Based on the information provided, this item is testing the learner's ability to make a clinical decision by diagnosing the most likely cause of the patient's presentation based on the key laboratory findings provided in the stem. The stem provides sufficient relevant information to answer the question without being tricked or misled. The alternatives provided are plausible and independent diagnoses to consider. This item follows best practices for writing multiple choice questions that test clinical decision making abilities.

1. The Development of Multiple-
Choice Questions using the
Key-features Approach
Claire Touchie, MD, FRCPC
University of Ottawa
Medical Council of Canada

2. Conflict of Interest
Medical Education: none
2

3. Workshop Agenda
1. 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. 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. 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. Why are we doing this?
A 62 year-old woman with a history of confusion and constipation comes to
the office for a follow-up visit. Laboratory investigations reveal a serum
calcium of 2.9mmol/L, a creatinine of 146 µmol/L, and a hemoglobin of 108
g/L.
Which one of the following is the most likely diagnosis?
1. Hyperparathyroidism
2. Chronic renal failure
3. Multiple myeloma*
4. Vitamin D intoxication
5. Renal cell carcinoma

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 focusing
exclusively on the unique challenges (key
features) in the resolution of each problem
– Essential issues or specific difficulty

8. Key Feature Problems
•First discussed at Cambridge Conference – 1984
•Developed by Georges Bordage and Gordon Page for
the MCC
•First incorporated into the MCCQE Part I – 1992
•Known under different names
– Q4, Clinical Reasoning Skills (CRS), Clinical Decision
Making (CDM)

9. So what? Who cares?
•Studies show validity evidence and reliability in
testing 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. Key Feature Problems
Assesses decision-making skills NOT recall
of factual information
Knowledge
Clinical Decision
Application of knowledge

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 action
OR evaluate the severity/probability of an
outcome
•To select a management course

12. Example of Knowledge question
•Which of the following are characteristic
of delirium?

13. Alternate type of question
Should 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. Key Feature – Definition
•A critical or essential step in the resolution of a
problem
•A step in which examinees are most likely to
make errors in the resolution of a problem
•A difficult or challenging aspect in the
identification and management of the problem in
practice

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. Key Question of Key Features
“What are the critical, essential elements in
the resolution of the problem?”

17. Process in Key Feature Development
•Problem definition
•Selecting a key feature
•Developing a clinical scenario
•Identifying the correct answer (in the case of
single correct MCQ)
•Identifying plausible distractors

18. How can this be applied?
Let us try…

19. Problem Definition
Select an objective or a clinical
problem…delirium/confusion
Select a clinical situation
– Undifferentiated complaint
– A single typical problem*
– A multi-system problem
– A life-threatening event*
– Preventive care and health promotion

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. Exercise #1
Writing key features
21

22. How to write multiple-choice items
1. The What
2. The How
22

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. The What
Prior to writing your question, ask the
following questions
• What concept do I want to test?
• Where does the learner go wrong?
• Focus on areas of “challenge” for the learner
24

25. Example of the What
Purpose: To assess the clinical clerk’s
knowledge and decision making capability
at the end of an Internal Medicine six week
rotation
• Concept/Objective: Management of
CHF
• Challenge to the learner: ???
25

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. The How – Anatomy of a MC item
Stem
• 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. The How-Anatomy of a MC item
Lead-in question
• Which one of the following diagnostic test
would be most useful to confirm the
diagnosis?
28

29. The How – Anatomy of a MC item
Correct/Best answer and distractors
1. Chest radiograph
2. CT of the chest *
3. Sputum culture
4. Electrocardiogram
5. Echocardiogram
29

30. What did you notice about this question?
Could you answer it without seeing the
alternatives?
Could you answer without being given the
diagnosis?
30

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. 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. 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. 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. Lead-in Question
Try 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. 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. Item testing clinical decision-making
A 62 year-old woman with a history of confusion and constipation comes to
the office for a follow-up visit. Laboratory investigations reveal a serum
calcium of 2.9mmol/L, a creatinine of 146 µmol/L, and a hemoglobin of 108
g/L.
Which one of the following is the most likely diagnosis?
1. Hyperparathyroidism
2. Chronic renal failure
3. Multiple myeloma*
4. Vitamin D intoxication
5. Renal cell carcinoma

38. Item testing clinical decision-making
A 62 year-old woman with a history of confusion and constipation
comes to the office for a follow-up visit. Laboratory investigations
reveal a serum calcium of 2.9mmol/L, a creatinine of 146 µmol/L, and
a hemoglobin of 108 g/L.
Which one of the following would help confirm the diagnosis?
1. Parathyroid hormone
2. Serum protein electrophoresis*
3. 25-OH vitamin D
4. Serum creatinine
5. Abdominal ultrasound

39. What is wrong with this item?
A previously healthy person suddenly presents with
pleuritic pain in the left chest and shortness of breath.
Which one of the following is the most likely
diagnosis?
1. Mycoplasma pneumonia
2. Spontaneous pneumothorax
3. Pulmonary embolism
4. Acute pericarditis
5. Epidemic pleurodynia

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 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
40

41. What is wrong with this item?
Aortic insufficiency may be caused by all of the
following, EXCEPT:
1. syphilis
2. Marfan’s syndrome
3. aortic dissection
4. bacterial endocarditis
5. myocardial infarction*

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. Leg Stretch
43

44. Exercise #2 – Pre-test
A Test of General Rock and Roll
Knowledge
44

45. Technical Flaws
Violations of test item writing principles
• Flawed items are usually more difficult
• Fail more students
Downing, 2002
45

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. Unfocused item
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
47

48. Negative stem or lead-in question
Which of the following does not cause aortic
insufficiency?
1. syphilis
2. Marfan’s syndrome
3. aortic dissection
4. bacterial endocarditis
5. myocardial infarction*
48

49. Heterogeneous option
A 24-year-old female presents to a walk-in clinic with
fever, flank pain, frequency and dysuria. The urinalysis (urine
microscopy) shows 1+proteinuria, 25 white blood cells per high
power 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. Logical cues
A 47-year old man present with an acute episode of
psychosis. Which one of the following treatment would
you consider prescribing?
1. Alprazolam
2. Lorazepam
3. Haloperidol*
4. Diazepam
5. Quetiapine
50

51. Grammatical cues
A 78-year old man undergoes a thoracentesis for a large
pleural effusion. Three hours later, he develops sudden
onset of shortness of breath. What is your most likely
diagnosis?
1. Reaccumulation of fluid
2. Pneumothorax*
3. Lung infection
4. Bleeding
5. Blood clot
51

52. Word repeats
Also known as “clang association”:
A 45-year-old woman presents with sudden loss of consciousness. On
exam, 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 conversion
symptom 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. Convergence strategy
An 86-year-old woman fell at the local nursing home and
sustained an intertrochanteric fracture of her left hip. On clinical
examination, 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. Post-test
A Test of General Rock and Roll
Knowledge
54

55. Now review the items you have written
using the checklist!
55

56. In Summary
Prior to writing MCQ items:
• Determine the purpose of the test
• Determine WHAT you want to test
• Use key-features to help you develop your
questions
Write questions avoiding technical flaws
56

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. Thank you!
Questions? Comments?
ctouchie@mcc.ca
58