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Writing MCQs. Susan Chamberlain Dept of OBS/GYN Queen’s University. Writing MCQs. At the end of this session, the participant will be able to Identify different types of MCQ items Describe the structure of an MCQ List the technical flaws common to MCQ’s

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writing mcqs

Writing MCQs

Susan Chamberlain

Dept of OBS/GYN

Queen’s University

writing mcqs2
Writing MCQs

At the end of this session, the participant will be able to

  • Identify different types of MCQ items
  • Describe the structure of an MCQ
  • List the technical flaws common to MCQ’s
  • write one well-structured MCQ testing appropriate content
writing mcqs3
Writing MCQs

At the end of this session, the participant will be able to

  • Identify different types of MCQ items
  • Describe the structure of an MCQ
  • List the technical flaws common to MCQ’s
  • write one well-structured MCQ testing appropriate content
  • All of the above
mcq check list
MCQ Check-list
  • Why we write them
  • What type is best
  • What flaws are to be avoided
  • What content to test
  • How to construct it
why do we test
Why do we test?
  • Communicate to the students what material is important (formative vs summative)
  • Motivate students to study
  • Identify areas of deficiency in need of remediation or further learning
  • Determine final grades or make promotion decisions
  • Identify areas where the course/curriculum is weak
what should be tested
What Should Be Tested?
  • Exam content should match course objectives
  • Important topics should be weighted more heavily than less important topics
  • The testing time devoted to each topic should reflect the relative importance of the topics
  • The sample of items should be representative of the instructional goals
what should be tested7
What Should Be Tested?
  • Sampling

“Performance on the sample provides a basis for estimating achievement in the broader domain that is actually of interest.”

  • Questions sample:
    • TOPICS
    • SKILLS ie determining diagnosis, next step in management, etc.
mcq items
MCQ ‘Items’
  • Should test important information – either common or life-threatening
  • Should be well-structured
    • Flaws benefit test-wise examinees
    • Irrelevant difficulty does not test examinees’ specific knowledge
anatomy of an mcq item
Anatomy of an MCQ Item
  • Stem
  • Lead-in
  • Options
    • One correct answer
    • Distractors
types of mcq s
Types of MCQ’s

True/False family

  • Assess recall of isolated facts
    • Stems must be clear and unambiguous
    • Options must be absolutely true or false or examinee must decide how true options are
  • Generally not recommended – usually have subtle flaws
types of mcq s true false
Types of MCQ’s: True/False

Which of the following statements is true regarding contraception?

  • oral contraceptives should not be initiated until six weeks after therapeutic abortion to avoid the risk of hypercoagulability
  • an intrauterine device can provide good contraceptive protection 5 years after insertion
  • oral contraceptives should not be prescribed to individuals under the age of 15 without parental consent
  • lesbian women do not require counseling about contraception or sexually transmitted diseases
  • oral contraceptives should not be prescribed for women overthe age of 35
types of mcq s12
Types of MCQ’s

One-Best-Answer family (A type)

  • Options may be diagrammed:

D C A E B

  • Correct answer is the most likely correct
  • Better application of knowledge, integration, synthesis and judgment

Least correct

Most correct

types of mcq s one best answer family
Types of MCQ’s: One-Best-Answer family

A 24 year old university student came to see you because she is missing several days of school each month because of severe dysmenorrhea unresponsive to the OCP and NSAIDS. She also complains of deep dyspareunia and has a tender uterosacral nodule on the pelvic examination. Which one of the following conditions is most likely responsible for her symptoms?

  • Chronic pelvic inflammatory disease
  • Endometriosis
  • Adenomyosis
  • Fibroids
mcq check list14
MCQ Check-list
  • Why we write them
  • What type is best
  • What flaws are to be avoided
  • What content to test
  • How to construct it
mcq technical flaws
MCQ Technical Flaws
  • Issues Related to Test-Wiseness
  • Issues Related to Irrelevant Difficulty
mcq technical flaws16
MCQ Technical Flaws
  • Issues Related to Test-Wiseness
    • provide clues to the right answer
    • examinee can eliminate options based on flaws and not on knowledge
  • Issues Related to Irrelevant Difficulty
item flaws test wiseness
Item Flaws: Test-wiseness
  • Grammatical cues
  • Logical cues
  • Absolute terms
  • Long correct answer
  • Word repeats
  • Convergence strategy
item flaws test wiseness18
Item Flaws: Test-wiseness

Grammatical cues

  • One or more distractors don’t follow grammatically from the stem
item flaws test wiseness19
Item Flaws: Test-wiseness

Grammatical cues

A 24 year old patient presents with a one year history of dysmenorrhea, mid-cycle pain, dyspareunia, and painful bowel movements with her periods. The most likely diagnosis is:

  • Fibroid uterus
  • Adenomyosis
  • Endometriosis
  • Psychosomatic condition
item flaws test wiseness20
Item Flaws: Test-wiseness

Logical cues

  • A subset of the options are collectively exhaustive
item flaws test wiseness21
Item Flaws: Test-wiseness

Logical cues

Arterial blood gases in a normal pregnant woman, compared to her non-pregnant state may show which of the following?

  • Decreased pO2
  • Increased pCO2
  • Decreased pCO2
  • Decreased pH
  • No difference in pCO2
item flaws test wiseness22
Item Flaws: Test-wiseness

Logical cues

  • One or more distractors don’t follow logically from the stem
item flaws test wiseness23
Item Flaws: Test-wiseness

Logical cues

An important tool for assessing fetal well-being is the Non Stress test. A well baby demonstrates the following fetal heart rate pattern:

  • A baseline heart rate above 120 bpm
  • Evidence of fetal movement
  • Baseline variability
  • Two fetal heart rate accelerations in 20 minutes
  • Fetal breathing movements
item flaws test wiseness24
Item Flaws: Test-wiseness

Absolute terms

  • Always, never
  • Not a problem if stem is long and lead-in asks a precise question
item flaws test wiseness25
Item Flaws: Test-wiseness

Absolute terms

In patients with a previous Cesarean section:

  • Vaginal birth is NEVER an option
  • Repeat Cesarean section is less dangerous to the mother
  • The uterine scar may rupture during labour
  • Care should ALWAYS be supervised by an obstetrician
  • No further pregnancies should EVER be considered
item flaws test wiseness26
Item Flaws: Test-wiseness

Long correct answer

  • Correct answer is longer, more specific, or more complete than other options
item flaws test wiseness27
Item Flaws: Test-wiseness

Long correct answer

Which of the following problems in vaginal breech delivery is most likely to cause serious long-term complications?

  • Failure to descend
  • Cord prolapse
  • Nuchal arms
  • Entrapment of the after coming head with an incompletely dilated cervix
  • 1 minute Apgar score of 4
item flaws test wiseness28
Item Flaws: Test-wiseness

Word repeats

  • A word or phase is included in the stem and in the correct answer
item flaws test wiseness29
Item Flaws: Test-wiseness

Word repeats

A 24 year old with a previous history of chronic PID presents with primary infertility. Select the procedure that would be most appropriate to evaluate the status of her tubes and pelvic anatomy

  • Post-coital test
  • Endometrial biopsy
  • Laparoscopy with dye insufflation of the fallopian tubes
  • Hysterosalpingogram
item flaws test wiseness30
Item Flaws: Test-wiseness

Convergence strategy

  • The correct answer includes the most elements in common with the other options
item flaws test wiseness31
Item Flaws: Test-wiseness

Convergence strategy

Normal bladder neck mobility is measured by:

  • A Q-tip angle measurement under 40 degrees
  • A Q-tip angle measurement under 30 degrees
  • A bladder neck ultrasound angle less than 30 degrees
  • A Q-tip angle measurement under 20 degrees
mcq technical flaws32
MCQ Technical Flaws
  • Issues Related to Test-Wiseness
  • Issues Related to Irrelevant Difficulty
    • do not assess knowledge of intended topic
irrelevant difficulty
Irrelevant Difficulty
  • Options are long, complicated or double
  • Extraneous details in stem
  • Numeric data not stated consistently
  • Vague frequency terms
  • Non-parallel language in options
  • Stems are tricky or unnecessarily complicated
  • ‘None of the above’
irrelevant difficulty34
Irrelevant Difficulty

Options are long, complicated or double

Extraneous details in stem

  • Shifts difficulty from content knowledge to speed reading
irrelevant difficulty35
Irrelevant Difficulty

Options are long, complicated or double

Mrs. Brown is a 70 year old woman who had a stroke 6 months ago and is still impaired. Her daughter tells you that her mother’s recent urinary incontinence makes her care unmanageable. She is seeking permanent placement. Mrs. Brown complains of urinary frequency, nocturia, and urge incontinence. Which of the following statements is true?

  • Neurological conditions are involved in the majority of women with symptoms like those presented by Mrs. Brown
  • Diabetes has a greater impact on quality of life than Mrs. Brown’s condition.
  • The pharmacological blockage of muscarinic receptors in the detrusor muscle controls symptoms compatible with Mrs. Brown’s condition
  • Overactive bladder is defined as urinary incontinence accompanied by or immediately preceded by urgency
  • Alpha stimulants are effective in treating this condition
irrelevant difficulty36
Irrelevant Difficulty

Extraneous details in stem

You see in your office a 24 year old woman for her routine postpartum visit, at 6 weeks. Her baby is irritable and cries “all the time’ (including during her visit.) As she is changing the diaper during her visit, you notice that the child has a very red bum but upon questioning, she tells you she did not notice anything abnormal. Her partner is away in Afghanistan and she does not have a lot of friends, as they just recently were posted in Kingston. She states that she has a hard time getting dressed in the morning, cries easily and feels like she does not love her child. She denies any medical or psychiatric history. Her exam is essentially normal. She weighs 2 kg less than at her first antenatal visit at 10 weeks. You most likely clinical diagnosis is:

  • Postpartum hypothyroidism
  • Hyperthyroidism
  • Postpartum blues
  • Postpartum depression
  • Psychotic depression
irrelevant difficulty37
Irrelevant Difficulty

Numeric Data

  • Not stated consistently
  • Mixed format
  • Illogical order
irrelevant difficulty38
Irrelevant Difficulty

Numeric Data not stated consistently

Following a second episode of salpingitis, what is the likelihood that a woman is infertile?

  • Less than 20%
  • 20 – 30 %
  • Greater than 50 %
  • 90%
  • 75%
irrelevant difficulty39
Irrelevant Difficulty

Vague frequency terms

  • Often, usually, rarely, frequently
  • Not consistently defined

*may be used in stem if otherwise carefully constructed unambiguous question

irrelevant difficulty40
Irrelevant Difficulty

Vague frequency terms

Gonorrhea is

A) sometimes asymptomatic

B) treated with cefixime 450 mg orally

C) caused by a gram positive intracellular diplococcus

D) diagnosed by a DNA test

E) usually associated with vulvar ulcers

irrelevant difficulty41
Irrelevant Difficulty
  • Non-parallel language in options
  • Non-logical order
irrelevant difficulty42
Irrelevant Difficulty

Non-parallel language in options

In a vaccine trial, 200 2-year-old boys were given a vaccine against a certain disease and then monitored for five years for occurrence of the disease. Of this group, 85% never contracted the disease. Which of the following statements concerning these results is correct?

  • No conclusion can be drawn, since no follow-up was made of non-vaccinated children
  • The number of cases (ie 30 cases over five year) is too small for statistically meaningful conclusions
  • No conclusions can be drawn because the trial involved only boys
  • Vaccine efficacy (%) is calculated as 85-15/100
irrelevant difficulty43
Irrelevant Difficulty

“None of the above”

  • Problematic where judgment is involved or if options not absolutely true or false
  • Turns question into true/false question
  • Confuses very knowledgeable students
irrelevant difficulty44
Irrelevant Difficulty

“None of the above”

The main reason that fertility is reduced in a woman in her early 40’s is:

  • Irregular cycles make it hard to time intercourse
  • Chromosomal damage adversely affects oocytes’ genetic complement
  • Male erectile difficulties increase
  • Hormone imbalance leads to poor endometrial development
  • None of the above
irrelevant difficulty45
Irrelevant Difficulty

Stems are tricky or unnecessarily complicated

Arrange the parents of the following children with Down’s syndrome in order of the highest to lowest risk of recurrence. Assume that the maternal age in all cases is 22 years and that a subsequent pregnancy occurs within 5 years. The karyotypes of the daughters are:

I: 46, XX, –14,+T (14q21q) pat

II: 46, XX, –14,+T (14q21q) de novo

III: 46, XX, –14,+T (14q21q) mat

IV: 46, XX, –21,+T (14q21q) pat

V: 46, XX, –21,+T (21q21q) (parents not typed)

  • III, IV, I, V, II
  • IV, III, V, 1, II
  • III, I, IV, V, II
  • I, V, III, I, V, II
  • III, IV, I, II, V
mcq check list46
MCQ Check-list
  • Why we write them
  • What type is best
  • What flaws are to be avoided
  • What content to test
  • How to construct it
what to test
What to test?

Items classified by cognitive processes required to answer the question:

  • Recall (Memory)– tests knowledge of isolated facts
  • Interpretation (Comprehension)– review information to reach conclusion, eg diagnosis
  • Problem solving (Reasoning) – situation requires action, eg next step in management
    • Process depends on background of trainee
what to test48
What to test?

Simpler classification based on task:

  • Application of knowledge item **
    • Reach conclusions
    • Make predictions
    • Select course of action
  • Recall item
    • Test knowledge of isolated facts
what to test49
What to test?
  • Test application of knowledge using clinical vignettes
    • Adds ‘face-validity’
    • Usually selects more important, less trivial
    • Identifies student who’ve memorized but do not understand

BUT experience in patient care should not be necessary

what to test summary
What to test - summary
  • Focus item on key concepts and principles that are essential information (without access to references) for all examinees to understand
  • Test material that is relevant to learning in clinical clerkships and beyond
  • Avoid items that only require recall of isolated facts
  • Avoid esoteric or interesting topics that are not essential
mcq check list51
MCQ Check-list
  • Why we write them
  • What type is best
  • What flaws are to be avoided
  • What content to test
  • How to construct it
writing the questions
Writing the Questions
  • Construct stem –include all necessary information to arrive at the right answer
  • Choose lead-in – pose a clear question
  • Choose distractors
slide53
Stem*
  • Usually a clinical scenario
  • Clear, unambiguous
  • Should be long relative to options
  • Includes all pertinent information
    • Patient’s age/gender
    • Clinical setting
    • Complaint
    • Other important info – history, physical findings, test results
lead in
Lead-in*
  • Follows stem
  • In the form of a question
  • Should relate to the stem
  • Should be answerable without looking at options
    • “Cover the Options test”
distractors
Distractors
  • Each should be selected by some, therefore all plausible, none obviously incorrect
  • 3 or 4 choices
    • Common misconceptions
    • Faulty reasoning
distractors56
Distractors
  • Homogeneous in content to the correct answer
  • Should be in same category as correct answer– diagnosis, treatment, diagnostic test
  • Clearly incorrect or inferior to the correct answer
  • Plausible and attractive to the uninformed
  • Similar to the correct answer in construction and length
  • Grammatically consistent and logically compatible with the stem
general guidelines for item construction
General Guidelines for Item Construction
  • Include as much of the item as possible in the stems: Long stems, short options
  • Avoid negatively phrased items (except or not in the lead-in). If you must, use only with short options
  • Avoid writing question of the form:
    • Which of the following statements is correct?
    • Each of the following statements is correct EXCEPT
      • Unfocussed
      • Heterogeneous options
top down versus bottom up
“Top-down” versus “Bottom-up”

Top-Down

  • Knowledge or recall question
  • Cite a disease and then ask what patient findings are expected
  • Structured like textbooks

Clinically backward

top down versus bottom up59
“Top-down” versus “Bottom-up”

Bottom-up

  • Application of knowledge
  • Gives findings and asks examinee to indicate the disease
  • Examinees need to be able to synthesize information from several pages of a textbook (or notes) to answer these questions

Clinically realistic

guidelines for clinical sciences ie clerkship and beyond
Guidelines for Clinical Sciencesie Clerkship and beyond…
  • Test application of knowledge using clinical vignettes to pose medical decisions in patient care situations
  • Focus items on common or potentially catastrophic problems
  • Pose clinical decisions that would be expected of a successful examinee
  • Avoid clinical situations that would be handled by a (sub)specialist
mcq check list61
MCQ Check-list
  • Why we write them
  • What type is best
  • What flaws are to be avoided
  • What content to test
  • How to construct it
basic rules for mcq s a type
Basic Rules for MCQ’s (A type)*
  • Focus item on important concept
  • Item should assess application of knowledge, not recall of an isolated fact
  • Stem must pose clear question – ‘Cover the options’ test
  • All distractors should be homogeneous
  • Avoid technical item flaws
reference
Reference

Constructing Written Test Questions For the Basic and Clinical Sciences

  • Case & Swanson, NBME 1996