detail aboyt mcqs writing

1. Dr. Mokhtar Shatla
MCQ Writing Skills

2. Why MCQ?

3. Validity
*Testing knowledge
*Testing recall / application of knowledge
*Clinical scenarios simulate reality
*Testing learning outcomes / broad
curriculum content

4. *
Knows
Shows how
Knows how
Does
Knows Factual knowledge (Recall):
MCQ, essay type, oral…..
Shows how
Performance assessment in vitro:
OSCE, SP-based test, long case, short case
Does
Performance assessment in vivo:
WPBA, portfolio, Mini-CEX, Video, Audits, research..
Knows how
(Clinical) scenario based tests:
AKT (MCQ), KFQ, modified essay type, oral…

5. Domain of Interest / ILOs


Test Sample
Test Sample

6. Reliability
*More frequent testing of every
individual ILO
*Testing broad curriculum content
*Objective Scoring (computerized)
compared to essay Qs
*Less guessing than True/False items

7. Testing
Time in
Hours
1
2
4
8
MCQ1
0.62
0.76
0.93
0.93
Case-
Based
Short
Essay2
0.68
0.73
0.84
0.82
Oral
Exam3
0.50
0.69
0.82
0.90
Long
Case4
0.60
0.75
0.86
0.90
OSCE5
0.47
0.64
0.88
0.92
Practice
Video
Assess-
ment7
0.62
0.76
0.93
0.93
1Norcini et al., 1985
2Stalenhoef-Halling et al., 1990
3Swanson, 1987
4Wass et al., 2001
5Petrusa, 2002
6Norcini et al., 1999
Mini
CEX6
0.73
0.84
0.92
0.96
7Ram et al., 1999
8Gorter, 2002
Reliabilities across methods

8. No
True / False
Formats

9. Rare for items to
be completely
true or false

10. * Which of the following is the most likely diagnosis?
A) 20%
b)
c)
d)
e)
Which of the following is true:
A) T
B) F
C) T
D) T
E) F

11. Use Single Best Answer Format
(SBA)
“Best of Five”

12. Typical SBA
*Stem (clinical scenario)
*Lead in question
*5 Options:
*One correct
*4 distractors

13. *
Stem:
A.
B.
C.
D.
E.
Lead in question?

14. Stem:
A 75-year-old man with early dementia who lives in a
residential home is refusing to comb his hair or have
it washed saying that his head is sore. He is also
having difficulty getting out of a chair and is asking
for paracetamol for his aching arms.
Lead in:
Which of the following is the most likely diagnosis?

15. Options:
A. Benign intracranial hypertension
B. Temporal arteritis
C. Extradural haematoma
D. Cluster headaches
E. Meningioma

16. *Homogenous
And can be laid out on a line…

17. Common student errors provide the
best source of distractors

18. *Criteria for Good
MCQ Items

19. *Overall item
1. Common or important clinical problem
2. Testing ability to apply knowledge
3. The level of difficulty is appropriate (30%-70%)
4. Homogenous & common formats (House style)

20. *House Style
1.Starting sentence.
*A 30-year-old woman comes …..
*A 30 years old woman came …..
*Fatimah is a 30 years old female who came….
*30 years old lady comes….
*30 Y.O. lady comes to ….
2. Grammar (present)
3. Length
4. Numbers: 1-9 (letters), above 9 (numbers)
4. Lead in question: bolded, separated from the stem, followed by ?
5. Options: A-E capitals, arranged alphabetically

21. A 75-year-old man with early dementia who lives in a
residential home is refusing to comb his hair or have it
washed saying that his head is sore. He is also having
difficulty getting out of a chair and is asking for
paracetamol for his aching arms.
Which of the following is the most likely diagnosis?
A. Benign intracranial hypertension
B. Cluster headaches
C. Extradural haematoma
D. Meningioma
E. Temporal arteritis

22. Isolated fact MCQ items should be avoided in
the exam.
e.g. Which of the following hematopoietic factors is
produced by the kidney?
(a) Rennin
(b) Angiotensin
(c) Erythropoietin
(d) Aldosterone
(e) Cortisol
*Overall item

23. A 65-year-old man with chronic renal failure is
complaining of progressive easy fatigability.
Examination revealed pale conjunctiva and oral
mucosa. Anemia was suspected.
What is the most likely explanation of anemia in this
patient?
A. Increased secretion of renin
B. Disturbed renin-angiotensin
C. Reduced production of erythropieotin
D. Increased production of aldosterone
E. Increased secretion of cortisol

24. *Recall Item Stem:
What area is supplied with
blood by the posterior
inferior cerebellar artery?
*Application of Knowledge:
A 62-year-old man develops left-side
limb ataxia, Horner’s syndrome,
nystagmus, and loss of appreciation
of facial pain and temperature
sensations.
What artery is most likely to be
occluded?
A. Basilar
B. Right posterior inferior cerebellar
*C. Left posterior inferior cerebellar
D. Right superior cerebellar
E. Left superior cerebellar

25. * Instead of asking examinees to identify the muscles
innervated by a cranial nerve, provide a set of physical
findings and ask to identify the most likely site of the
lesion.
*Instead of asking for a description of respiratory acidosis
or alkalosis, provide values for arterial blood gases (and
other patient findings as needed) and ask to identify the
most likely pathophysiologic explanation.

26. Acute intermittent porphyria is the result of a
defect in the biosynthetic pathway for which of
the following?
A. Collagen
B. Corticosteroid
C. Fatty acid
D. Glucose
E. Heme

27. An otherwise healthy 33-year-old man has mild
weakness and occasional episodes of steady, severe
abdominal pain with some cramping but no diarrhea.
One aunt and a cousin have had similar episodes.
During an episode, his abdomen is distended, and bowel
sounds are decreased. Neurologic examination shows
mild weakness in the upper arms.
These findings suggest a defect in the biosynthetic
pathway for which of the following?
A. Collagen
B. Corticosteroid
C. Fatty acid
D. Glucose
E. Heme

28. *A34-year-old woman has had severe watery diarrhea for
the past four days. Two months earlier she had
infectious mononucleosis. She abuses drugs
intravenously and has antibodies to HIV in her blood.
Physical examination shows dehydration and marked
muscle weakness.
Laboratory studies are most likely to show which of the
following?
A. decreased serum potassium (K+) concentration
B. decreased serum calcium (Ca2+) concentration
C. increased serum bicarbonate (HCO3-) concentration
*D. increased serum sodium (Na+) concentration
E. increased serum pH

29. *Benefits clinical scenario based MCQ:
“Face validity” of the exam is greatly enhanced by
using “problem-solving” items
More likely to focus on important information,
rather than trivia
Identify those examinees who have memorized a
factual information, but are unable to use it
effectively

30. *Stem
 Clinical scenario (story) mimic reality
 Clear Simple language
 Grammatically correct
 25-50 words
 Each word has its importance in reaching answer
 Avoid words like ‘always’, ‘never’, ‘none of the above’ and
vague terms (eg ‘usually’, ‘rarely’, ‘fairly often’)
 Avoid repeated use of a word or words
 No abbreviations (hypertension instead of HTN)
 Include reference ranges of lab results
 Avoid interpretation of examination or lab results

31. *Stem
*A 65-year-old man has difficulty rising from a seated position
and straightening his trunk, but he has no difficulty flexing
his leg.
Which of the following muscles is most likely to have been
injured?
A. Gluteus maximus
B. Gluteus minimus
C. Hamstrings
D. Iliopsoas
E. Obturator internu

32. *Stem
* The stem may include some or all of the following components:
*Age, Gender (eg, A 45-year-old man)
*Site of Care (eg, comes to the emergency department)
*Presenting Complaint (eg, because of a headache)
*Duration (eg, that has continued for 2 days).
*Patient History (with Family History ?)
*Physical Findings +/- (start w’ abnormal findings)
*Results and investigations presented in a logical, standardised order
*Initial Treatment
*Subsequent Findings, etc.

33. *Lead in Question
*Focuses on aspects e.g. diagnosis, investigation,
management, … etc
*Can be answered without looking at the options
(cover test)
*Do not use EXCEPT
*Do not use NOT
*Do not use ambiguous terms (e.g. always, never,
frequent, generally, commonly, only, usually, same
as, can be, may be, possible)

34. A 30-year-old man presents to your clinic complaining
of productive cough of one month duration, and night
fever and sweets. He lost 8 kilograms of his weight
without dietary control. Chest x-ray shows a 2-
centimeters rounded cavity at the base of right upper
lobe.
All of the following are first line treatment of this
patient EXCEPT?
A. Isoniazide,
B. Rifampicin
C. Pyrazinamide
D. Ethambutol
E. Ibuprofen

35. A 30-year-old man presents to your clinic complaining
of productive cough of one month duration, and night
fever and sweets. He lost 8 kilograms of his weight
without dietary control. Chest x-ray shows a 2-
centimeters rounded cavity at the base of right upper
lobe.
Which of the following is NOT a first line treatment of
this patient’s condition?
A. Isoniazide
B. Rifampicin
C. Pyrazinamide
D. Ethambutol
E. Ibuprofen

36. A 30-year-old man presents to your clinic complaining
of productive cough of one month duration, and night
fever and sweets. He lost 8 kilograms of his weight
without dietary control. Chest x-ray shows a 2-
centimeters rounded cavity at the base of right upper
lobe.
Which of the following is a first line treatment of
active pulmonary tuberculosis?
A. Isoniazide
B. Rifampicin
C. Pyrazinamide
D. Ethambutol
E. Ibuprofen

37. A 30-year-old man presents to your clinic complaining of
productive cough of one month duration, and night fever
and sweets. He lost 8 kilograms of his weight without
dietary control. Chest x-ray shows a 2-centimeters
rounded cavity at the base of right upper lobe.
Which of the following is a first line treatment of this
patient?
A. Isoniazide – Rifampicin - Pyrazinamide
B. Isoniazidec - Rifampicin- Pyrazinamide - Ethambutol
C. Isoniazidec - Rifampicin- Pyrazinamide - streptomycin
D. Isoniazidec - Rifampicin - Ethionamide - streptomycin
E. Para-aminosalicylic acid - Capreomycin - Kanamycin

38. Commonly used questions
What is the most likely diagnosis ?
Which of the following findings is most likely?
What is the next step in management ?
What is the initial investigation?
What is the most accurate or Gold standard diagnostic test?
What is the most specific or sensitive test?
What is the best drug or therapy ?
What is the initial treatment ?
What is the most effective therapy?

39. Commonly used questions
What is the most likely cause ?
What is the most likely defective enzyme ?
What is the most likely nerve/muscle injury/artery occlusion?
What is the most likely laboratory finding ?
What is the most specific / sensitive test?

40. If more than one question is attached to a single scenario
(such as in data interpretation papers) avoid:
 Cueing: the answer to the first question being cued by the
options for subsequent questions
 Hinging: the answer to subsequent questions depending
on knowing the answer to the first question

41.  Options:
Homogenous: all diagnosis, investigations, treatment or
next step in management, … etc
Who was the primary author of the Declaration of Independence?
A. George Washington
B. Thomas Jefferson
C. Alexander Hamilton
D. Benjamin Franklin
E. James Madison
A. Abraham Lincoln
B. Thomas Jefferson
C. Franklin Roosevelt
D. King George II
E. Catherine the Great

42. *Options
Homogenous: all diagnosis, investigations, treatment
or next step in management, … etc
Uniform grammar (consistent with the stem)
Similar in length
Similar language
Do not give clue to the answer

43. *Options
Do not use: all of the above, none of the above
(not recognized correct option) or a & b
 Do not use of absolute/ambiguous terms (e.g.
almost, never, only, frequent, generally, commonly,
usually, same as, can be, may be, possible)
Arrange in alphabetical manner
Arrange numbers in an ascending or descending order

44. *Pre-Submission Checklist for MCQ:
* MCQ Number: Content Area: ILO:
Submitted by:
Overall Yes No Comment
The topic is important for the learners
The level of difficulty is appropriate
Tests beyond knowledge recall and memorization
Stem
Common format
Simple language, clear and complete
Correct grammar
No jargon or abbreviations
Context-based/contains integrated clinical vignette
Lead-in
Focuses on one aspect (e.g. indication, side-effects,
contraindication, mechanism of action)
Can be answered without looking at the options
No negative phrasing (NOT, EXCEPT)
No ambiguous term (always, never, almost, may be ,…)
Options
All options are homogenous (diagnosis, investigation, ttt,…)
All options are uniform (length, grammer)
Do not give clue to the answer
No ambiguous term (e.g. almost, never, frequent)
No "all of the above" or "none of the above" option

45. *
* Decision:
* Accept; as it is
* Revise; minor changes (see comments below)
* Resubmit; major changes necessary (see comments below).
*
* Comments:
* ………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………

46. *15-years-old male with a history of nocturnal enuresis
presented to the GP with sore throat. He also complaints of
fever for 4 days and malaise. O/E: his cervical LN enlarged
and tender. His girl friend has similar symptoms. His
peripheral blood film shows atypical lymphocytes. Which of
the following is the causative organism:
a) adenovirus
b) corynebacterium diphtheriae
f) Hemophilus influenzae
c) coxsackie virus
d) cytomegalovirus
e) Epstein-Barr virus

47. *A seven-year-old boy presents to the pediatrician with acute onset of
fever and sore throat. On examination, the tonsils are swollen with
creamy exudates. His cervical lymph nodes are enlarged and tender.
Several of his classmates recently had similar symptoms. His full
blood count shows the following: total white count 18,000/ml
(normal: 4,000-11,000 /ml), neutrophil 84% (normal: 40-80%).
Which of the following is the most likely causative organism?
A) Adenovirus
B) Corynebacterium diphtheriae
C) Cytomegalovirus
D) Epstein-Barr virus
E) Streptococcus pyogenes

48. A 42 year old woman who has
previously had treatment for
cervical CIN 2 has
had a lump affecting her left
upper lid for three months. It is
asymptomatic
What is the single most likely
diagnosis in this patient?
1. Entropion
2. Meibomian cyst
3. Metastatic deposit
4. Stye
5. Xanthelasma

49. THANK YOU