1. MCQ’s 2: Technical Flaws to Avoid

2. MCQ Check-list  This presentation will focus on: Why we write them Why we write them What type is best What type is best What flaws are to be avoided What flaws are to be avoided  What content to test  How to construct it

3. Writing MCQ’s At the end of this session, the participant will be able to Describe the structure of an MCQ Describe the structure of an MCQ List the technical flaws common to MCQ’s List the technical flaws common to MCQ’s

4. Why do we test? Formative assessment Formative assessment Communicate to the students what material is important Communicate to the students what material is important Identify areas of deficiency in need of remediation or further learning Identify areas of deficiency in need of remediation or further learning Summative assessment Summative assessment Determine final grades Determine final grades Make promotion decisions Make promotion decisions Both Both Motivate students to study Motivate students to study Identify areas where the course/curriculum is weak Identify areas where the course/curriculum is weak

5. Anatomy of an MCQ Item Stem Stem Lead-in Lead-in Options Options One correct answer One correct answer Distractors Distractors

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

7. Types of MCQ’s: True/False Which of the following statements is true regarding contraception? A) oral contraceptives should not be initiated until six weeks after therapeutic abortion to avoid the risk of hypercoagulability B) an intrauterine device can provide good contraceptive protection 5 years after insertion C) oral contraceptives should not be prescribed to individuals under the age of 15 without parental consent D) lesbian women do not require counseling about contraception or sexually transmitted diseases E) oral contraceptives should not be prescribed for women over the age of 35

8. Types of MCQ’s One-Best-Answer family (A type) Options may be diagrammed: Options may be diagrammed: D C A E B Correct answer is the most likely correct Correct answer is the most likely correct Better application of knowledge, integration, synthesis and judgment Better application of knowledge, integration, synthesis and judgment Least correctMost correct

9. 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 pelvic examination. Which one of the following conditions is most likely responsible for her symptoms? 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 pelvic examination. Which one of the following conditions is most likely responsible for her symptoms? A) Chronic pelvic inflammatory disease B) Endometriosis C) Adenomyosis D) Fibroids

10. MCQ ‘Items’ Should test important information – either common or life-threatening Should test important information – either common or life-threatening Should be well-structured Should be well-structured Flaws benefit test-wise examinees Flaws benefit test-wise examinees Irrelevant difficulty does not test examinees’ specific knowledge Irrelevant difficulty does not test examinees’ specific knowledge

11. MCQ Technical Flaws Issues Related to Test-Wiseness Issues Related to Test-Wiseness Issues Related to Irrelevant Difficulty Issues Related to Irrelevant Difficulty

12. MCQ Technical Flaws Issues Related to Test-Wiseness Issues Related to Test-Wiseness provide clues to the right answer provide clues to the right answer examinee can eliminate options based on flaws and not on knowledge examinee can eliminate options based on flaws and not on knowledge Issues Related to Irrelevant Difficulty Issues Related to Irrelevant Difficulty

13. Item Flaws: Test-wiseness Grammatical cues Grammatical cues Logical cues Logical cues Absolute terms Absolute terms Long correct answer Long correct answer Word repeats Word repeats Convergence strategy Convergence strategy

14. Item Flaws: Test-wiseness Grammatical cues One or more distractors don’t follow grammatically from the stem One or more distractors don’t follow grammatically from the stem

15. 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: A) Fibroid uterus B) Adenomyosis C) Endometriosis D) Psychosomatic condition

16. Item Flaws: Test-wiseness Logical cues A subset of the options are collectively exhaustive A subset of the options are collectively exhaustive

17. 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? Arterial blood gases in a normal pregnant woman, compared to her non-pregnant state may show which of the following? A) Decreased pO 2 B) Increased pCO 2 C) Decreased pCO 2 D) Decreased pH E) No difference in pCO 2

18. Item Flaws: Test-wiseness Logical cues One or more distractors don’t follow logically from the stem One or more distractors don’t follow logically from the stem

19. 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) A baseline heart rate above 120 bpm B) Evidence of fetal movement C) Baseline variability D) Two fetal heart rate accelerations in 20 minutes E) Fetal breathing movements

20. Item Flaws: Test-wiseness Absolute terms Always, never Always, never Not a problem if stem is long and lead-in asks a precise question Not a problem if stem is long and lead-in asks a precise question

21. Item Flaws: Test-wiseness Absolute terms In patients with a previous Cesarean section: A) Vaginal birth is NEVER an option B) Repeat Cesarean section is less dangerous to the mother C) The uterine scar may rupture during labour D) Care should ALWAYS be supervised by an obstetrician E) No further pregnancies should EVER be considered

22. Item Flaws: Test-wiseness Long correct answer Correct answer is longer, more specific, or more complete than other options Correct answer is longer, more specific, or more complete than other options

23. 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? Which of the following problems in vaginal breech delivery is most likely to cause serious long-term complications? A) Failure to descend B) Cord prolapse C) Nuchal arms D) Entrapment of the after coming head with an incompletely dilated cervix E) 1 minute Apgar score of 4

24. Item Flaws: Test-wiseness Word repeats A word or phase is included in the stem and in the correct answer A word or phase is included in the stem and in the correct answer

25. 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 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 A) Post-coital test B) Endometrial biopsy C) Hysterosalpingogram D) Laparoscopy with dye insufflation of the fallopian tubes

26. Item Flaws: Test-wiseness Convergence strategy The correct answer includes the most elements in common with the other options The correct answer includes the most elements in common with the other options

27. Item Flaws: Test-wiseness Convergence strategy Normal bladder neck mobility is measured by: A) A Q-tip angle measurement under 40 degrees B) A Q-tip angle measurement under 30 degrees C) A bladder neck ultrasound angle less than 30 degrees D) A Q-tip angle measurement under 20 degrees

28. MCQ Technical Flaws Issues Related to Test-Wiseness Issues Related to Test-Wiseness Issues Related to Irrelevant Difficulty Issues Related to Irrelevant Difficulty do not assess knowledge of intended topic do not assess knowledge of intended topic

29. Irrelevant Difficulty Options are long, complicated or double Options are long, complicated or double Extraneous details in stem Extraneous details in stem Numeric data not stated consistently Numeric data not stated consistently Vague frequency terms Vague frequency terms Non-parallel language in options Non-parallel language in options Stems are tricky or unnecessarily complicated Stems are tricky or unnecessarily complicated ‘None of the above’ ‘None of the above’

30. Irrelevant Difficulty Options are long, complicated or double Extraneous details in stem Shifts difficulty from content knowledge to speed reading Shifts difficulty from content knowledge to speed reading

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

32. 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: 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: A) Postpartum hypothyroidism B) Hyperthyroidism C) Postpartum blues D) Postpartum depression E) Psychotic depression

33. Irrelevant Difficulty Numeric Data Not stated consistently Not stated consistently Mixed format Mixed format Illogical order Illogical order

34. Irrelevant Difficulty Numeric Data not stated consistently Following a second episode of salpingitis, what is the likelihood that a woman is infertile? Following a second episode of salpingitis, what is the likelihood that a woman is infertile? A) 20 – 30 % B) Less than 20% C) Greater than 50 % D) 90% E) 75%

35. Irrelevant Difficulty Vague frequency terms Often, usually, rarely, frequently Often, usually, rarely, frequently Not consistently defined Not consistently defined *may be used in stem if otherwise carefully constructed unambiguous question

36. 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

37. Irrelevant Difficulty Non-parallel language in options Non-parallel language in options Non-logical order Non-logical order

38. 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? A) No conclusion can be drawn, since no follow-up was made of non-vaccinated children B) The number of cases (ie 30 cases over five year) is too small for statistically meaningful conclusions C) It is not possible to draw a conclusion because the trial involved only boys D) Vaccine efficacy (%) is calculated as 85-15/100

39. Irrelevant Difficulty “None of the above” Problematic where judgment is involved or if options not absolutely true or false Problematic where judgment is involved or if options not absolutely true or false Turns question into true/false question Turns question into true/false question Confuses very knowledgeable students Confuses very knowledgeable students

40. Irrelevant Difficulty “None of the above” The main reason that fertility is reduced in a woman in her early 40’s is: The main reason that fertility is reduced in a woman in her early 40’s is: A) Irregular cycles make it hard to time intercourse B) Chromosomal damage adversely affects oocytes’ genetic complement C) Male erectile difficulties increase D) Hormone imbalance leads to poor endometrial development E) None of the above

41. 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: 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) A) III, IV, I, V, II B) IV, III, V, 1, II C) III, I, IV, V, II D) I, V, III, I, V, II E) III, IV, I, II, V

42. MCQ Check-list Why we write them Why we write them What type is best What type is best What flaws are to be avoided What flaws are to be avoided  What content to test  How to construct it

43. General Guidelines for Item Construction Include as much of the item as possible in the stems: Long stems, short options 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 negatively phrased items (except or not in the lead-in). If you must, use only with short options Avoid writing questions of the form: Avoid writing questions of the form: Which of the following statements is correct? Which of the following statements is correct? Each of the following statements is correct EXCEPT Each of the following statements is correct EXCEPT Unfocussed Unfocussed Heterogeneous options Heterogeneous options

44. Basic Rules for MCQ’s (A type)* Focus item on important concept Focus item on important concept Item should assess application of knowledge, not recall of an isolated fact Item should assess application of knowledge, not recall of an isolated fact Stem must pose clear question – ‘Cover the options’ test Stem must pose clear question – ‘Cover the options’ test All distractors should be homogeneous All distractors should be homogeneous Avoid technical item flaws Avoid technical item flaws

45. Reference Constructing Written Test Questions For the Basic and Clinical Sciences Case & Swanson, NBME 1996 Case & Swanson, NBME 1996

46. One last step… Get a colleague to read over your questions Get a colleague to read over your questions Detects more than one right answer Detects more than one right answer Discovers the ‘what am I thinking?’ question Discovers the ‘what am I thinking?’ question Identifies not enough information in the stem Identifies not enough information in the stem …