MCQWritingDr.IssamFrancis

Introduction

• ThisbriefpresentationispreparedtoguidemedicalprofessionalsontheartofwritingexcellentMCQsforthemedicalpractitioners.

• Thepresentationisbasedonmultipleresourcesmanyavailableonthewebforfree.

• MCQ-basedassessmentsareanexcellenttooltoassessvariousaspectsofthemedicalcurriculabothunderandpostgraduatePROVIDEDtheyarewellwritten.

X X X X X X X X

Fewrecallquestionsontrulyessentialitemsmaybejustified

ApplicationofKnowledgeWhattoAsk?

• Predictfindingsfromspecificconditions• Explain whysomethinghasoccurred• Calculatearesultusingaformula• Interpreting data,graphs,tables• Order interpretdiagnosticstudies• Differentialdiagnosis• Initiate treatment• Determineprognosis

TestingApplicationofKnowledgeCommonlyusedphrasesinthelead–inquestion

• Whichofthefollowing– isthemostlikelycauseofthepatient’scondition?– isthemostlikelydiagnosis?– isthemostappropriatenextstep?– isthemostappropriatenextstepinthepatient’smanagement?– additionalfindingsismostlikelytodevelopinthispatient?– physicalfindingsismostlikely?– resultsofdiagnosticstudiesismostlikely?– findingsisABNORMAL?- Identifyyournextmanagementinthiscase

• Forwhichofthefollowingconditionsisthepatientmostatrisk?• Resultsofwhichofthefollowingtestswillmostlikelybediagnostic.

Anatomy of an MCQ

Stem

Lead-in/Question

Distractor

Distractor

Distractor

Distractor

Correct Option

A

E

B

C

D

Stem

Lead-in/Question

Distractor

Distractor

Distractor

Distractor

Correct OptionA

E

B

C

D

Theproblembeingtestedgoeshere

Question/Requestgoeshere

Answersgoesher• 5Choices• Writecorrectanswerfirst• Writeotheranswers• Allanswersmusthavesome truth

Distractorsareaspectrumofmostcorrectdarkgreentoleastcorrectlightgreen

BestAnswerLeastCorrectAnswer

STEP1

STEP2

STEP3

• Clinical Vignette • Image: replace /supplement• Unambiguous • Length relative to options• Includes All pertinent information

• Age • Gender • Clinical setting• History• Complaint

• Physical findings• Radiology• Lab results• Drug H.• Disease progress

1.Stem

Question stem (including only information relevant to the question):

• USE A CLINIAL VIGNET • Patient details (gender/age)• Presenting complaint (PC)• History of presenting complaint (HPC)• Relevant medical history• Physical Examination • Results (e.g. laboratory/radiology)• Autopsy • Microscopic • Immunohistochemistry• Molecular

PHOTOGRAPH

Replaceby

MCQsusingclinicalvignettesinstem

• “Questionswithrichdescriptionsofclinicalcontextinvitethemorecomplexcognitiveprocessesthatarecharacteristicofclinicalpractice.”

• “Conversely,context-poorquestionscantestbasicfactualknowledgebutnotitstransferabilitytorealclinicalproblems.”

EpsteinRJ:AssessmentinMedicalEducation,NewEnglandJournalofMedicine2007;356:387-396.

“Thereisnothingnewunderthesun” (Ecclesiastes1:9)

“Noteachingshouldbedonewithoutapatientforatext.” (OslerWilliam:OntheNeedofARadicalReforminourMethodsofTeachingMedicalStudents;MedicalNews82:49-53,1904.)

NBMEannouncement2010-2011:UseonlyclinicalorexperimentalvignetteformatsonUSMLEstep1.

SirWilliamOsler

• 1849–1919• Canadianphysician• Oneofthefoundersof JohnsHopkinsHospital• Createdthefirstresidencyprogram• FatherofModernMedicine• Medicalstudentstobedsideclinicaltraining

TheClinicalVignette

•ClinicalStory/Scenario•Relatedtothequestionandanswer•Outline(Onlyrelevantpartsincluded):

• Ageandgender (42-year-oldwoman)• Siteofcare (comestotheemergencydepartment)• Complaint (becauseofheadache)• Duration (haspersistedfor2days)• Pasthistory (maynotberelevant)• Physicalfindings (pulsatingarteryanteriortoear)• Diagnosticstudies(HerCBCshows,HerChestX-ray)• Treatments (Shewasprescribed…..)• Courseofds. (Herconditiondeteriorated)

TheClinicalVignetteforpathology/cytology

•ClinicalStory/Scenario•RADIOLOGY:MRI,CT,HRCT,PET/CT,ISOTOPESCAN.• POSTMORTEMFINDING• TISSUESECTIONFINDINGONHE• HISTOCHEMICALSTAINS•MOLECULARTEST• CYTOGENETICS,KARYOTYPE• LABEQUIPMENT• LABPROCEDURE

Anyoneoftheseitemscanbereplacedbyanexcellentrepresentativeimage

FormatofClinicalVignette

• Example:Questiontestingmemory:Whatisthecommonestcauseofintracerebralhemorrhage?

Samequestionusingvignette:

A 62-year-old man develops sudden severe throbbingheadache and arrives in hospital in deep coma. Two days laterhe dies. A hospital autopsy shows a large hematoma in leftcerebral hemisphere and filling the left lateral ventricle.

Which other autopsy finding in this patient would help suggestthe correct underlying cause of this finding?

Which clinical history would be consistent with this autopsyfinding?

Thisistheappearanceofbrainofa45yearoldmanwhocollapsedinhisofficewhileworking.

FormatofClinicalVignette

• Example:Questiontestingmemory:Whatisthemainmicroscopicfindingofpseudomembranouscolitis?

Samequestionusingvignette:

A 45 year old woman is admitted in shock and severe sepsis.She was treated for community-acquired pneumonia a weekago and was discharge home. Two days later, she collapses anddies. You are charge of performing a hospital autopsy on thiscase.

Identify an autopsy procedure which will suggest the correctdiagnosis in this case.

NotetheLead-Incanbearequesttodosomething.

Which clinical scenario would you like to inquire about prior tosigning this case?

Thisisacolonicbiopsyina35yearoldwomanadmittedwithfreshbleedingperrectumfor1day.

Stemcanbereplacedbyapathology/cytology/molecularreport

Thisisasynopticreportonabreastlumpectomyina45yearoldfemale

Tumourhistologictype:ductalcarcinomaNOSTumourhistologicgrade:3DCIS:Present,25%DCIStype:HighgradewithcomedonecrosisMargins:DCISpresentatlateralmarginER:Positive,90%PR:Positive,40%Her2:Positivescoreof3TNM:T1N0

Thiscaseisdiscussedinatumourboardmeeting.Youareaskedtocommentonthemajorfindingwhichwilldriveprognosisinthiscase.Identifyyourselection.

• Follows stem• In the form of a question or instruction• Related to stem• Answerable without looking at options (cover options and try to answer)• Communicate a learning objective

2. Lead-in

• Write the correct option/answer first• Vary its place among options (alphabetic sequence method)• Length and grammar similar to distractors• Should not have a clue built into it

3. Correct Option

DonotalwaysplaceitemkeysinBandCpositionsEmpiricalstudiesshowwriterstendto“hide” keysinoneoftheinnerpositionscandidatestendtolookforcorrectresponsesinthesesamepositions.Modernexamsoftwarerandomizeoptionssothisfactorcanbeignorednow.

• Allplausible&attractive• Noneobviouslyincorrect• Faultyreasoning• Samecategoryascorrectoption• Similarlengthtocorrectoption• Grammaticallyconsistentwithstem• Logicallycompatiblewiththestem

4. Distractors

SingleBestAnswerMCQ

A 16 yr old girl complains of muscular weakness of the extremities which has beenprogressive over the last 4-5 days. She has always been in good health. A little overa week ago she had an infection of the upper respiratory tract. On physical exam,her temp is 37.9°C, BP: 112/78 mmHg, HR 90/min and RR 42/min with superficialrespirations. She is noted to have symmetrical weakness on both sides of the faceand of the proximal and distal muscles of the extremities. The sensibility is intact.The plantar reflex shows flexion; and the deep tendon reflexes are absent.Which of the following is the most likely diagnosis ?

a. Acuteencephalomyelitisb. Guillain-Barré Syndromec. Myastheniagravisd. Duchenemuscledystrophye. Bacterialmeningitis

Single Best Answer (A type)

D C A E B

• Correct answer is the Most Likely correct not Only correct on

Least correct Most correct

a. Acuteencephalomyelitisb. Guillain-Barré Syndromec. Myastheniagravisd. Duchenemuscledystrophye. Bacterialmeningitis

Appropriate MCQ Anatomy

StemLead-in/Question

Distractor

Distractor

Distractor

Distractor

Correct Option

A

E

B

C

D

Inappropriate MCQ Anatomy

Stem

Lead-in/Question

Distractor

Distractor

Distractor

Distractor

Correct Option

A

E

B

C

D

VerylongLead-In

Lead-in/Question

Distractor

Distractor

Distractor

Distractor

Correct Option

A

E

B

C

D

Inappropriate MCQ Anatomy

Correctanswerlong,mayattractattentionit’sthecorrectone.

Stem

Lead-in/Question

Distractor

Distractor

Distractor

Distractor

Correct Option

A

E

B

C

D

Inappropriate MCQ Anatomy

Shortstem,unequaloptions.Correctanswershort

Stem

Lead-in/Question

Distractor

Distractor

Distractor

Distractor

Correct Option

A

E

B

C

D

Inappropriate MCQ Anatomy

Tooshortstem

ThreeNOsinMCQs

NoFlaws

NoClues

NoTricks

WritingGoodItemsEmphasisontheStem

• Writequestionsthatexamineimportantconcepts;avoidquestionsaddressingminutedetails.• Makethestemclearandunambiguous.• Usesimplegrammarandsentencestructure.• Donotusevocabularymoreadvancedthanrequired.• Includeinthestemanyword(s)thatotherwisewouldberepeatedineachalternative.

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WritingGoodItemsEmphasisonAlternatives

� Donotletanyportionofthestemprovideunintendedclues.� Donotletthelengthofalternativesprovideunintendedclues.� Makealldistractersplausible(usecommonerrors).� Makethealternativesmutuallyexclusive.� Keepthegrammarofeachalternativeconsistent.� Becarefultokeepitemsindependent,sothattheanswertoone

questiondoesnotprovideacluetosolvinganother.� Makethepositionofthekeyresponse(correctanswer)random.

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Advantages• Adequatesamplingofcontent.

• Effectivelystructuretheproblemtobeaddressed

• Efficientlyandreliablyscoredthansupplyitems

• Responsealternativescanprovidediagnosticfeedback• Constructedtoaddressvariouslevelsofcognitivecomplexity

Disadvantages• Difficult&timeconsumingtoconstructgooditems• Instructorfavorsimplerecalloffacts• Dependenceonstudentreadingability• Dependenceinstructorwritingability• Inappropriatetoassessskilledperformance

IsMCQthebestexamformat?

14 GOLDENRULESFORWRITINGMCQs

1. UsePlausibleDistractors

2. UseaQuestionFormat

3. EmphasizeHigher-LevelThinking

4. KeepOptionLengthsSimilar

5. BalancethePlacementoftheCorrectAnswer6. BeGrammaticallyCorrect

7. AvoidCluestotheCorrectAnswer

8. AvoidNegativeQuestions

9. UseOnlyOnebestoptionthatisclearlythebestoption

10. GiveClearInstructions

11. UseOnlyaSingle,Clearly-DefinedProblemandIncludetheMainIdeaintheQuestion12. Avoidthe“AlltheAbove”Option

13. Avoidthe“NoneoftheAbove”Option

14. Don’tUseMCQsWhenOtherItemTypesAreMoreAppropriate

High-QualityMCQ

Ahigh-qualitymultiple-choicequestion

1. Assessescontentconsideredtobeimportant2. Isfreeofflaws inbothstemandoptions3. Identifies thosewhocanusetheirknowledgetoassess

dataandmakedecisions

ModifiedfromCaseSMSwansonDB:ConstructingWrittenTestQuestionsfortheBasicandClinicalSciences,NationalBoardofMedicalExaminers,2002

ThankYou