This document provides an overview of multiple choice question (MCQ) item writing and item analysis. It discusses various MCQ response formats including true/false and single best answer. It describes different stimulus formats such as context-free and context-rich questions. Technical flaws in MCQ items like grammatical cues, absolutes, and word repeats are explained. The document also introduces item analysis concepts including item difficulty, distractor analysis, and measures of discrimination like point biserial correlation. Overall, the summary provides guidance on writing high-quality MCQs and using item analysis to evaluate question performance.

1. Multiple Choice Questions -
Item writing & item analysis
15th April 2014
Jane Holland MD PhD MRCSI
RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn
including slides from Richard Arnett, PhD

2. MCQ Item writing & item analysis - Outline
 Introduction to item-writing
 Response formats
 Stimulus formats
 Technical item flaws
 Introduction to item analysis
Jane Holland
http://www.nbme.org/publications/item-writing-manual.html

3. MCQ response formats
• True / False
 The candidate is required to make a determination
as to whether each option provided is true or false
• One Best Answer
 The candidate is required to indicate a single
response i.e. the most likely diagnosis
NBME Manual p 13 – 18
Schuwirth: Med Educ. 2004 Sep;38(9):974-9.
Jane Holland

4. True / false vs. Single Best Answer
False True
 (Simple true/false items)
 (Complex true false items)
Q. True statements about dogs include:
A. They were first domesticated in New Zealand.
B. 35% of households own at least one dog.
C. They have a field of vision up to 200°.
D. They communicate by barking.
Jane Holland

5. True / false vs. Single Best Answer
Q. Which Irish rugby union player holds the record
for most international caps?
A. D’Arcy
B. Heaslip
C. Kearney
D. O’Connell
E. O’Driscoll
Jane Holland


6. Q. Which of the following statements about Ireland
is true?
A. Tayto exports exceed € 1 Bn
B. The climate is sub-tropical
C. The main export is zinc
D. The population is 5 million
E. Rainy weather frequently occursX
True / false vs. Single Best Answer
Trade / exports
Weather
Demographics
D
C
B
A
E
Jane Holland

7. 
True / false vs. Single Best Answer
Q. What colour is the sky?
A. A hazy shade of winter
B. Blue
C. Grey
D. Orange
E. Red
Jane Holland

8. Q. Which of the following calls is a rugby union referee most
likely to make in the case of an intercepted knock-on?
A. Advantage
B. Line out
C. Penalty kick
D. Penalty try
E. Scrum
Q. Which of the following was an original recording by
Meatloaf?
A. Bat out of Hell
B. One out of three ain’t bad
C. Paradise by the Kitchen Light
D. Stand by me
E. Total Eclipse of the Heart
Jane Holland
The “cover test”

9. MCQs – how many options?
Jane Holland
Swanson et al; Academic Medicine. 2005;80(10):S93-S6.
Tarrant & Ware; Nurse Education Today. 2010;30(6):539-43.

10. Stem /
vignette
Question
(Lead-in)
Options
Single Best Answer
Jane Holland

11. MCQ stimulus formats
 Context -free
 Tests factual
knowledge
 Context-rich
 Tests reasoning
or application
Schuwirth: Med Educ. 2004 Sep;38(9):974-9.
Kennedy, 2007
Jane Holland
Creating
Evaluating
Analysing
Applying
Understanding
Remembering

12. NBME Manual p 35 - 49
Q. Which dermatome is at the umbilicus?
A. T6
B. T8
C. T10
D. T12
E. L2
Q. A 65-year-old librarian presents with skin lesions
suggestive of a Herpes zoster infection affecting
the dermatome which includes the skin of the
umbilicus.
 Which segmental spinal nerve is associated with
that dermatome?
Jane Holland

13. Q. A 6 year old boy is admitted with a history of colicky
abdominal pain which has now localised to his right
iliac fossa.
 The initial, visceral pain felt with appendicitis is
referred along sympathetic fibres from which level
of the spinal cord?
A. T6
B. T8
C. T10
D. T12
E. L2
NBME Manual p 35 - 49
Jane Holland

14. Stem
Lead-in
Options
 Clinical (or contextual) vignette
• Age / gender
• Presenting Problem / history
• Examination findings / test results
 Which of the following is the most:
• Likely diagnosis
• Appropriate treatment
 Homogenous
• One correct & 4 distractors
• Alphabetical (or logical) order
• All plausible & same length (short!)
NBME Manual p 35 - 49
Jane Holland

15. Q. Which of the following Moodle activities
allows participants to select a single
option from a list?
A. Checklist
B. Choice
C. Forum
D. Survey
E. Workshop
Jane Holland

16. Q. Gavin is running a conference, at which there will
be a number of parallel workshops with limited
places. Which of the following Moodle activities
could he use to allow participants to preselect
their preferred workshop?
A. Checklist
B. Choice
C. Forum
D. Survey
E. Workshop
Jane Holland

17. Q. Which of the following Moodle activities
allows participants to select one choice
from a list of options?
Word repeats
Jane Holland
A. Checklist
B. Choice
C. Forum
D. Survey
E. Workshop

18. Grammatical
clues
Long
correct
answer
Absolutes
Word
repeats
Logical
cues
Convergence
Technical
Item flaws
NBME Manual p 19 - 27
Jane Holland

19. Q. Which of the following Moodle activities
allows participants to select one choice
from a list of options?
Word repeats
Jane Holland
A. Checklist
B. Choice
C. Forum
D. Survey
E. Workshop

20. Q. It is extremely important for teachers to
maintain a healthy diet. Therefore,
students should always give them an:
A. Apple
B. Banana
C. Bread roll
D. Chocolate bar
E. Mohito
Grammatical clues
Jane Holland
a / an
plural / singular

21. Q. A 76 year old diabetic is brought into the accident
and emergency department with suspected
diabetic ketoacidosis. After confirming that she is
hyperglycaemic, the first step in management
should be intravenous administration of:
A. Chest X-ray
B. Electrocardiogram
C. Fasting blood glucose level
D. Insulin
E. Placement of an nasogastric tube
Grammatical clues
Jane Holland

22. Word repeats
Q. A 58 year old man with a history of heavy alcohol
use and previous psychiatric hospitalisation is
confused and agitated. He speaks of experiencing
the world as unreal. This symptom is called:
A. Depersonalisation
B. Derailment
C. Derealisation
D. Focal memory deficit
E. Signal anxiety
Jane Holland

23. Logical clues
Q. Crime is:
A. Equally distributed among the social classes
B. Overrepresented among the poor
C. Overrepresented among the middle class &
rich
D. Primarily an indication of psychosocial
maladjustment
E. Reaching a plateau of tolerability for the nation
Jane Holland
Also be wary of overlapping numericals...

24. Convergence Strategy
Q. Local anaesthetics are most effective in the:
A. Anionic form, acting from inside the
nerve membrane
B. Cationic form, acting from inside the
nerve membrane
C. Cationic form, acting from outside the
nerve membrane
D. Uncharged form, acting from inside the
nerve membrane
E. Uncharged form, acting from outside the
nerve membrane
Jane Holland

25. Long correct answer
Q. Secondary gain is:
A. Synonymous with malingering
B. A frequent problem in OCD
C. A complication of a variety of illnesses and
tends to prolong many of them
D. Never seen in organic brain damage
Jane Holland

26. Absolutes...
Q. Which of the following shoes are never
worn by men?
A. Boots
B. Runners
C. Sandals
D. Stilettos
E. Wellies
Jane Holland

27. Absolutes
Holsgrove G, Medical Education 1998; 32: 343 - 350
Jane Holland
0
10
20
30
40
50
60
0% 1% 5%
“Never”
0
10
20
30
40
50
60
80% 95% 99% 100%
“Always”

28. Jane Holland

29.  Shape  Long vignette & stem  short options
 Cover test
• Ideally can know the correct answer before seeing the
possible options
 Use homogenous distracters
• i.e. all arteries, all medications, all diagnoses
• Grammatically consistent
• Logically compatible
• List in logical or alphabetical order
 Don’t use vague frequency terms
 Never use absolutes!
 Do not write a negative question!!
NBME Manual p 35 - 49
Some useful principles
Jane Holland

30. Jane Holland

31. Difficulty Discrimination
Corrected
Point
Biserial
Distractor
Choice
Introduction to Item Analysis
 Classical Test Theory
 Item Response Theory (IRT)
 Generalizability Theory (G-Theory)
Richard Arnett
De Champlain: Med Educ. 2010; 44:109-117.

32.  How did the items / questions perform??
1. What proportion of candidates got the
question correct?
2. Which options were chosen most frequently?
3. Which options were chosen by low, medium
and high performers on the test as a whole?
4. How did success on an item correlate with
overall test score?
Jane Holland
Difficulty Discrimination
Corrected
Point
Biserial
Distractor
Choice
De Champlain: Med Educ. 2010; 44:109-117.

33. Item difficulty (DIF) – or facility
 What proportion of candidates got the question correct?
90% of candidates answered correctly
 DIF = 0.90
 < 0.40 – hard
 > 0.80 – easy
 0.40 – 0.80 – good question
 0.45 – 0.55 are extremely discriminating
Jane Holland

34. Which options were chosen most frequently?
 Distractor choice
 Examine the proportion of candidates choosing
each option
 ALL options should be chosen by candidates
 Replace any options not chosen
Jane Holland

35. Discriminating Index (or power)
 Which options were chosen by low, medium
and high performers on the test as a whole?
Lower 27% Upper 27%Middle 
L
N
U
U – L
N
= DI
 Ideally, DP should be > 0.40
Jane Holland

36. Jane Holland

37. Richard Arnett

38. Additional measures of Discrimination
 Point biserial correlation (RPB)
 Equivalent to Pearson correlation co-efficient
 Is a measure of association between a binary (nominal)
variable and a continuous variable
 Corrected point biserial correlation (CRPB)
 The item is removed from the test total prior to calculation
 Range = -1 to +1
 >0.2 good, <0.2 weak
 Negative – inverse relationship!!!!
Jane Holland

39. Jane Holland

40. Jane Holland

41. Jane Holland

42. Moodle Quiz statistics
 Item Difficulty...
Jane Holland
 In a quiz with random questions...
 Position of items within the test may change
 Therefore, analyses must distinguish between positions in
the test, and test items
 Students may answer different sets of questions
 i.e. Answer 30 out of 50 possible questions from the bank
Np
N

43.  Click on the quiz, then access:
 Administration
 Quiz administration
 Results
 Statistics
Jane Holland

44. Jane Holland

45. Jane Holland

46. Jane Holland

47. Good Stats Good Questions
Good stats don’t necessarily mean good
questions and good questions don’t
always get good stats...
...but it is a good place to start
Richard Arnett