Mc qs formation

MCQs Formation
28/6/1440 -5/3l/2019
Dr. Itedal Abdelraheem Mohamed Ahmed
Assistance Professor and Researcher,
PhD of Human Anatomy
Department of Anatomy – Faculty Medicine Najran University

What Can MCQs Assess?
MCQS can test well in the cognitive domain at all
levels;
It tends to assess only recall of knowledge,
however, it can test any higher level of the cognitive
domain.
It can also discriminate well between students, if it
is well constructed.

Types of MCQs
There are many types of MCQs described in the literature,
the most commonly used:
 A type: define as the one is one that asks the students
to choose the best or correct answer.
• Usually has 4 or 5 options for the student to choose from
them.
• There is no psychometrical law behind the number of
options;

Types of MCQs
On the other hand the three options technique has more
tractability and discrimination than more options technique;
It saves time of teachers
Gives them a chance to use that time to add more questions
It improves the validity of tests

Types of MCQs
 Matching Questions or R type
Students should match the options given (usually 3-26) with the
Scenarios (usually 5-10), the matching process is led by a lead -
in question.
Based on the above mentioned introduction to the types of
MCQs, I m going to discuss in details some constructions of
“A Type questions”.
For further information on the other types of MCQs please visit:
http://www.nbme.org/PDF/ItemWriting_2003/2003IWGwhole.
pdf

Structures of MCQs A type
The “A type” question is composed of three parts; the Stem, the
Leadin question and the Options. As illustrated below:
A type
Options
Leadin
Stem

• Stem
o Should include as much information as possible of the
item.
o Should be relatively long and should not contain any
unwanted information.
• Leadin question?
• Options (It could be 4- 5 options)
o Should be relatively short with no additional data than
the stem.

A. Distracter.
B. Key answer. *
C. Distracter .
D. Distracter.
E. Distracter.
Key
answer.
*
Distracter.
Distracter.
Distracter.
Distracter.

A. Example:
Stem:
A 40 year old female has a 3day history of progressive
weakness in her extremities. She has been healthy except for
an upper respiratory tract infection 10 days ago. Her
temperature is 37.8C , blood pressure is 130/80 mm Hg, pulse
is 94/min, and respirations are 42/min and shallow. She has
symmetric weakness of both sides of the face and the
proximal and distal muscles of the extremities. Sensation is
intact. No deep tendon reflexes can be elicited; the plantar
responses are flexor.

Leadin:
Which of the following is the most likely diagnosis for that
case?
Options:
A. Acute disseminated encephalomyelitis
B. Guillain Barré syndrome*
C. Myasthenia gravis
D. Poliomyelitis
E. Polymyositis

The questions can
be:
1.Context
free
2.Conte
xt rich
stimula
nts

The context free: usually tests factual knowledge,
which is an important part of problems solving.
The context rich question is attempting to test
higher levels of knowledge and reflects relevance
to the professional life, that is why it is more
recommended to be used in medical education.

Examples:
The following are two examples of context free and context
rich stimulant questions, to elicit the difference between the
two types:
1 What is the most important mechanism of Heart Failure
in children of one year old?
A. Ventricular weakness.
B. Volume Overload.
C. Pressure Overload.
D. Ventricular dysfunction.
E. Ventricular dilatation.

2 A 1yearold baby who is a known case of VSD, was admitted to the
ER by his mother, complaining of cough, shortness of breath which
disturbs his feeding for the last 3 days. On examination the baby
was found ill, his temperature was 38.7C, his pulse was 110/min,
which is regular, dyspenic with respiratory rate of 70/min and
intercostal recessions, and has a liver was 4 cm below the costal
margin.
What is the most likely mechanism of his symptoms?
A. Ventricular weakness.
B. Volume Overload.
C. Pressure Overload.
D. Ventricular dysfunction.
E. Ventricular dilatation.

Construction of MCQs
Common Technical Item Flaws are
classified into two groups Table 1:
 Irrelevant Difficulty
 Test wiseness

Table 1: Common Technical Item Flaws
Irrelevant Difficulty
Test wiseness
1.Vague terms
2. Poor sequence in numeric
data
3. Unnecessary information
4. Unclear or ambiguous
information
5. >1 or no correct answer
6. Fails the “Hand Cover
Test”
7. Negative(s) (not, except)
in the stem
1.Grammatical cues
2. Logical cues
3. Word repeats
4. Longest option is correct
5. Absolute terms
6. Implausible distracters
7. Convergence (Options in C
are all in 3 options each, rest
are only in 2 options)
8. All of the Above
9. None of the Above

Examples: MCQS with technical item flaws
Example 1
Which of the following strategies is the best for
prevention of type 2 Diabetes Mellitus?
A. A population based strategy.
B. Ahigh risk strategy.
C. Screening strategy.
D. Population, high risk and screening strategy.*
(Convergence and longest option is the correct option)
(MCQS with technical item flaws)

Example 2
What is the target population for primordial
prevention activities?
A. High risk groups.
B. Total population.*
C. Patients.
D. Patients with complications
(Word repeated in the stem and correct option. It is
fine to repeat the word in the stem and distracter)

Example 3
Mr. Khalid is a patient admitted to the A & E in shock. After 10
minutes you observe an ECG abnormality and subsequently a
ventricular fibrillation (VF). Mr. Khalid is unconscious and not
breathing. What is the most reliable sign of cardiac arrest?
A. Absence of pulse.*
B. Absence of breathing.
C. Unconsciousness.
D. All of the above.
(Unnecessary information, Unclear or ambiguous information (ECG
abnormality) and the use of "all of the above")

Example4
Which one of the following factors is NOT
associated with Type 2 diabetes?
A. Obesity.
B. Physical inactivity.
C. IGT and IFG.
D. Viral infections.*
(Negative (not, except) in the stem)

Example 5
A medical doctor is assessing a patient with a brainstem
injury, after performing the Glasgow Coma Scale, what is his
next step in the assessment plan?
A. Conduct lumbar puncture.
B. Perform arterial blood gas measurement.
C. Check cranial nerve functioning and respiratory rate. *
D. Perform a pulmonary wedge pressure measurement.
(Logical cue is that the word "cranial" used in option C is
logically homogeneous with the word "brainstem" in stem)

Example 5
Which one of the following is true about
Malaria?
A. Common in children under five.
B. Caused by Plasmodium Vivax.
C. Fansidar is the drug of choice.
D. Use of impregnated bed nets us advisable.
(Fails the “Hand Cover Test” and the options
are heterogeneous.)

The table below illustrates evidence based
Multiple Choice (MC) Item Writing Guidelines
prepared by Haladyna et al.
(Item-Writing guidelines)

Content concerns
1. Every item should reflect specific content and a single specific mental
behavior, as called for in test specifications (two-way grid, test blueprint).
2. Base each item on important content to learn; avoid trivial content.
3. Use novel material to test higher level learning. Paraphrase textbook
language or language used during instruction when used in a test item to
avoid testing for simply recall.
4. Keep the content of each item independent from content of other items
on the test.
5. Avoid over specific and over general content when writing MC items.
6. Avoid opinion based items.
7. Avoid trick items.
8. Keep vocabulary simple for the group of students being tested.

Formatting concerns
9. Use the question, completion, and best answer versions of the
conventional MC, the alternate choice, true false (TF), multiple true false
(MTF), matching, and the context dependent item and item set formats,
but AVOID the complex MC (Type K) format.
10. Format the item vertically instead of horizontally.

Style concerns
11. Edit and proof items.
12. Use correct grammar, punctuation, capitalization,
and spelling.
13. Minimize the amount of reading in each item.

Writing the stem
14. Ensure that the directions in the stem are very
clear.
15. Include the central idea in the stem instead of the
choices.
16. Avoid window dressing (excessive verbiage).
17. 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.

Writing the choices
18. Develop as many effective choices as you can, but research
suggests three choices are adequate.
19. Make sure that only one of these choices is the right answer.
20. Vary the location of the right answer according to the number
of choices.
21. Place choices in logical or numerical order.
22. Keep choices independent; choices should not be
overlapping.
23. Keep choices homogeneous in content and grammatical
structure.
24. Keep the length of choices about equal.
25. None-of-the-above should be used carefully.

Writing the choices
26. Avoid All-of-the-above.
27. Phrase choices positively; avoid negatives such as NOT.
28. Avoid giving clues to the right answer, such as:
a. Specific determiners including always, never, completely, and
absolutely. b. Clang associations, choices identical to or
resembling words in the stem. c. Grammatical inconsistencies that
cue the test taker to the correct choice. d. Conspicuous correct
choice.
e. Pairs or triplets of options that clue the test taker to the correct
choice.
f. Blatantly absurd, ridiculous options.
29. Make all distractors plausible.
30. Use typical errors of students to write your distracters.
31. Use humor if it is compatible with the teacher and the learning
environment.

Bloom's taxonomy of educational objectives
has described six cognitive levels:
knowledge,
Comprehension,
 Application of knowledge,
 Analysis, synthesis
Evaluation.
(Writing high cognitive level MCQs)

Lower level thinking
High level thinking skills
Level II
Level I

Students always learn what we assess, and not
what we teach, and if we just examine them in
fact and how to recall the knowledge they will
only learn how to recall knowledge,
But
If we change our assessment to focus on
assessing upper cognitive functions
(comprehension, application of knowledge and
analysis) they will learn by this way.

The good test is the test
that assesses what we
want our students to
learn.
To assess higher level of
thinking in MCQS,
students need some
information or scenario
to solve a problem, not
just recall the facts.

Examples:
Thrombocytopenia results from the deficiency of which blood
component?
A. Prothrombin
B. Fibrinogen
C. Thrombin
D. Platelets *
E. Iron
This question assesses a recall of knowledge, but if we change
the form of the question by adding some information for the
students, it can assess higher cognitive functions rather than
lower ones.

The same question can be changed to be:
Mrs. Chan, a 32 year old woman is admitted to the Accident and
Emergency Department complaining of fatigue and generalized
weakness. She reports that her gums have been bleeding
excessively when brushing her teeth. An assessment reveals
small red dots over her trunk and gums and bruising on her
upper arms. A blood chemical analysis would most likely reveal a
deficiency of which blood component in this patient?
A. Prothrombin
B. Fibrinogen
C. Thrombin
D. Platelets *
E. Iron

The new question now can assess application
of knowledge rather than recall the knowledge.
This new format is called scenario or vignette,
which includes information about the patient
and his/her health condition, and other
information needed by the student to solve the
problem or to answer the question.

• How to write a vignette
To develop a good vignette it should include all or
part of the following parts:
General information about the patient:
Age,
Gender,
Socio economic status,
education level. etc..
(e.g., A 40yearold female, low socio economic
class)

• Site of Care:
Hospital
Health center
Department.
Clinic
(e.g., comes to the outpatient clinic)
• Presenting Complaint (e.g., complaining of
abdominal pain)
• Duration of symptoms (e.g., that has continued
for 2 days).

• Patient health history
Family History
Chronic illness
Previous attacks
Current treatments
• Physical Findings
Examination findings
+/ Results of Diagnostic Studies
+/ Initial Treatment, Subsequent Findings, etc.
The first three items are essential and the other depend on
the scenario and the question
you want to ask.

• How to develop your lead-in question?
After developing your vignette you have to develop your
question from that vignette.
Here are some example of questions that you can use;
Suggested lead-in questions:
• (patients scenario)with(symptoms and signs).Which of the
following is the most common diagnosis?
• (patient scenario) has (symptoms and signs).Which
[additional]finding would prefer a diagnosis of (disease1)
rather than (disease 2)?
(You can ask more than one question from same vignette)

Development of the distracters
• First you have to write the key answer of the question, it
should be agreed upon and it is advisable to avoid the
answers which do not meet a consensus.
• Write the distracters after that, you have to be sure that
they are plausible distracters. They should be directly
related to the lead in question (All are investigations,
Diagnoses, etc.)
• The golden rule in developing the MCQs is that it should be
revised in a panel before delivered to the students.

Scenario or vignette
A 15-year-old girl is brought into the emergency room with severe
abdominal pain and a fever. Laboratory examination is remarkable
for an elevated white blood cell count and a pregnancy test is
positive. Upon questioning, it is determined that she attempted to
terminate her pregnancy by inserting a sharp object into her vagina.
The physician determines that the wall of the posterior fornix of the
vagina has been penetrated.

lead-in question
Into what region did the sharp object penetrate?
A. Deep perineal pouch.
B. Ischioanal space.
C. Rectouterine space.
D. Rectovesical space.
E. Vesicouterine space.

• Vleuten, Lambert W T Schuwirth & Cees P M van der. Different
written assessment methods: whatcan be said about their strengths
and weaknesses? MEDICAL EDUCATION. 2004, 38, pp. 974–979.
• Case, Susan M. Constructing Written Test Questions For the Basic
and Clinical Sciences. Philadelphia :Naonal Board of Medical
Examiners, 2002.
• Vleuten, Lambert W T Schuwirth & Cees P M van der. Different
written assessment methods: whatcan be said about their strengths
and weaknesses? MEDICAL EDUCATION. 2004, 38, pp. 974–979.
• Steven M Downing, Thomas M Haladyna. Validity threats:
overcoming interference with proposedinterpretations of assessment
data. MEDICAL EDUCATION. 2004, 38, pp. 327333
Bibliography

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