Writing MCQs

1. Writing MCQs Susan Chamberlain Dept of OBS/GYN Queen’s University

2. Writing MCQs At the end of this session, the participant will be able to • Identify different types of MCQ items • Describe the structure of an MCQ • List the technical flaws common to MCQ’s • write one well-structured MCQ testing appropriate content

3. Writing MCQs At the end of this session, the participant will be able to • Identify different types of MCQ items • Describe the structure of an MCQ • List the technical flaws common to MCQ’s • write one well-structured MCQ testing appropriate content • All of the above

4. MCQ Check-list • Why we write them • What type is best • What flaws are to be avoided • What content to test • How to construct it

5. Why do we test? • Communicate to the students what material is important (formative vs summative) • Motivate students to study • Identify areas of deficiency in need of remediation or further learning • Determine final grades or make promotion decisions • Identify areas where the course/curriculum is weak

6. What Should Be Tested? • Exam content should match course objectives • Important topics should be weighted more heavily than less important topics • The testing time devoted to each topic should reflect the relative importance of the topics • The sample of items should be representative of the instructional goals

7. What Should Be Tested? • Sampling “Performance on the sample provides a basis for estimating achievement in the broader domain that is actually of interest.” • Questions sample: • TOPICS • SKILLS ie determining diagnosis, next step in management, etc.

8. MCQ ‘Items’ • Should test important information – either common or life-threatening • Should be well-structured • Flaws benefit test-wise examinees • Irrelevant difficulty does not test examinees’ specific knowledge

9. Anatomy of an MCQ Item • Stem • Lead-in • Options • One correct answer • Distractors

10. Types of MCQ’s True/False family • Assess recall of isolated facts • Stems must be clear and unambiguous • Options must be absolutely true or false or examinee must decide how true options are • Generally not recommended – usually have subtle flaws

11. Types of MCQ’s: True/False Which of the following statements is true regarding contraception? • oral contraceptives should not be initiated until six weeks after therapeutic abortion to avoid the risk of hypercoagulability • an intrauterine device can provide good contraceptive protection 5 years after insertion • oral contraceptives should not be prescribed to individuals under the age of 15 without parental consent • lesbian women do not require counseling about contraception or sexually transmitted diseases • oral contraceptives should not be prescribed for women overthe age of 35

12. Types of MCQ’s One-Best-Answer family (A type) • Options may be diagrammed: D C A E B • Correct answer is the most likely correct • Better application of knowledge, integration, synthesis and judgment Least correct Most correct

13. Types of MCQ’s: One-Best-Answer family A 24 year old university student came to see you because she is missing several days of school each month because of severe dysmenorrhea unresponsive to the OCP and NSAIDS. She also complains of deep dyspareunia and has a tender uterosacral nodule on the pelvic examination. Which one of the following conditions is most likely responsible for her symptoms? • Chronic pelvic inflammatory disease • Endometriosis • Adenomyosis • Fibroids

14. MCQ Check-list • Why we write them • What type is best • What flaws are to be avoided • What content to test • How to construct it

15. MCQ Technical Flaws • Issues Related to Test-Wiseness • Issues Related to Irrelevant Difficulty

16. MCQ Technical Flaws • Issues Related to Test-Wiseness • provide clues to the right answer • examinee can eliminate options based on flaws and not on knowledge • Issues Related to Irrelevant Difficulty

17. Item Flaws: Test-wiseness • Grammatical cues • Logical cues • Absolute terms • Long correct answer • Word repeats • Convergence strategy

18. Item Flaws: Test-wiseness Grammatical cues • One or more distractors don’t follow grammatically from the stem

19. Item Flaws: Test-wiseness Grammatical cues A 24 year old patient presents with a one year history of dysmenorrhea, mid-cycle pain, dyspareunia, and painful bowel movements with her periods. The most likely diagnosis is: • Fibroid uterus • Adenomyosis • Endometriosis • Psychosomatic condition

20. Item Flaws: Test-wiseness Logical cues • A subset of the options are collectively exhaustive

21. Item Flaws: Test-wiseness Logical cues Arterial blood gases in a normal pregnant woman, compared to her non-pregnant state may show which of the following? • Decreased pO2 • Increased pCO2 • Decreased pCO2 • Decreased pH • No difference in pCO2

22. Item Flaws: Test-wiseness Logical cues • One or more distractors don’t follow logically from the stem

23. Item Flaws: Test-wiseness Logical cues An important tool for assessing fetal well-being is the Non Stress test. A well baby demonstrates the following fetal heart rate pattern: • A baseline heart rate above 120 bpm • Evidence of fetal movement • Baseline variability • Two fetal heart rate accelerations in 20 minutes • Fetal breathing movements

24. Item Flaws: Test-wiseness Absolute terms • Always, never • Not a problem if stem is long and lead-in asks a precise question

25. Item Flaws: Test-wiseness Absolute terms In patients with a previous Cesarean section: • Vaginal birth is NEVER an option • Repeat Cesarean section is less dangerous to the mother • The uterine scar may rupture during labour • Care should ALWAYS be supervised by an obstetrician • No further pregnancies should EVER be considered

26. Item Flaws: Test-wiseness Long correct answer • Correct answer is longer, more specific, or more complete than other options

27. Item Flaws: Test-wiseness Long correct answer Which of the following problems in vaginal breech delivery is most likely to cause serious long-term complications? • Failure to descend • Cord prolapse • Nuchal arms • Entrapment of the after coming head with an incompletely dilated cervix • 1 minute Apgar score of 4

28. Item Flaws: Test-wiseness Word repeats • A word or phase is included in the stem and in the correct answer

29. Item Flaws: Test-wiseness Word repeats A 24 year old with a previous history of chronic PID presents with primary infertility. Select the procedure that would be most appropriate to evaluate the status of her tubes and pelvic anatomy • Post-coital test • Endometrial biopsy • Laparoscopy with dye insufflation of the fallopian tubes • Hysterosalpingogram

30. Item Flaws: Test-wiseness Convergence strategy • The correct answer includes the most elements in common with the other options

31. Item Flaws: Test-wiseness Convergence strategy Normal bladder neck mobility is measured by: • A Q-tip angle measurement under 40 degrees • A Q-tip angle measurement under 30 degrees • A bladder neck ultrasound angle less than 30 degrees • A Q-tip angle measurement under 20 degrees

32. MCQ Technical Flaws • Issues Related to Test-Wiseness • Issues Related to Irrelevant Difficulty • do not assess knowledge of intended topic

33. Irrelevant Difficulty • Options are long, complicated or double • Extraneous details in stem • Numeric data not stated consistently • Vague frequency terms • Non-parallel language in options • Stems are tricky or unnecessarily complicated • ‘None of the above’

34. Irrelevant Difficulty Options are long, complicated or double Extraneous details in stem • Shifts difficulty from content knowledge to speed reading

35. Irrelevant Difficulty Options are long, complicated or double Mrs. Brown is a 70 year old woman who had a stroke 6 months ago and is still impaired. Her daughter tells you that her mother’s recent urinary incontinence makes her care unmanageable. She is seeking permanent placement. Mrs. Brown complains of urinary frequency, nocturia, and urge incontinence. Which of the following statements is true? • Neurological conditions are involved in the majority of women with symptoms like those presented by Mrs. Brown • Diabetes has a greater impact on quality of life than Mrs. Brown’s condition. • The pharmacological blockage of muscarinic receptors in the detrusor muscle controls symptoms compatible with Mrs. Brown’s condition • Overactive bladder is defined as urinary incontinence accompanied by or immediately preceded by urgency • Alpha stimulants are effective in treating this condition

36. Irrelevant Difficulty Extraneous details in stem You see in your office a 24 year old woman for her routine postpartum visit, at 6 weeks. Her baby is irritable and cries “all the time’ (including during her visit.) As she is changing the diaper during her visit, you notice that the child has a very red bum but upon questioning, she tells you she did not notice anything abnormal. Her partner is away in Afghanistan and she does not have a lot of friends, as they just recently were posted in Kingston. She states that she has a hard time getting dressed in the morning, cries easily and feels like she does not love her child. She denies any medical or psychiatric history. Her exam is essentially normal. She weighs 2 kg less than at her first antenatal visit at 10 weeks. You most likely clinical diagnosis is: • Postpartum hypothyroidism • Hyperthyroidism • Postpartum blues • Postpartum depression • Psychotic depression

37. Irrelevant Difficulty Numeric Data • Not stated consistently • Mixed format • Illogical order

38. Irrelevant Difficulty Numeric Data not stated consistently Following a second episode of salpingitis, what is the likelihood that a woman is infertile? • Less than 20% • 20 – 30 % • Greater than 50 % • 90% • 75%

39. Irrelevant Difficulty Vague frequency terms • Often, usually, rarely, frequently • Not consistently defined *may be used in stem if otherwise carefully constructed unambiguous question

40. Irrelevant Difficulty Vague frequency terms Gonorrhea is A) sometimes asymptomatic B) treated with cefixime 450 mg orally C) caused by a gram positive intracellular diplococcus D) diagnosed by a DNA test E) usually associated with vulvar ulcers

41. Irrelevant Difficulty • Non-parallel language in options • Non-logical order

42. Irrelevant Difficulty Non-parallel language in options In a vaccine trial, 200 2-year-old boys were given a vaccine against a certain disease and then monitored for five years for occurrence of the disease. Of this group, 85% never contracted the disease. Which of the following statements concerning these results is correct? • No conclusion can be drawn, since no follow-up was made of non-vaccinated children • The number of cases (ie 30 cases over five year) is too small for statistically meaningful conclusions • No conclusions can be drawn because the trial involved only boys • Vaccine efficacy (%) is calculated as 85-15/100

43. Irrelevant Difficulty “None of the above” • Problematic where judgment is involved or if options not absolutely true or false • Turns question into true/false question • Confuses very knowledgeable students

44. Irrelevant Difficulty “None of the above” The main reason that fertility is reduced in a woman in her early 40’s is: • Irregular cycles make it hard to time intercourse • Chromosomal damage adversely affects oocytes’ genetic complement • Male erectile difficulties increase • Hormone imbalance leads to poor endometrial development • None of the above

45. Irrelevant Difficulty Stems are tricky or unnecessarily complicated Arrange the parents of the following children with Down’s syndrome in order of the highest to lowest risk of recurrence. Assume that the maternal age in all cases is 22 years and that a subsequent pregnancy occurs within 5 years. The karyotypes of the daughters are: I: 46, XX, –14,+T (14q21q) pat II: 46, XX, –14,+T (14q21q) de novo III: 46, XX, –14,+T (14q21q) mat IV: 46, XX, –21,+T (14q21q) pat V: 46, XX, –21,+T (21q21q) (parents not typed) • III, IV, I, V, II • IV, III, V, 1, II • III, I, IV, V, II • I, V, III, I, V, II • III, IV, I, II, V

46. MCQ Check-list • Why we write them • What type is best • What flaws are to be avoided • What content to test • How to construct it

47. What to test? Items classified by cognitive processes required to answer the question: • Recall (Memory)– tests knowledge of isolated facts • Interpretation (Comprehension)– review information to reach conclusion, eg diagnosis • Problem solving (Reasoning) – situation requires action, eg next step in management • Process depends on background of trainee

48. What to test? Simpler classification based on task: • Application of knowledge item ** • Reach conclusions • Make predictions • Select course of action • Recall item • Test knowledge of isolated facts

49. What to test? • Test application of knowledge using clinical vignettes • Adds ‘face-validity’ • Usually selects more important, less trivial • Identifies student who’ve memorized but do not understand BUT experience in patient care should not be necessary

50. What to test - summary • Focus item on key concepts and principles that are essential information (without access to references) for all examinees to understand • Test material that is relevant to learning in clinical clerkships and beyond • Avoid items that only require recall of isolated facts • Avoid esoteric or interesting topics that are not essential