) United States.

The gold standard still has ardent supporters who believe that it provides

a) an effective hedge against price inflation.

b) fixed exchange rates between all currencies.

c) monetary policy autonomy.

d) the world economy can be subject to inflationary pressure without changes in the supply of monetary gold.

During a foot series the shoes should _____ be removeda) always (apart from laminitics) b) never c) sometimes d) remain in place until the foot balance views are

taken then e) if due for shoeing

Floating-rate notes (FRN)

a) always trade at par value.

b) have contractually specified coupon payments, therefore they are fixed rate bonds.

c) appeal to investors with strong need to preserve the principal value of the investment should they need to liquidate prior to the maturity of the bonds.

d) They experience very volatile price changes between reset dates.

Sedation for equine radiography is

a) never needed

b) only needed for foals

c) usually needed

d) only needed for adult horses

Which of the following statements about hedging a stock portfolio with stock index futures is NOT true?

a) Futures contracts magnify gains (or losses) on the stock portfolio

b) In a declining market, futures contracts help offset losses on the portfolio

c) A risk-taker would probably not hedge the entire portfolio with stock index futures

d) All of the above are true

Writing guidelines

Item writing guidelines

• Test application of knowledge not recall• Don’t test “trivial” knowledge• Focus on real life problems• Use novel material - clinical vignettes are good

as long as they are realistic• Use a blueprint

Item writing guidelines

• Minimize the amount of reading in each item• Avoid unnecessary words• Use correct grammar, punctuation,

capitalization, and spelling.• Edit and proof items

Item writing guidelines

• Include the central idea in the stem instead of the choices.

• Ensure that the directions in the stem are very clear.

• Word the stem positively, avoid negatives such as NOT or EXCEPT. If negative words are used, use the word cautiously and always ensure that the word appears capitalized and boldface

Item writing guidelines

• Place choices in logical or numerical order.• Keep choices independent; choices should not be

overlapping.• Keep choices homogeneous in content and

grammatical structure.• Keep the length of choices about equal.• Make sure that only one answer is right or clearly

better than any other• Make all distractors plausible

Sample lead in and option lists for clinical vignettes

• Which of the following is (abnormal)?Options sets could include sites of lesions; list of nerves; list of muscles; list of enzymes; list of hormones; types of cells; list of neurotransmitters; list of toxins, molecules, vessels, spinal segments.

• Which of the following findings is most likely?Options sets could include list of laboratory results; list of additional physical signs; autopsy results; results of microscopic examination of fluids, muscle or joint tissue; DNA analysis results; serum levels.

Constructing Written Test Questions For the Basic and Clinical Sciences, 3rd edn, 2001, National Board of Medical Examiners (NBME), USA http://www.nbme.org/publications/item-writing-manual.html

Sample lead in and option lists for clinical vignettes

• Which of the following is the most likely cause?Options sets could include list of underlying mechanisms of the disease; medications that might cause side effects; drugs or drug classes; toxic agents; hemodynamic mechanisms, viruses, metabolic defects.

• Which of the following should be administered?Options sets could include drugs, vitamins, amino acids, enzymes, hormones.

• Which of the following is defective/deficient/nonfunctioning?Options sets could include list of enzymes, feedback mechanisms, endocrine structures, dietary elements, vitamins.

http://www.nbme.org/publications/item-writing-manual.html

Reviewing MCQs

Reviewing MCQs

• Peer review– Both by subject experts and non-subject experts

• Evaluate Q performance after the exam– Q difficulty – how many got the Q right– Discrimination - How high performing and low

performing students answered each Q– Utility of distracters

Evaluate Q performance

“Effective item writers are trained, not born”

Steven M Downing (2006) Twelve steps for effective test development, In: Downing SM and Haladyna TM (Eds), Handbook of Test Development, Lawrence Erlbaum Associates, Mahwah, NJ, USA, p.11

http://www.slideshare.net/liznorman