October 2020 How to Write a Good Multiple Choice Question

October 2020

How to Write a Good Multiple Choice Question

Justin B. Long, MD, MHI, Emory University

Getting Started

• Every multiple choice question (MCQ) or item consists

of a stem (i.e. the scenario and lead-in question) as well

as a list of alternatives. One alternative is the best or

correct answer while the other choices are distractors.

• Designing a robust MCQ requires the author to begin

with a well-defined learning gap or a teaching point they

wish to address. It is often useful to start with keywords

lists or a recent publication for inspiration.

• Think of the audience and the level of expertise required

to answer the question (e.g. trainee, fellowship-trained

pediatric anesthesiologist, general anesthesiologist, etc.).

• The stem and alternatives should generally not contain

abbreviations, medical slang, or medical jargon.

• As a stem and lead-in question grow in length, the

cognitive load to read, comprehend, and remember the

scenario increases and this challenge becomes greater

than the question itself.

Designing the Stem and Lead-In Question

• A MCQ stem should be meaningful in and of itself. This

means a stem should contain a clinically relevant

scenario and ask a direct question at the end. The

question should generally be answerable without looking

at the distractor options.

• The lead-in question should depend on the scenario that

precedes it. If the question can be answered without the

clinical scenario then it is likely that the question either

is rote memorization, the question does not require

clinical application, the stem could be shortened, or the

stem is not meaningful.

• The lead-in question should not be fill-in-the-blank or a

true/false type question.

• The lead-in question should generally be positively

worded (e.g. best, most, correct) rather than negatively

worded (e.g. avoid, not, except, worst, least, incorrect)

but there are exceptions where a question is impossible

to ask in a positively-worded way.

Designing a List of Alternatives

• The alternatives should all be plausible, concise, and

homogenous.

• The alternatives should not contain clues as to the correct

answer. Alternatives that are too wordy, contain “all of

the above”, and “none of the above” generally give clues

about the answer. Alternatives that utilize the same

phrasing, are similar in length, and homogenous usually

avoid clues that savvy test-takers pick up on.

• Avoid complex answer combinations (e.g. A&C, C&D,

etc.)

Bad Example

A 13-year-old boy presents for laparoscopic appy under

MAC. He has central core disease, which requires MH

precautions. Which of the choices is not contraindicated to

use?

A. Succinylcholine

B. Sevoflurane

C. Isoflurane

D. Dextrose-containing IV fluids

The above example contains medical jargon, teaches in the

stem, contains a double negative in the lead-in question, the

choices are heterogeneous, the distractor order isn’t uniform,

and is clinically implausible.

Better Example

A 13-year-old boy presents for laparoscopic appendectomy.

He has a history of central core disease. Which of the

following medications is most associated with a life-

threatening reaction during a general anesthetic for this

patient?

A. Fentanyl

B. Nitrous oxide

C. Rocuronium

D. Succinylcholine

References and Further Reading:

• Brame, C. Writing good multiple choice test questions. Vanderbilt University Center for Teaching. 2013. Accessed

October 18, 2020.

https://cft.vanderbilt.edu/guides-sub-pages/writing-good-multiple-choice-test-questions/

• Paniagua, M & Swygert, K, eds. Constructing Written Test Questions for the Basic and Clinical Sciences. The

National Board of Medical Examiners. 2020. Accessed October 18, 2020.

https://www.nbme.org/sites/default/files/2020-01/IWW_Gold_Book.pdf