Multiple Choice Questions

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• Multiple Choice Questions
• Dr. V.L. PATTANKAR M.D. F.I.C.P.
• Professor of Pathology Coordinator Medical
  Education Cell,M.R. Medical College, Gulbarga.

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• MULTIPLE CHOICE QUESTIONS (M.C.Q)
• EVALUATION
• On Examiners
• When I would willingly have displayed my
  knowledge they sought to expose my ignorance.
• W. Churchill
• On Examinations
• Examinations are formidable even to the best
  prepared, for the greatest fool may ask more than
  wisest may can answer Charles Cotton
• On Students
• Students works to pass,
• Not to know,
• They do pass they do not know.
• Huxley Thomas

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• MCQ Evaluation An integral part of educational
  spiral
• Tests outcome of teaching-learning sessions,
  extent to which objectives are achieved helps
  in modification of objectives.
• Uses of MCQ Appropriately formulated validated
  MCQ.
• Evaluation
• Performance of students
• Provide them with feed back
• Selection e.g., CET
• Summative In some universities
• Advantages of MCQ
• 2) Teaching Aid Topic
• Objectivity validity
• Ability to measure higher levels of cognition
• Ability to discriminate good poor students

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• d) Ability to cover wider portions
• e) Ease of correction
• f) Good for students with difficulty in
  expression in foreign languages.
• g) Interactive feedback to teacher student.
• DISADVANTAGES OF MCQ
• Tedious job to construct relevant, appro. MCQ
• Considerable time spent in pre post validation
• Needs adequate resources
• Management of MCQ bank Money, Faculty, Manpower.
• Cant test power of expression or logical thought
  process.

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• MULTIPLE CHOICE QUESTIONS
• Individual questions are also known as items
• I. Components of multiple choice item
• Direction Instructions to the candidate. Tick (
  ) the correct answer.
• Stem The problem is called stem. It may be
  stated in the form of direct question or
  incomplete statement.
• Choices are called ALTERNATIVES OPTIONS
• A)
• B)
• C)
• D)
• E)

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• Correct alternative (s) is called the ANSWER
  Keyed response
• Remaining alternatives are called DISTRACTORS.
• II. Directions for framing MCQs
• Design each item to measure an important learning
  outcome
• Present a single, clearly formulated problem in
  the stem
• State the stem of the item briefly in simple and
  clear language.
• Make certain that the stem consists of a
  statement or an idea, not just a single word
  (exceptation matching type MCQ).
• Place all common elements in the stem of the
  item. It makes the item compact.

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• 6) State the stem in positive from as far as
  possible.
• 7) The words NOT or EXCEPT should be
  underlined when used in the stem.
• 8) Make certain that only the intended answer is
  correct or clearly the best.
• 9) All the alternatives should be grammatically
  consistent with the stem and parallel in form.
• 10) Use plausible distracters. Each distracter
  should by its nature and content be such that it
  appears to have something to do with the
  question.
• 11) Avoid clues that may suggest correct answer
  or answer to other items. Make each item complete
  and independent.
• 12) The distracter and the correct response
  should be similar in relative length so as to
  avoid any clue.

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• 13) Avoid use of the distracter all of the
  above as far as possible.
• 14) Be careful while using None of the above as
  a distracter or a correct answer.
• 15) Avoid double negatives and abbreviations as
  far as possible.
• 16) In items with numerical alternatives, arrange
  the alternatives in rank order.
• 17) Options can be written as A) Plausible but
  incorrect, B) Correct but not pertinent to the
  problem posed in the question, C) Incorrect but
  related to correct answer.
• 18) Questions should be generally structured to
  ask for correct answer not wrong answer.
  Negative MCQ tend to be less effective more
  difficult to readily understand.
• 19) Time 40-65 secs.

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• TYPES OF MULTIPLE CHOICE QUESTIONS
• One best response type (Four or five choice
  items)
• Matching type
• Multiple completion type
• Multiple true-false type
• Relationship analysis type
• Pictorial or tabulated or graphic type
• Simulated patient management problem
• Examples of some common types multiple choice
  questions
• One best response type
• Item No. 1 The most effective prophylactic agent
  for the prevention of reoccurrence of rheumatic
  fever is
• Acetylsalicylic acid
• Adrenocorticotrophic hormone
• Cortisone
• D) Para-amino benzoic acid
• E) Penicillin

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• Please Note- All items are numbered
  consecutively. Correct responses are given in
• parenthesis.
• A verification of the above item without giving
  the correct response among the given
• choices could be written as follows.
• Item No. 2 The most effective prophylactic agent.
  For the prevention of recurrence of
• rheumatic fever is.
• Acetylsalicylic acid
• Adrenocorticotrophic hormone
• Cortisone
• D) Para-amino benzoic acid
• E) None of the above
• While in the above version none of the above
  in the correct
• response it could be made an incorrect response
  also (see item
• No. 3). But while writing make sure that each
  choice is
• unequivocally correct or incorrect, when you use
  none of the
• above as fifth choice.
• Item No. 3. The most effective prophylactic
  agent for the prevention of recurrence of
  rheumatic fever is
• Acetylsalicylic acid
• Cortisone

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• A matching Type-Five choice association
• Direction A list of lettered heading is followed
  by a list of numbered words or phrases, select
  the one lettered heading most closely more than
  once, or not all.
• Item No. 5-8.
• Prednisolone
• Hydroxy chloroquine
• Cyclophosphamide
• Methotrexate
• Azathioprine
• 5) Relaspsing polychondritis (A)
• 6) Discoid lupus (B)
• 7) Giant cell Arteritis (A)
• 8) Wegeners granulomatosis (C)

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• Multiple Completion Type
• Direction For each question or incomplete
  statement below
• one or more of answers or completion given in
  correct. Select
• If only 1,2 3 are correct
• If only 1 and 3 are correct
• If only 2 and 4 correct
• If all are correct
• Item No. 9 Intravenous pyelography is dangerous
  in patient with
• Acute pyelonephritis
• Bilateral stag-horn calculi
• An increased blood urea
• Allergy to iodides.

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• IV. Multiple True-False Type
• Direction You are to respond Yes or No to each
  of the four alternatives, bearing in mind that
  all, some or one of the alternatives may be
  correct.
• Item No. 10 Toxic doses of digitalis may produce
• Anorexia Yes No ( )
• Disturbances of
• colour vision Yes No ( )
• Ventricular ectopics Yes No ( )
• Vomiting Yes No ( )
• V. RELATIONSHIP ANALYSIS TYPE
• Direction Two statements, connected with
  conjunction are given below with suggested cause
  and effect relationship. Mark your answer
  according to following instructions

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• If both statements are correct and are having
  cause and effect relationship.
• If both the statement are correct but are not
  having cause and effect relations.
• If the first statement alone is correct.
• If both the statement are incorrect.
• Item No. 11 Peu-do-orange is a manifestation of
  carcinoma breast and it is caused by lymphatic
  blockage.
• Item No. 12 A high concentration of insulin is
  embryopathic because the embryo does not secrete
  insulin.
• Item No. 13 Metaphysis is the site of active
  bone growth in long bones of children because
  nutrient artery is the principal artery supplying
  it.
• Item No. 14 Brunners glands are found in the
  esophagus because mucus secretion in the
  esophagus helps propulsion of food.

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• VI. PICTORIAL TYPE
• Direction For items 15 to 17 refer to the figure
  given below. For each disorder indicate the most
  appropriate TSH response to intravenous infusion
  of Thyrotropin releasing hormone (TRH).
• Item No. 15 Thyrotoxicosis due to Graves
  disease
• Item No. 16 Primary hypothyroidism
• Item No. 17 Hypopituitrism due to pituitary
  adenoma
• VII. CASE HISTORY TYPE
• A 62 year old women presents with anasarca of 4
  months
• duration. She has a blood pressure of 160/70 and
  a pulse of 78.
• Her urine shows 4 protein which on
  electrophoresis consists
• of mainly albumin. The urine sediment, contains
  many doubly refractile fat bodies and oval fat
  bodies and nothing else. Serum creatinine is 1.2
  mg/dl, BUN is 22 mg/dl and serum cholesterol is
  550 mg/dl.

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• Which of the following would you to find on renal
  biopsy
• Multiple small juxta medullary cysts
• Thickening of glomerular basement membrane and
  mesangieal proliferation.
• A normal looking glomerulus on light microscopy
  but diffuse foot process fusion on electron
  microscopy.
• Linear deposite of IgG on the glomerular basement
  membrane.
• Changes consistent with malignant hypertension.
• Simulated patient management problem (SPMP)

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• Assembling a Question Paper with MCQ
• Selection of questions Syllabus, number, type
  time for 1
• response type 40 secs, multiple response type
  50-60 sec for 60 min. exam 80-90 items (majority
  1 best type) 50-60 items for multiple
  response/case history.
• 2. Grouping
• 3. Instructions
• 4. Preparation of answer sheets
• Marking methodology
• Validation of MCQ
• Value of MCQ is questionable unless validated by
  colleagues who are subject experts, fellow
  examiners as well as students who were first
  administered MCQ.

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• Prevalidation Is done by subject experts before
  exposing students to MCQ, each item is tested for
  clarity in structure, grammatical errors,
  selection of key distractors.
• Post Validation (Item Analyses) It tests
  validity of MCQ after administration to students
  as a test. It answers
• How difficult/easy item was (difficulty index)
• Can it discriminate students (facility value) who
  understood subject who have not (discrimination
  index)
• Are distractors serving purpose effectively
• (Effectivity of distractor)
• Purpose of distractor is to distract a naïve
  student from correct answer (key)
• Hence distracters should be plausible response
• If a distractor has not been responsed by even 5
  students, it is a poor or ineffective distractor
  has to be replaced.

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• Item Analysis (Post Validation)
• After a test has been administered and scored it
  is
• usually desirable to evaluate the effectiveness
  of item.
• This is done by studying the students response to
  each
• item. When formalised the procedure is called
  item
• analysis and it provides information concerning
  each
• of the following
• The difficulty of the item (Difficulty index)
• The discriminating power of the item
  (Discriminating index)
• The effectiveness of each alternatives
  (Distractor effectiveness)

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• Item analysis information can tell us if an item
  (i.e., the question) was too easy or too
  difficult , how well it discriminated between
  high and low scorers on the test and whether all
  of the alternatives functioned as intended.
• The questions with item difficulty 50-60 are
  considered good, 30-70 are acceptable and those
  with index above 70 or below 30 require
  modification.
• The questions with discrimination index of 0.35
  and above are considered as excellent, 0,25 to
  0.34 good, 0.2 to 0.25 acceptable and those below
  0.2 require modification.
• We should choose items at the 50 level of
  difficulty and those with highest discriminating
  power. Sometimes doubt arises whether items with
  high difficulty index should be retained for
  future use or not. In such cases if the item
  provides positive index of discrimination and if
  all the alternatives are functioning effectively
  and if the item measures an educationally
  significant outcome it should be retained and
  placed in an item bank for future use.

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• Item analysis has several benefits
• It aids in detecting specific technical flaws and
  thus provides information for improving test
  item.
• It provides useful information for class
  discussion of the test, eg. Easy item can be
  skipped over and treated lightly, answers to
  difficult items can be explained more fully and
  items be pointed out to students rather than
  defended as fair.
• It provides data for helping the students to
  improve their learning. The frequency with which
  incorrect answer is chosen reveals common errors
  and misconception which provides a focus for
  remedial work.
• It provides insight in skills which lead to the
  preparation of better test on future occasions.

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• It is a good practice to record the item analysis
  data on a card and maintaining an item bank. Each
  time when an item is used it is useful to item
  analyses and record the results in the item card.
  An accumulation of such data will show the
  variability in the item indices of difficulty and
  discriminating power and thus makes the
  information more interpretable.
• Simplified item analysis procedure
• Arrange the test paper in rank order from the
  highest score to the lowest score.
• Select one third of the papers with high scores
  and call them the upper group.
• Select another one third of the papers with low
  scores and call them the lower group.
• Set aside the middle third.

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• 5) For each item Prepare a FREQUENCY TABLE by
  counting the number of students in the upper
  group who selected each alternative, similarly
  count for lower group also.
• Example Item No.
• Alternatives No.of responses upper No. of
  responses
• group lower group
• ---- ----
  
• ---- ----
  
• ---- ----
• ---- ----
• ---- ----
• No response ---- ----
• Total response (T)
• Encircle the correct answer for each item.

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• 6) Calculate the item difficulty (P) by using the
  formula
• H L
• P ---------- x 100
• T
• Where H Number of correct responses in upper
  group
• L Number of correct responses in lower
  group
• T Total number of response in both groups.
• Note P is usually expressed as percent. The
  lower the percentage figure, the more difficult
  is the item.
• 7) Calculate the index of discrimination of item
  (d) using the formula
• H - L
• d 2 x ----------
• T
• Note d is reported as a decimal fraction.
  Maximum positive discrimination power is
  indicated by 1.00

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• General guidelines for the interpretation of
  result of item analysis
• Discriminating index (Dis. Ind.)
• Poor Marginal Good Excellent
• lt0.15 0.15-.25 (0.25-.35) gt 0.35
• (discard) (revise)
• Item difficulty (item diff.)
• 30 40 50 60 70
• Too difficult Acceptable Ideal Acceptable Simple

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• QUESTION BANK CARD (SPECIMEN)
• Side 1 (Front)
• Reference

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• Side 2 (Back)
• --------------------------------------------------
  -------------------------
• Course Date Group Size of Group
  Answer Difficulty Discri-
• group A B C D E Blank index
  mination
• Index
• --------------------------------------------------
  --------------------------------------------------
  ------
• 2nd yr. 1976 High 60 55 2 3 0 0 0
  60 0.63
• --------------------------------------------------
  --------------------------------------------------
  ------
• Low 60 17 5 3 7 28 0

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• Negative Marking (Counter Marking)
• Why?
• Dissuade guess work
• Compensate for guessing
• Disadv. - May avoid answering
• - Less than certain answer not rewarded
• - Complicated data analysis computation
• How Much?
• No agreement
• Sufficient deterrent
• Methods 1) Compel to answer all question
• (Completion or True/False format)
• Scoring 1, - 1.
• Disadv. 50 guess work

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• 2) Fractional Deduction (Newcastle system )
• - Depending on No. of alternatives/Question.
• - - 1/C (C choices)
• Disadv. Artificial weightage on No. of
  alternatives per question not on importance of
  knowledge.
• 3) Increase No. of options (Confidence testing)
• True False Don't know
• Scoring 1correct, 0 dont know, - 1 incorrect
• ii) Weighted punishment
• Answer Confidence Scoring
• Rothman Patton
• Correct Very sure 4/3 5/3
• fairly sure 1 4/3
• Guess 2/3 1
• Incorrect Guess 1/3 -1/3
• fairly sure 0 -1/2
• Very sure -1/3 -1

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• Formula for guessing correction
• Corrected score No. of right answers-No. of
  wrong answers
• No. of choices 1
• Fixation of pass level
• Based on objectives being tested
• Must know to wt 100 x 70 7000
• Desirable to know 20 50 x 20 1000
• Nice to know 10 20 x 10 200
• Total 8200
• Therefore mean pass marks 8200/100 82
• b) Based on mean between maximum chance score
  maximum possible score.
• 20 100 / 2 60
• c) Mean between maximum chance score
• highest actual score 20 80 / 2 50

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• d) Obtain mean of maximum possible chance score
  lowest score obtained (x)
• Obtained average of ideal mean score actual
  mean score (y)
• Passing score x y
• Fixed as percentile for each batch
• MCQ function much better for ranking students
  rather than deciding pass/fail situation.
• In no case, MCQ should have same marks as for
  essay questions.
• Secrecy Imp.
• Have a large pool of MCQ
• Periodic revision in 3 5 yrs.
• Uses of item analysis
• Creation of item bank
• Use in class room teaching
• Better teaching better learning

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• Check list for items in MCQ
• Item as a whole
• Is the direction clear?
• Is each item wholly independent of others?
• Are all unrelated details eliminated?
• Does the item test an imp. Learning outcome?
  Content area.
• Is it specific?
• Is it brief not too involved?
• Is the level of difficulty/discrimination
  appropriate?
• What is the appropriate time for item?
• Are there clues which suggest correct answer?
• Are negative statements used with care
  appropriately emphasized?

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• B) STEM
• It is clear, concise unambiguous?
• Does it ask for an opinion?
• Does it contain complete sentence or idea not
  merely a word?
• Have vague expressions fairly high,
  considerably greater avoided?
• Are all the common elements placed in stem?
• Are words like never, always, usually, sometimes
  used with caution?
• Are double negatively avoided?
• C) OPTIONS
• Are they logical possible?
• Are they parallel homogenous?
• Are the options wherever appro. arranged
  numerically?
• Do all options complete the stem grammatically?
• Are all distracters functional?

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• D) Key (correct Answers)
• Is it undeniably the only correct response?
• Are letters corresponding to key equally
  distributed?
• Is key to an item provided by data in other item?
• Is care taken not to use words in key which are
  synonyms or very similar to words in stem?