Writing MCQs

Liz NormanMassey University

MCQs – why?, why not?

Sampling advantages

• Can test a wide breadth of subjects in a time-efficient manner

• Sampling across the subject may therefore be more representative – validity

• Longer tests (more items) have better reliability

Applied vs fact recall

Fact recall:Questions capable of being answered by reference to one paragraph in a text or notes (or several paragraphs for questions requiring recall of several facts)

Applied (higher order)Questions that require the use of facts or concepts, the solution of a diagnostic or physiologic problem, the perception of a relationship, or other process beyond recalling discrete fact

From: Peitzman et al. (1990). Academic Medicine, 65(9), S59-60.

Positive consequences of MCQs on learning

• All examinations reinforce learning including MCQ examinations – MCQ formats may provide a feasible way to increase

formative assessment– MCQs formats facilitate timely feedback when used

formatively

• MCQs foster a deep approach to learning

Other advantages

• Can construct examinations of known difficulty (assuming psychometric analysis carried out)

• Established methods for setting cutpoints

Efficiency of MCQ

• Efficient and cost effective for large numbers of candidates

• Possibility of automated development

Disadvantages of MCQ

Realising the advantages requires procedures which makes them resource intensive and expensive

– Creation of a large question bank– Pretesting and statistical analysis of Qs– Post examination statistical analysis

Problems that can occur with MCQs

• Fact recall Qs are easier to write therefore tend to dominate

• Beginning writers will usually write fact recall Qs• Some topics are particularly difficult to write

MCQs for

Problems that can occur with MCQs

• If the test is poorly crafted, then the validity of the interpretation made of the resulting score is questionable

• Candidates can’t indicate their interpretation of the Q

• Identification of a correct response requires a different type of thinking from candidates than generation of a response

• Guessing can be rewarded

Other problems

• What is correct is still a subjective decision

Leastcorrect

Mostcorrect

D E AC B

Other problems

• Circulating recall papers may reduce even higher order Qs to recall Qs

Negative consequences of MCQs on learning

• False data present in MCQ distractors can result in learning of incorrect information

Item writing flaws

• 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

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.

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

How many options is enough?

The probability of selecting the correct answer by chance in a three-option multiple choice question is:

A. 33%

B. 50%

C. 75%

The probability of achieving a score of 70% by chance in a test comprising 30 three-option multiple choice questions is:

D. 0.00356%

E. 3.56%

F. 35.6%

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

A content free test

• From Phil Race who got this from Roger Lewis who cant remember where it came from…..

Q1

The usual function of grunge prowkers is to remove

A. grunges.

B. snarts.

C. trigs.

D. grods.

Q1

The usual function of grunge prowkers is to remove

A. grunges.

B. snarts.

C. trigs.

D. grods.

Don’t include a word from the stem in one of the options, or it will make people think it is the correct option

Q2

Antigrottification occurs

A. on spring mornings.

B. on summer evenings provided there is no rain before dusk.

C. on autumn afternoons.

D. on winter nights

Q2

Antigrottification occurs

A. on spring mornings.

B. on summer evenings provided there is no rain before dusk.

C. on autumn afternoons.

D. on winter nights

This option looks more probable, because it is longer, and because it is the only one which is qualified

Q3

Lurkies suffer from trangitis because:

A. their prads are always underdeveloped.

B. all their brizes are horizontal.

C. their curnpieces are usually imperfect.

D. none of their dringoes can ever adapt.

Q3

Lurkies suffer from trangitis because:

A. their prads are always underdeveloped.

B. all their brizes are horizontal.

C. their curnpieces are usually imperfect.

D. none of their dringoes can ever adapt.

Don’t mix indefinites with definites – indefinites are more likely to be correct. (Indefinites: usually, sometimes, often, seldom…;

Definites: all, never, none, and so on)

Q4

Non-responsive frattling is usually found in an:

A. gringle.

B. janket.

C. kloppie.

D. uckerpod

Q4

Non-responsive frattling is usually found in an:

A. gringle.

B. janket.

C. kloppie.

D. uckerpod

Don’t allow the indefinite article (‘an’) to give away the right answer

Q5

Which are exceptions to the law of lompicality?

A. The miltrip and the nattercup.

B. The bifid pantrip.

C. The common queeter.

D. The flanged ozzer

Q5

Which are exceptions to the law of lompicality?

A. The miltrip and the nattercup.

B. The bifid pantrip.

C. The common queeter.

D. The flanged ozzer

Don’t ask for something plural, then make just one option plural

Q6

Which must be present for parbling to take place?

A. Phlot and runge.

B. Runge.

C. Stuke and runge.

D. Runge and trake

Q6

Which must be present for parbling to take place?

A. Phlot and runge.

B. Runge.

C. Stuke and runge.

D. Runge and trake

If it’s not this option, it can’t be any of them (one way of thinking about it!!)

Q7

One common disorder of an overspragged uckerpod is:

A. copious vezzling.

B. intermittent weggerment.

C. non-responsive frattling.

D. uneven yerkation

Q7

One common disorder of an overspragged uckerpod is:

A. copious vezzling.

B. intermittent weggerment.

C. non-responsive frattling.

D. uneven yerkation

Be careful about overlapping questions! Candidates should look at both questions, and get maximum thinking

Q7

One common disorder of an overspragged uckerpod is:

A. copious vezzling.

B. intermittent weggerment.

C. non-responsive frattling.

D. uneven yerkation

Be careful about overlapping questions! Candidates should look at both questions, and get maximum thinking

Q8

Which of these is the correct answer?

A.

B.

C.

D.

Q8

Which of these is the correct answer?

A.

B.

C.

D.

There was a pattern. ‘D’ is due to come up again1: A; 2: B; 3: C; 4: D; 5: A; 6: B; 7: C; 8: D

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

Item difficulty and the purpose of testing

• If we are trying to rank students (norm-referenced) we need to create items with a range of difficulty to try and distinguish them, including some items we expect are well above the standard required .

• If we are trying to determine competence or attainment of a learning outcome (criterion-referenced) then items need be no more difficult than required to determine the difference between attainment and non-attainment.

• Remember that items can be difficult for the wrong reasons

“Effective item writers are trained, not born … “

Downing and Haladyna 2006, Handbook of test development ,p. 11

http://www.slideshare.net/liznorman