McGill Workshop

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The Development of Multiple-Choice Questions using the Key-features Approach

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McGill Workshop

  1. 1. The Development of Multiple- Choice Questions using the Key-features Approach Claire Touchie, MD, FRCPC University of Ottawa Medical Council of Canada
  2. 2. Conflict of InterestMedical Education: none 2
  3. 3. Workshop Agenda1. Introductions (10 min)2. What is the key-features approach (20 min)3. Exercise 1: Defining key-features (15 min)4. How to write multiple choice items (25 min)5. Exercise 2: Writing multiple-choice questions (30 min)6. Leg Stretch (10 min)7. Large group discussion: Review of MCQs (30 min)8. Exercise 3: Technical flaws (15 min)9. What are technical flaws (15 min)10. Wrap up and evaluations 3
  4. 4. Workshop Objectives• Describe what can be tested with multiple- choice items• Define the anatomy of a multiple-choice item• Define and identify technical flaws• Create multiple-choice items for own stated purpose• Define and criticize poor performing items 4
  5. 5. Why are we doing this? Which one of the following is true about pseudogout? 1. It occurs frequently in women. 2. Seldom associated with acute pain in a joint 3. May be associated with a finding of chondrocalcinosis. 4. It is hereditary in all cases 5. It responds well to treatment with allopurinol
  6. 6. Why are we doing this?A 62 year-old woman with a history of confusion and constipation comes tothe office for a follow-up visit. Laboratory investigations reveal a serumcalcium of 2.9mmol/L, a creatinine of 146 µmol/L, and a hemoglobin of 108g/L.Which one of the following is the most likely diagnosis?1. Hyperparathyroidism2. Chronic renal failure3. Multiple myeloma*4. Vitamin D intoxication5. Renal cell carcinoma
  7. 7. Key Feature Problems•Based on the concept of “Case Specificity” – The clinical performance on one problem is NOT a good predictor for performance on other problems•Assessment is best served when focusingexclusively on the unique challenges (keyfeatures) in the resolution of each problem – Essential issues or specific difficulty
  8. 8. Key Feature Problems•First discussed at Cambridge Conference – 1984•Developed by Georges Bordage and Gordon Page forthe MCC•First incorporated into the MCCQE Part I – 1992•Known under different names – Q4, Clinical Reasoning Skills (CRS), Clinical Decision Making (CDM)
  9. 9. So what? Who cares?•Studies show validity evidence and reliability intesting settings•Wenghofer et al. (Med Educ 2009) – Candidates in the bottom quartile had a 3-fold increase in the risk of an unacceptable quality-of-care assessment outcome (OR 3.41)
  10. 10. Key Feature ProblemsAssesses decision-making skills NOT recallof factual information Knowledge Clinical Decision Application of knowledge
  11. 11. Application of Knowledge•To elicit clinical clues•To formulate diagnostic impressions•To order investigative or f/u procedures•To acquire data to monitor a course of actionOR evaluate the severity/probability of anoutcome•To select a management course
  12. 12. Example of Knowledge question•Which of the following are characteristicof delirium?
  13. 13. Alternate type of questionShould assess the ability to: – Recognize delirium tremens in a specific patient • An example of a “clinical reasoning” issue – Prescribe appropriate therapeutic measures • An example of a “clinical decision” issue
  14. 14. Key Feature – Definition•A critical or essential step in the resolution of aproblem•A step in which examinees are most likely tomake errors in the resolution of a problem•A difficult or challenging aspect in theidentification and management of the problem inpractice
  15. 15. Advantages of the Key Feature Approach•More discriminating•Shifts the emphasis from – The method of assessment to the object of assessment – Assessing all aspects of solving a problem to assessing only the essential element
  16. 16. Key Question of Key Features“What are the critical, essential elements in the resolution of the problem?”
  17. 17. Process in Key Feature Development•Problem definition•Selecting a key feature•Developing a clinical scenario•Identifying the correct answer (in the case ofsingle correct MCQ)•Identifying plausible distractors
  18. 18. How can this be applied?Let us try…
  19. 19. Problem DefinitionSelect an objective or a clinicalproblem…delirium/confusionSelect a clinical situation – Undifferentiated complaint – A single typical problem* – A multi-system problem – A life-threatening event* – Preventive care and health promotion
  20. 20. Selecting a Key Feature•Ask the question – What are the critical essential elements in the resolution of the problem?•Key feature 1 – Given a patient with post-operative delirium, ask about EtOH consumption•Key feature 2 – Given a patient with post-operative delirium, recognize delirium tremens and manage with benzodiazepines
  21. 21. Exercise #1Writing key features 21
  22. 22. How to write multiple-choice items1. The What2. The How 22
  23. 23. The What• What can I test with MCQs? • Knowledge • Clinical-decision making• Clearly define the purpose of your exam• Define what it is you want to test • For the overall test • For your specific question 23
  24. 24. The WhatPrior to writing your question, ask thefollowing questions• What concept do I want to test?• Where does the learner go wrong? • Focus on areas of “challenge” for the learner 24
  25. 25. Example of the WhatPurpose: To assess the clinical clerk’sknowledge and decision making capabilityat the end of an Internal Medicine six weekrotation• Concept/Objective: Management of CHF• Challenge to the learner: ??? 25
  26. 26. The How – Anatomy of a MC item• Stem • Clinical vignette which describes the setting, the patient’s age and complaint along with pertinent historical facts, physical exam details, and/or laboratory findings• Lead-in question • The task• Answer and alternatives • The most correct answer and the plausible distractors 26
  27. 27. The How – Anatomy of a MC itemStem• A 58-year old man presents to the ED with sudden onset of left-sided chest pain associated with shortness of breath, palpitations and dizziness. His past history is relevant for a recent diagnosis of lung carcinoma. His examination is only remarkable for a heart rate of 112/minute. 27
  28. 28. The How-Anatomy of a MC itemLead-in question• Which one of the following diagnostic test would be most useful to confirm the diagnosis? 28
  29. 29. The How – Anatomy of a MC itemCorrect/Best answer and distractors1. Chest radiograph2. CT of the chest *3. Sputum culture4. Electrocardiogram5. Echocardiogram 29
  30. 30. What did you notice about this question?Could you answer it without seeing thealternatives?Could you answer without being given thediagnosis? 30
  31. 31. The Stem• Short description of a clinical scenario • Common or clinically important • Clear and contains relevant information to the clinical problem – avoid window-dressing• Word the stem positively • Avoid EXCEPT questions • Use negative words with caution • Eg: contraindication, what to avoid 31
  32. 32. The Stem• Provide sufficient information to answer the item • DO NOT create tricky items by omitting essential information • DO NOT add extraneous information • Stem should be a clinical vignette 32
  33. 33. Lead-in Question• Ensure the directions are very clear with a clear task • Can the stem be administered in a short answer (constructed-response) format? • “Cover answer test”
  34. 34. Lead-in Question• Different clinical tasks can be tested• Can be done with the same stem (cloning of question) • History • Diagnosis • Investigations • Management/Treatment/Drug therapy • Counseling
  35. 35. Lead-in QuestionTry asking questions that lead to clinical decision-making?Which one of the following – … is the most likely diagnosis? – … investigations would you now order? – …is the next step in the work-up of this patient? – … is the most important step in the initial management of this patient?
  36. 36. Distractors• Only one right choice with distractors• Number of distractors is a policy decision (3? vs. 4?)• Use plausible distractor choices• Keep distractors independent, they should not be overlapping • E.g.: 1. 11-20; 2. 15-30• Keep distractors homogeneous in content and grammatical structure• Keep the length about equal• Avoid specific determiners such as All, Never, Always, Completely and Absolutely• Do not use All of the Above or None of the Above
  37. 37. Item testing clinical decision-makingA 62 year-old woman with a history of confusion and constipation comes tothe office for a follow-up visit. Laboratory investigations reveal a serumcalcium of 2.9mmol/L, a creatinine of 146 µmol/L, and a hemoglobin of 108g/L.Which one of the following is the most likely diagnosis?1. Hyperparathyroidism2. Chronic renal failure3. Multiple myeloma*4. Vitamin D intoxication5. Renal cell carcinoma
  38. 38. Item testing clinical decision-makingA 62 year-old woman with a history of confusion and constipationcomes to the office for a follow-up visit. Laboratory investigationsreveal a serum calcium of 2.9mmol/L, a creatinine of 146 µmol/L, anda hemoglobin of 108 g/L.Which one of the following would help confirm the diagnosis?1. Parathyroid hormone2. Serum protein electrophoresis*3. 25-OH vitamin D4. Serum creatinine5. Abdominal ultrasound
  39. 39. What is wrong with this item?A previously healthy person suddenly presents withpleuritic pain in the left chest and shortness of breath.Which one of the following is the most likelydiagnosis?1. Mycoplasma pneumonia2. Spontaneous pneumothorax3. Pulmonary embolism4. Acute pericarditis5. Epidemic pleurodynia
  40. 40. What is wrong with this item?Which one of the following is true about pseudogout?1. It occurs frequently in women.2. Seldom associated with acute pain in a joint3. May be associated with a finding of chondrocalcinosis.4. It is hereditary in all cases5. It responds well to treatment with allopurinol 40
  41. 41. What is wrong with this item?Aortic insufficiency may be caused by all of thefollowing, EXCEPT:1. syphilis2. Marfan’s syndrome3. aortic dissection4. bacterial endocarditis5. myocardial infarction*
  42. 42. Exercise #2 – 30 minutes Writing MCQ items• Pair up with a partner• Using the MCQ item development worksheet, develop MCQ items that will be useful to you 42
  43. 43. Leg Stretch 43
  44. 44. Exercise #2 – Pre-testA Test of General Rock and Roll Knowledge 44
  45. 45. Technical FlawsViolations of test item writing principles• Flawed items are usually more difficult• Fail more students Downing, 2002 45
  46. 46. Technical Flaws• Unfocused items• Negative stem or lead-in question• Heterogeneous options• Logical or grammatical cues• Long correct answer• Word repeats• Convergence strategy 46
  47. 47. Unfocused itemWhich one of the following is true about pseudogout?1. It occurs frequently in women.2. Seldom associated with acute pain in a joint3. May be associated with a finding of chondrocalcinosis.4. It is hereditary in all cases5. It responds well to treatment with allopurinol 47
  48. 48. Negative stem or lead-in questionWhich of the following does not cause aorticinsufficiency?1. syphilis2. Marfan’s syndrome3. aortic dissection4. bacterial endocarditis5. myocardial infarction* 48
  49. 49. Heterogeneous optionA 24-year-old female presents to a walk-in clinic withfever, flank pain, frequency and dysuria. The urinalysis (urinemicroscopy) shows 1+proteinuria, 25 white blood cells per highpower field and a few granular casts.Which one of the following investigations is the next best step?1. Intravenous pyelography.2. Intravenous antibiotics.3. Creatinine clearance.4. Midstream urine culture.*5. Oral analgesia. 49
  50. 50. Logical cuesA 47-year old man present with an acute episode ofpsychosis. Which one of the following treatment wouldyou consider prescribing?1. Alprazolam2. Lorazepam3. Haloperidol*4. Diazepam5. Quetiapine 50
  51. 51. Grammatical cuesA 78-year old man undergoes a thoracentesis for a largepleural effusion. Three hours later, he develops suddenonset of shortness of breath. What is your most likelydiagnosis?1. Reaccumulation of fluid2. Pneumothorax*3. Lung infection4. Bleeding5. Blood clot 51
  52. 52. Word repeatsAlso known as “clang association”:A 45-year-old woman presents with sudden loss of consciousness. Onexam, her vitals are normal, she is not pale and she is not diaphoretic.Which one of the following is more typical of “fainting” as a conversionsymptom than of a syncopal attack due to orthostatic hypotension?1. Bradycardia.2. Muscle twitching.3. Absence of pallor and sweating.*4. Urinary incontinence.5. Rapid recovery. 52
  53. 53. Convergence strategyAn 86-year-old woman fell at the local nursing home andsustained an intertrochanteric fracture of her left hip. On clinicalexamination, you would expect to find her left leg:1. Shortened, abducted and internally rotated.2. Lengthened, abducted and internally rotated.3. Shortened, adducted and externally rotated.4. Shortened, abducted and externally rotated.*5. Lengthened, abducted and externally rotated. 53
  54. 54. Post-testA Test of General Rock and Roll Knowledge 54
  55. 55. Now review the items you have written using the checklist! 55
  56. 56. In SummaryPrior to writing MCQ items: • Determine the purpose of the test • Determine WHAT you want to test • Use key-features to help you develop your questionsWrite questions avoiding technical flaws 56
  57. 57. References• Guidelines for the Development of Multiple-Choice Questions at http://www.mcc.ca/pdf/MCQ_Guidelines_e.pdf• Haladyna TM, Downing SM, Rodriguez MC. A Review of Multiple-Choice Item-Writing Guidelines for Classroom Assessment. Applied Measurement in Education 2002;15:309-334 57
  58. 58. Thank you!Questions? Comments? ctouchie@mcc.ca 58

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