1. Developing Extended Matching Questions (EMQs)
RACP Assessment and Selection
Developing Extended Matching Questions (EMQs)

2. What are Extended Matching Questions (EMQs)?
Similar to Select-the-correct option (Type A) questions BUT the same option list is reused across many questions.
RACP EMQs pose 2 questions, and include a list of 8 options (A–H) from which candidates draw both answers.
First developed in 1993 by Case & Swanson, EMQs were intended to promoted the assessment of clinical decision-making in the United States Medical Licensing Examination (USMLE).
Note: most of this presentation has been adapted from Susan Case’s ‘Writing R-Type Items’

3. Example EMQ Theme: Back pain Lead-in statement:
Option list:
A. Ankylosing spondylitis.
B. Aortic dissection.
C. Prolapsed intervertebral disc.
D. Lumbar spondylosis.
E. Vertebral fracture.
F. Intervertebral disc infection.
G. Pars interarticularis defect.
H. Metastatic malignancy.
Theme: Back pain
Question 1
A 23-year-old man has a 6-month history of lower back pain. His pain is predominantly at the thoracolumbar junction and in the right buttock. The pain is worse in the morning and he has difficulty in getting out of bed. There is some improvement during the day. Examination
shows restriction of lumbar spinal movements, particularly lateral flexion.
(Answer: A)
Question 2
A 32-year-old woman presents with acute onset of low back pain. The pain is constant and is not significantly affected by posture. All spinal movements are painful and difficult. Three weeks earlier, she had a urinary tract infection, which had been treated with amoxicillin.
(Answer: F)
Lead-in statement:
For each patient with back pain, select the most likely diagnosis.

4. Components of an EMQ Theme: Antifungal Medication
Fungal infections cause significant morbidity and mortality. Please choose the most appropriate antifungal medication for the clinical situation described.
Components of an EMQ
Fungal infections cause significant morbidity and mortality. Please choose the most appropriate antifungal medication for the clinical situation described.
A. 5-Flucytosine.
B. Caspofungin.
C. Fluconazole.
D. Griseofulvin.
E. Itraconazole.
F. Liposomal amphotericin.
G. Terbinafine.
H. Voriconazole.
Lead-in
Theme: Antifungal Medication
Option List
Questions
Q1: Which antifungal is first-line therapy for treatment of invasive aspergillosis?
Q2: Which antifungal is first-line therapy for an intensive care patient with Candida glaberata candidaemia?

5. Steps to Create EMQs
Decide on the theme of your EMQ item (e.g. establishing a diagnosis of patients with abdominal pain)
Identify all realistic and relevant options
Develop the lead-in for your set
Write a patient description for each of the diagnoses in the list
Ask a colleague to review your questions (patient descriptions) without the correct answers noted
For each item, review and edit to finalise.

6. Making the EMQ Clinical …
First Sentence:
Age, Gender (A 45-year-old man)
Site of Care (comes to the emergency unit)
Presenting Complaint (because of a headache)
Duration (that has continued for 2 days.)
Next:
Patient History (with Family History?)
Physical Findings
+/- Results of Diagnostic Studies
+/- Initial Treatment, Subsequent Findings, etc.

7. Theme: Congenital heart defects
Question 1
A 2-week-old baby was born at 26 weeks gestation. It has not been possible to take the baby off the ventilator. It has a loud, continuous heart murmur best heard under the left clavicle. (Answer: E)
Question 2
A 6-day-old baby is brought by ambulance to hospital. He is breathless, pale and responding only to painful stimuli. He has weak radial pulses and absent femoral pulses. No murmur is heard. He has hepatomegaly. (Answer: D)
Option list:
Aortic stenosis.
Atrial septal defect.
Atrioventricular septal defect.
Coarctation of the aorta.
Patent ductus arteriosus.
Pulmonary stenosis.
Tetralogy of Fallot.
Transposition of the great arteries.
Lead-in statement:
For each patient with back pain, select the most likely diagnosis.
Age, Gender Patient History
Site of Care Physical Findings
Presenting Complaint +/- Results of Diagnostic Studies
Duration +/- Initial Treatment, Subsequent Findings, etc

8. Rules for Developing EMQs
Options should be single terms, or very short phrases. Include all appropriate options but exclude ‘zebras’. Make sure the options are homogeneous.
A lead-in must be specified for each set to make the examinee task explicit by specifying the relationship between the items and the options.
Items should assess application of knowledge, not just one-word associations. Items in a set must be similar in structure (eg, all vignettes of a similar level of specificity).
Distractors should be plentiful. Add distractors that would be used in a traditional item if necessary.

9. Performance Evidence of EMQs
Designed to assess realistic clinical scenarios
Lower “recognition effect” (i.e. more to choose from) and harder to guess compared to regular MCQs (Type A).
Some suggest that EMQs have better discrimination statistics – strong candidates pick the correct option but weaker candidates have more distractors to choose from.
Reliability measures may also improve with the use of EMQs.
Case S.M., Swanson D.B. & Ripkey D.R 1994, ‘Comparison of items in five-option and extended-matching formats for assessment of diagnostic skills’, Academic Medicine, vol. 69 (suppl.), S1–S3.
Case S.M. & Swanson D.B. 1989, ‘Evaluating diagnostic pattern recognition: A psychometric comparison of items with 15, 5, and 2 options’, paper presentation, Annual Meeting of the American Educational Research Association, San Francisco, CA, March.