Constructing Written Test Questions

For the Basic and Clinical Sciences

Third Edition
(Revised)

National Board of Medical Examiners

3750 Market Street
Philadelphia, PA 19104

Printed copies of this publication are not available from the National Board of Medical Examiners (NBME). Additional
copies can be obtained by downloading the manual from the NBMEs web site. Permission to copy and distribute this document is granted by the NBME provided that (1) the copyright and permission notices appear on all reproductions; (2) use
of the document is for noncommercial, educational, and scientific purposes only; and (3) the document is not modified in
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Copyright 1996, 1998 National Board of Medical Examiners (NBME).

Copyright 2001, 2002 National Board of Medical Examiners (NBME).
All right reserved. Printed in the United States of America.

Constructing Written Test Questions

For the Basic and Clinical Sciences
Third Edition
(Revised)

Contributing Authors
Susan M. Case, PhD and David B. Swanson, PhD*
National Board of Medical Examiners
3750 Market Street
Philadelphia, PA 19104
*Dr. Case was a Senior Evaluation Officer at the National Board of Medical Examiners when the first three editions
of this manual were published; she is currently the Director of Testing at the National Conference of Bar Examiners.
Dr. Swanson is the Deputy Vice President of Professional Services at the National Board of Medical Examiners.

Table of Contents

Section I
Issues Regarding Format and Structure of Test Questions

Page
............................................ 7

Chapter 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Assessment: An Important Component of Instruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Issues of Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Importance of Psychometric Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Chapter 2. Multiple-Choice-Item Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
True/False vs One-Best-Answer Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The True/False Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The One-Best-Answer Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Bottom Line on Item Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13
13
14
16
18

Chapter 3. Technical Item Flaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Issues Related to Testwiseness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Issues Related to Irrelevant Difficulty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Summary of Technical Item Flaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Use of Imprecise Terms in Examination Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19
19
22
26
27

Section II
Writing One-Best-Answer Questions for the Basic and Clinical Sciences

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

The Basic Rules for One-Best-Answer Items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Chapter 4. Item Content: Testing Application of Basic Science Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Item Content for the Basic Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Item Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Additional Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Types of Questions and Sample Lead-ins and Option Lists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Writing the Options: Altering Item Difficulty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Item Shape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Problem-Based Learning and Use of Case Clusters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Sample Items for the Basic Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Chapter 5. Item Content: Testing Application of Clinical Science Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Methods for Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
General Issues Regarding What to Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Testing Recall of Isolated Facts or Application of Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Writing One-Best-Answer Items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fine Points on Item Stems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Verbosity, Window Dressing, and Red Herrings:
Do They Make a Better Test Item? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Writing Items Related to Physician Tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Writing Items on Difficult Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Section III
Extended-Matching Items

53
56
57
58
61
66

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Chapter 6. Extended-Matching (R-Type) Items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Avoiding Flaws When You Write Extended-Matching Items for Your Own Examination . . . . . . . . . . . . . . . . . . . . .
Sample Lead-ins and Topics for Option Lists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
More on Options for R-Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Writing the Item Stems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sample Good and Bad Item Stems Using the Same Option List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Overview of the Steps for Writing Extended-Matching Items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sample Extended-Matching Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Steps for Organizing a Group to Write Clinical R-sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Form for Writing R-Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sample SPSSX Code to Score Multiple-Choice Tests Including Extended-Matching Items . . . . . . . . . . . . . . . . . . . .
Comparison of Items in Five-Option and Extended-Matching Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
As to Rs and Back Again . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

71
72
74
75
76
77
81
82
90
93
94
96
97

Chapter 7. Pick N Items: An Extension of the Extended-Matching Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Section IV
Additional Issues

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Chapter 8. Interpretation of Item Analysis Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Chapter 9. Establishing a Pass/Fail Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Definitions and Basic Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Two Standard-Setting Methods Based on Judgements about Items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Relative/Absolute Compromise Standards: The Hofstee Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

111
111
112
114

Chapter 10. Miscellaneous Thoughts on Topics Related to Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Appendix A. The Graveyard of NBME Item Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Appendix B. Sample Item-Writing Templates, Items, Lead-Ins, and Option Lists For the Basic and Clinical Sciences . .129

Preface to Third Edition

This manual was written to help faculty members improve the quality of the multiple-choice questions written for their examinations. The manual provides an overview of item formats, concentrating on the traditional one-best-answer and matching
formats. It reviews issues related to technical item flaws and issues related to item content. The manual also provides basic
information to help faculty review statistical indices of item quality after test administration. An overview of standard-setting techniques is also provided. Issues related to exam blueprinting are not addressed in any detail. We have focused almost
exclusively on the item level, leaving exam level planning for another manuscript.
We anticipate that this manual will be useful primarily by faculty who are teaching medical students in basic science courses and clinical clerkships. The examples focus on undergraduate medical education, though the general approach to item
writing may be useful for assessing examinees at other levels.
This manual reflects lessons that we have learned in developing items and tests over the past 20 years. During this period, we
have reviewed (quite literally) tens of thousands of multiple-choice questions and have conducted item-writing workshops for
thousands of item writers preparing USMLE, NBME, and specialty board examinations as well as faculty at more than 60
medical schools developing test questions for their own examinations. Each workshop attendee has helped us to frame our
thoughts regarding how to write better quality test questions, and, over the years, we have become better able (we believe) to
articulate the whys and wherefores. We hope this manual helps to communicate these thoughts.

Susan M. Case, PhD

David B. Swanson, PhD
January 1998

Section I
Issues Regarding Format and Structure of
Test Questions

This section reviews structural issues important for the construction of

high-quality test questions. The following section will review issues
related to item content.

Chapter 1
Introduction

Assessment: An Important Component of Instruction

Assessment is a critical component of instruction; properly used, it can aid in accomplishing key curricular goals. The impact
of decisions regarding how and when to evaluate the knowledge and performance of your students cannot be overestimated.
A primary purpose of testing is to communicate what you view as important. Tests are a powerful motivator, and students
will learn what they believe you value. Assessment also helps to fill instructional gaps by encouraging students to read broadly on their own and to participate broadly as educational opportunities are available. This outcome of testing is especially
important in the clerkships, where the curriculum may vary from student to student, depending on factors such as the clinical
setting and the random flow of patients. This outcome may also be important in some basic-science settings (eg, problembased learning), where the educational experiences may vary from student to student.
Because tests have such a powerful influence on student learning, it is important to develop tests that will further your educational goals. Introduction of a hands-on clinical skills test drives students out of the library into the clinic, where they may
seek help with their physical-exam skills; introduction of a test assessing only recall of isolated facts, on the other hand, drives them to cram course review books. This manual focuses on how to write high-quality, multiple-choice questions that
assess skill in interpreting data and making decisions, which we believe are important components of clinical skills.
Students paths toward mastery or even excellence will be less rocky if they receive ongoing feedback on their progress.

Chapter 1. Introduction

Purposes of Testing

What Should Be Tested?

Communicate to students what material is

important

Exam content should match course/clerkship

objectives

Motivate students to study

Important topics should be weighted more

heavily than less important topics

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

The testing time devoted to each topic should reflect

the relative importance of the topic
The sample of items should be representative of the
instructional goals

Issues of Sampling
The purpose of any assessment is to permit inferences to be drawn concerning the skills of examinees: inferences that extend
beyond the particular problems (or, equivalently, cases or test questions) included in the exam to the larger domain from
which the cases (or questions) are sampled. Its clear to all of us that assessment takes time. Its also clear that, if you
increase time spent in one activity, you have to decrease time spent in other activities. Whether youre deciding on an overall plan for evaluation or youre deciding what to include on a single test, youre basically faced with a sampling problem.
Performance on the sample provides a basis for estimating achievement in the broader domain that is actually of interest.
With multiple-choice questions (MCQs), you first need to decide what you want to include on the test. The amount of attention given to evaluating something should reflect its relative importance. You need to sample topics and also sample skills
(eg, determining the diagnosis, deciding on the next step in management); you cannot ask everything. Performance on the
sample provides a basis for estimating achievement in the broader domain that is actually of interest. The nature of the sample determines the extent to which the estimate of true ability is reproducible (reliable, generalizable) and accurate (valid).
If the sample is not representative of the broader domain of interest (eg, including only cardiovascular-related content in a

10

test of competence in general medical practice), exam results will be biased and will not provide a good basis for estimating achievement in the domain of interest. If the sample is too small, exam results may not be sufficiently precise (reproducible, reliable) to ensure that they reflect true proficiency.
With a multiple-choice test, theres almost always one grader (usually the computer) and a series of questions or sets of questions; sampling involves selecting a subset of questions to include on the test. With other evaluation methods (eg, oral exams
based on patient cases, standardized patient exams, essay exams), the sampling is much more complicated. Any method that
cant be scored mechanically requires sampling on a second dimension: the dimension of grader. In these exams, you are
interested in performance across a range of cases and you want the grade to be independent of who the examiner is. You
therefore need to sample across two dimensions: one for the questions or cases and one for the judges or raters. You need
to sample across a range of cases, because performance on one case is not a very good predictor of performance on other
cases. You also need to sample across different raters to minimize the effects of rater harshness or leniency, and other issues
like halo that cause problems in the consistency of scoring across raters. With broad samples, peaks and valleys in performance and peaks and valleys in rater differences tend to average out.
Although this manual focuses on multiple-choice questions, we believe that it is generally appropriate to use a variety of testing methods. No one method is likely to assess all the skills of interest. It should also be noted that the method used for
assessment does not directly affect test quality, nor does it determine the component of competence measured by the test.

Importance of Psychometric Considerations

The extent to which the psychometric characteristics of an assessment method are important is determined by the purpose of
the test and the decisions that will be made based on the results. For high-stakes tests (those used for promotion or graduation decisions, even course grades), test results must be reasonably reproducible (precise, reliable) and accurate (valid).
For low-stakes tests, the psychometric characteristics are less important, and the primary consideration should be on directing student learning. As noted above, in order to generate a reproducible score, you need to sample content broadly (ie, typically, a dozen or more cases, 100 or more MCQs or short-answer items).
The following papers include more detail about assessment issues in general.
Swanson DB. (1987) A measurement framework for performance-based tests. In Hart I, Harden R (Eds.), Further Developments in Assessing Clinical Competence. Montreal: Can-Heal Publications, 13-4.
Swanson DB, Norcini JJ, Grosso L. (1987) Assessment of clinical competence: written and computer-based simulations. Assessment and Evaluation in Higher Education, 12(3), 220-246.

Chapter 1. Introduction

11

Friedman C, de Bliek R, Greer D, Mennin S, Norman G, Sheps C, Swanson DB, Woodward C. (1990) Charting the winds of change: recommendations for evaluating innovative medical curricula. Academic Medicine, 65, 8-14.
Swanson DB, Case SM, van der Vleuten CP. (1991:1997/2nd edition) Strategies for student assessment. In Boud, D. & Feletti, G (Eds.), The Challenge of Problem-Based Learning. London, Kogan Page Ltd., 269-282.
Newble DI, Dauphinee D, Woolliscroft JO, MacDonald M, Mulholland H, Page G, Swanson DB, Thomson A, van der Vleuten CP. (1994) Guidelines for assessing clinical competence. Teaching and Learning in Medicine, 6:3, 213-220.
Swanson DB, Norman G, Linn R. (1995) Performance-based assessment: Lessons from the health professions. Educational Researcher, 24:5, pp511,35. Abridged version reprinted in Pedagogue: Perspectives on Health Sciences Education, 6(Summer 1996), McMaster University Program for
Educational Development, 1-7.
Swanson DB, Case SM (1997) Assessment in basic science instruction: Directions for practice and research. Advances in Health Sciences Education: Theory & Practice, 2: 71-84.
Case SM, (1997) Assessment of truths we hold as self-evident and their implications. In Scherpbier AJJA, van der Vleuten CPM, Rethans JJ, van
der Steeg AFW (Eds.), Advances in Medical Education. Dordrecht, The Netherlands: Kluwer Academic Publishers, 2-6.
Swanson DB, Clauser BE, Case SM. (1999) Clinical skills assessment with standardized patients in high-stakes tests: A framework for thinking
about score precision, equating, and security. Advances in Health Sciences Education, 4: 67-106.

The following papers discuss item format issues in greater detail.

Case SM, Downing SM. (1989) Performance of various multiple-choice item types on medical specialty examinations: types A, B, C, K, and X.
Proceedings of the 28th Annual Conference on Research in Medical Education, 167-172.
Swanson DB, Case SM. (1992) Trends in written assessment: a strangely biased perspective. In Harden R, Hart I, Mulholland H (Eds.), Approaches to the Assessment of Clinical Competence: Part 1. Page Brothers, Norwich, England, 38-53.
Case SM, Swanson DB. (1993) Extended-matching items: a practical alternative to free-response questions. Teaching and Learning in Medicine,
5(2), 107-115.
Swanson DB, Case SM. (1995) Variation in item difficulty and discrimination by item format on Part I (basic sciences) and Part II (clinical sciences)
of U.S. licensing examinations. In Rothman A, Cohen R (Eds.), Proceedings of the Sixth Ottawa Conference on Medical Education. University of
Toronto Bookstore Custom Publishing, 285-287.
Norman G, Swanson DB, Case SM. (1996) Conceptual and methodological issues in studies comparing assessment formats. Teaching and Learning in Medicine, 8(4):208-216.

12

Chapter 2
Multiple-Choice-Item Formats

In order for a test question to be a good one, it must satisfy two basic criteria. First, the test question must address important content. This is an essential condition, which will be addressed further along in the manual. Obviously, item content is
of critical importance, but, in and of itself, focusing on important content is not sufficient to guarantee that your test question is a good one. Items that attempt to assess critically important topics cannot do so unless they are well-structured
avoiding flaws that benefit the testwise examinee and avoiding irrelevant difficulty are prerequisites that must be met in
order for test questions to generate valid scores.

True/False vs One-Best-Answer Questions

The universe of multiple-choice questions (MCQs) can be divided into two families of items: those that require the examinee to indicate all responses that are appropriate (true/false) and those that require the examinee to indicate a single response
(one best answer).
Each family is represented by several specific formats, as listed below:
True/false-item formats require that examinees select all options that are true
C (A / B/ Both/ Neither items)
K (complex true/false items)
X (simple true/false items)
Simulations such as Patient Management Problems (PMPs)
One-best-answer item formats require that examinees select the single best response
A (4 or more options, single items or sets)
B (4 or 5 option matching items in sets of 2-5 items)
R (Extended-Matching items in sets of 2-20 items)
The letters used to label the item formats hold no intrinsic meaning. Letters have been assigned more or less sequentially
to new item formats as they are developed (see Appendix A).

Chapter 2. Multiple-Choice-Item Formats

13

The True/False Family

The true/false and one-best-answer families pose very different tasks for the examinee. True/false items require an examinee to select all the options that are true. For these items, the examinee must decide where to make the cut-off to what
extent must a response be true in order to be keyed as true. While this task requires additional judgement (beyond what
is required in selecting the one best answer), this additional judgment may be unrelated to clinical expertise or knowledge.
Too often, examinees have to guess what the item writer had in mind because the options are not either completely true or
completely false.
The following is an example of an acceptable true/false item from a structural perspective.* Note that the stem is clear and the options
are absolutely true or false with no ambiguity.
Which of the following is/are X-linked recessive
conditions?
1. Hemophilia A (classic hemophilia)
2. Cystic fibrosis
3. Duchennes muscular dystrophy
4. Tay-Sachs disease

True statements about cystic fibrosis (CF) include:

1. The incidence of CF is 1:2000.
2. Children with CF usually die in their teens.
3. Males with CF are sterile.
4. CF is an autosomal recessive disease.

The options can be diagramed as follows.

2
4

1
3

Totally Wrong
Options

Totally Correct
Options

This true/false item is flawed. Options 1, 2, and 3 cannot be

judged as absolutely true or false; a group of experts would
not agree on the answers. In thinking about Option 1, note
that the incidence is not exactly 1:2000; experts would want
more information: Is this in the USA? Is this among all ethnic groups? Modifying the language to approximately
1:2000 doesnt help, since the band is not specified. Similar issues arise with Options 2 and 3, while Option 4 is clear.

*Following tradition, for true/false items, the options are numbered; for one-best-answer items, the options are lettered.

14

While written in jest (by the second author), this true/false item
illustrates a common problem items for which the stem is
unclear. Depending on your perspective, Options 1, 2, and 3
might be true; alternatively, 1, 2, and 3 might be false while 4
is true.

In this true/false example, there are vague terms in the options

that provide cues to the testwise examinee. For example, the
term may in Options 1, 2, and 3 cues the testwise examinee
that those options are true. Option 4 is harder to guess
what does usually mean? Research has shown that these
vague frequency terms do not have a shared definition.
Experts would not agree on whether the fourth option is true
or false.

The flaws in this item are more subtle. The difficulty is that
the examinee has to make assumptions about the severity of
the disease, the age of the patient, and whether or not the disease has been treated. Different assumptions lead to different answers, even among experts.

The way to a mans heart is through his

1. aorta
2. pulmonary arteries
3. pulmonary veins
4. stomach

In the clinical assessment of chronic pain,

1. the physicians personal attitude concerning
pain may affect medical judgement
2. unpleasant emotions may be converted to
complaints of bodily pain
3. pain may have a symbolic meaning
4. facial appearance or body posture is usually
a clue to the severity of the pain

In children, ventricular septal defects are associated

with
1. systolic murmur
2. pulmonary hypertension
3. tetralogy of Fallot
4. cyanosis

Note that in each sample flawed item, the stem is unclear, the options contain vague terms, or the options are partially correct.
In each instance, a group of experts would have difficulty reaching a consensus on the correct answer.

Chapter 2. Multiple-Choice-Item Formats

15

Because examinees are required to select all the options that are true, true/false items must satisfy the following rules:
Stems must be clear and unambiguous. Imprecise phrases such as is associated with; is useful for; is important and
words that provide cueing such as may or could be; and vague terms such as usually or frequently should be avoided.
Options must be absolutely true or false; no shades of gray are permissible; avoid phrases and words noted in the
first item above.

The One-Best-Answer Family

In contrast to true/false questions, one-best-answer (A-type) questions make explicit the number of options to be selected. Atype items are the most widely used multiple-choice-item format. They consist of a stem (eg, a clinical case presentation) and
a lead-in question, followed by a series of choices, typically one correct answer and four distractors. The following question
describes a situation (in this instance, a patient) and asks the examinee to indicate the most likely cause of the problem.
Stem:
A 32-year-old man has a 4-day history of progressive weakness in his extremities. He has been healthy except for an
upper respiratory tract infection 10 days ago. His temperature is 37.8 C (100 F), blood pressure is 130/80 mm Hg, pulse
is 94/min, and respirations are 42/min and shallow. He has symmetric weakness of both sides of the face and the proximal and distal muscles of the extremities. Sensation is intact. No deep tendon reflexes can be elicited; the plantar
responses are flexor.
Lead-in:
Which of the following is the most likely diagnosis?
Options:
A. Acute disseminated encephalomyelitis
B. Guillain-Barr syndrome
C. Myasthenia gravis
D. Poliomyelitis
E. Polymyositis

16

Note that the incorrect options are not totally wrong. The options can be diagramed as follows:
D

Least
Correct

B
Most
Correct

Even though the incorrect answers are not completely wrong, they are less correct than the keyed answer. The examinee is
instructed to select the most likely diagnosis; experts would all agree that the most likely diagnosis is B; they would also
agree that the other diagnoses are somewhat likely, but less likely than B. As long as the options can be laid out on a single
continuum, in this case from Most Likely Diagnosis to Least Likely Diagnosis, options in one-best-answer questions do
not have to be totally wrong.
This item is flawed. After reading the stem, the examinee has
only the vaguest idea what the question is about. In an
attempt to determine the best answer, the examinees have to
decide whether it occurs frequently in women is more or
less true than it is seldom associated with acute pain in a
joint. This is a comparison of apples and oranges. In order
to rank-order the relative correctness of options, the options
must differ on a single dimension or else all options must be
absolutely 100% true or false.

Which of the following is true about pseudogout?

A. It occurs frequently in women.
B. It is seldom associated with acute pain in
a joint.
C. It may be associated with a finding of chondrocalcinosis.
D. It is clearly hereditary in most cases.
E. It responds well to treatment with
allopurinol.

The diagram of these options might look like this. The

options are heterogeneous and deal with miscellaneous
facts; they cannot be rank-ordered from least to most true
along a single dimension. Although this question appears to
assess knowledge of several different points, its inherent
flaws preclude this. The question by itself is not clear; the
item cannot be answered without looking at the options.

Chapter 2. Multiple-Choice-Item Formats

17

In contrast to the options in the item on pseudogout, the options in the item on Guillain-Barr syndrome are homogeneous (eg,
all diagnoses); knowledgeable examinees can rank-order the options along a single dimension.
Well-constructed one-best-answer questions satisfy the cover-the-options rule. The questions could be administered as writein questions. The entire question is included in the stem.

The Bottom Line on Item Formats

We recommend that you do not use true/false questions. While many item writers believe the true/false items are easier to write
than one-best-answer items, we find that they are more problematic. The item writer had something particular in mind when
the question was written, but careful review commonly reveals subtle difficulties that were not apparent to the item author.
Often the distinction between true and false is not clear, and it is not uncommon for subsequent reviewers to alter the answer
key. As a result, reviewers rewrite or discard true/false items far more frequently than items written in other formats. Some
ambiguities can be clarified, but others cannot.
There is a final reason that is more compelling than those noted above. We find that, to avoid ambiguity, we are pushed toward
assessing recall of an isolated fact something we are actively trying to avoid. We find that application of knowledge, integration, synthesis, and judgement questions can better be assessed by one-best-answer questions. As a result, the NBME has
completely stopped using true/false formats on its examinations.
We also recommend that you not use negative A-type questions. The most problematic are those that take the form: Each of
the following is correct EXCEPT or Which of the following statements is NOT correct? These suffer from the same problem as true/false questions: if options cannot be rank-ordered on a single continuum, the examinees cannot determine either the
least or the most correct answer. On the other hand, we occasionally use well-focused negative A-types with single-word
options on some exams, largely as a (poor) substitute for items that instruct the examinee to select more than one response. A
superior format for this purpose, the Pick N format, in which examinees are instructed to select N responses, is discussed
later in the manual.
The Appendix A illustrates a variety of item formats that are no longer used on NBME exams.

18

Chapter 3
Technical Item Flaws

This section describes two types of technical item flaws: testwiseness and irrelevant difficulty. Flaws related to testwiseness
make it easier for some students to answer the question correctly, based on their test-taking skills alone. These flaws commonly occur in items that are unfocused and do not satisfy the cover-the-options rule. Flaws related to irrelevant difficulty make the question difficult for reasons unrelated to the trait that is the focus of assessment.
The purpose of this section is to outline common flaws and to encourage you to eliminate these flaws from your questions
to provide a level playing field for the testwise and not-so-testwise students. The probability of answering a question correctly should relate to the examinees amount of expertise on the topic being assessed and should not relate to their expertise on test-taking strategies.

Issues Related to Testwiseness

Grammatical cues: one or more distractors dont follow grammatically from the stem
Because an item writer tends to pay more attention to the correct answer than to the distractors, grammatical errors are
more likely to occur in the distractors. In this example, testwise students would eliminate A and C as options because
they do not follow grammatically or logically from the stem.
Testwise students then have to choose only between B, D,
and E.

Chapter 3. Technical Item Flaws

A 60-year-old man is brought to the emergency

department by the police, who found him lying unconscious on the sidewalk. After ascertaining that the
airway is open, the first step in management should be
intravenous administration of
A. examination of cerebrospinal fluid
B. glucose with vitamin B1 (thiamine)
C. CT scan of the head
D. phenytoin
E. diazepam

19

Logical cues: a subset of the options are collectively exhaustive

In this item, Options A, B, and C include all possibilities.
The testwise student knows that A, B, or C must be correct,
whereas the non-testwise student spends time considering D
and E. Often, the item writers add D and E only because they
want to list five options. In these situations, the item writer
may not have paid much attention to the merits of options D
and E; sometimes, they are partially correct and confusing
because they cannot be rank-ordered on the same dimension
as Options A, B, and C. This flaw is commonly seen in items
with options such as Increases, Decreases, and Remains
the same.

Crime is
A. equally distributed among the social classes
B. overrepresented among the poor
C. overrepresented among the middle class
and rich
D. primarily an indication of psychosexual
maladjustment
E. reaching a plateau of tolerability for the nation

Absolute terms: terms such as always or never are used in options

In this item, Options A, B, and E contain terms that are less
absolute than those in Options C and D. The testwise student
will eliminate Options C and D as possibilities because they
are less likely to be true than something stated less absolutely. Note that this flaw would not arise if the stem was
focused and the options were short; it arises only when verbs
are included in the options rather than in the lead-in.

20

In patients with advanced dementia, Alzheimers type,

the memory defect
A. can be treated adequately with phosphatidylcholine (lecithin)
B. could be a sequela of early parkinsonism
C. is never seen in patients with neurofibrillary
tangles at autopsy
D. is never severe
E. possibly involves the cholinergic system

Long correct answer: correct answer is longer, more specific, or more complete than other options
In this item, Option C is longer than the other options; it is
also the only double option. Item writers tend to pay more
attention to the correct answer than to the distractors.
Because you are teachers, you write long correct answers
that include additional instructional material, parenthetical
information, caveats, etc. Sometimes this can be quite
extreme: the correct answer is a paragraph in length and the
distractors are single words.

Secondary gain is
A. synonymous with malingering
B. a frequent problem in obsessive-compulsive
disorder
C. a complication of a variety of illnesses and
tends to prolong many of them
D. never seen in organic brain damage

Word repeats: a word or phrase is included in the stem and in the correct answer
This item uses the word unreal in the stem, and derealization is the correct answer. Sometimes, a word is repeated
only in a metaphorical sense, eg, a stem mentioning bone pain,
with the correct answer beginning with the prefix osteo-.

Chapter 3. Technical Item Flaws

A 58-year-old man with a history of heavy alcohol use

and previous psychiatric hospitalization is confused
and agitated. He speaks of experiencing the world as
unreal. This symptom is called
A. depersonalization
B. derailment
C. derealization
D. focal memory deficit
E. signal anxiety

21

Convergence strategy: the correct answer includes the most elements in common with the other options
This item flaw is less obvious than the others, but it occurs frequently and is worth noting. The flaw is seen in several forms.
The underlying premise is that the correct answer is the option that has the most in common with the other options; it is not
likely to be an outlier. For example, in numeric options, the correct answer is more often the middle number than an extreme
value. In double options, the correct answer is more likely to be the option that has the most elements in common with the
other distractors. For example, if the options are Pencil and pen; Pencil and highlighter; Pencil and crayon; Pen and
marker, the correct answer is likely to be Pencil and pen (ie, by simple count, Pencil appeared 3 times in the options;
Pen appeared twice; other elements each appeared only once). While this might seem ridiculous, this flaw occurs because
item writers start with the correct answer and write permutations of the correct answer as the distractors. The correct
Local anesthetics are most effective in the
answer is, therefore, more likely to have elements in comA. anionic form, acting from inside the
mon with the rest of the options; the incorrect answers are
nerve membrane
more likely to be outliers as the item writer has difficulty
B. cationic form, acting from inside the
generating viable distractors. In this example, the testwise
nerve membrane
student would eliminate anionic form as unlikely because
C. cationic form, acting from outside the
anionic form appears only once; that student would also
nerve membrane
exclude outside the nerve membrane because outside
D. uncharged form, acting from inside the
appears less frequently than inside. The student would
nerve membrane
then have to decide between Options B and D. Since three
E. uncharged form, acting from outside the
of the five options involve a charge, the testwise student
nerve membrane
would then pick Option B.

Issues Related to Irrelevant Difficulty

Options are long, complicated, or double
This item illustrates a common flaw. The stem contains extraneous reading, but, more importantly, the options are very long
and complicated. Trying to decide among these options requires a significant amount of reading because of the number of
elements in each option. This can shift what is measured by an item from content knowledge to reading speed. Please note
that this flaw relates only to options. There are many well-constructed test questions that include a long stem. Decisions
about stem length should be made in accord with the purpose of the item. If the purpose of the item is to assess whether or

22

not the student can interpret and synthesize information to determine, for example, the most likely diagnosis, then it is appropriate for the stem to include a fairly complete description of the situation.

Peer review committees in HMOs may move to take action against a physicians credentials to care for participants
of the HMO. There is an associated requirement to assure that the physician receives due process in the course of
these activities. Due process must include which of the following?
A. Notice, an impartial forum, council, a chance to hear and confront evidence against him/her.
B. Proper notice, a tribunal empowered to make the decision, a chance to confront witnesses against him/her, and a
chance to present evidence in defense.
C. Reasonable and timely notice, impartial panel empowered to make a decision, a chance to hear evidence against
himself/herself and to confront witnesses, and the ability to present evidence in defense.

Numeric data are not stated consistently

When numeric options are used, the options should be listed in numeric order and the options should be listed in a single format (ie, as single terms or as ranges). Confusion occurs when formats are mixed and when the options are listed in an illogical order or in an inconsistent format.
In this example, Options A, B, and C are expressed as ranges,
whereas Options D and E are specific percentages. All
options should be expressed as ranges or as specific percentages; mixing them is ill-advised. In addition, the range for
Option C includes Options D and E, which almost certainly
rules out Options D and E as correct answers.

Chapter 3. Technical Item Flaws

Following a second episode of infection, what is the

likelihood that a woman is infertile?
A. Less than 20%
B. 20 to 30%
C. Greater than 50%
D. 90%
E. 75%

23

Frequency terms in the options are vague (eg, rarely, usually)

Research has shown that vague frequency terms are not consistently defined or interpreted, even by experts. A more complete
discussion of this research is included on page 29.

Severe obesity in early adolescence

A. usually responds dramatically to dietary
regimens
B. often is related to endocrine disorders
C. has a 75% chance of clearing spontaneously
D. shows a poor prognosis
E. usually responds to pharmacotherapy and
intensive psychotherapy

Language in the options is not parallel; options are in an illogical order

This item illustrates a common flaw in which the options are
long and the language makes it difficult and time-consuming to determine which is the most correct. Generally, this
flaw can be corrected by careful editing. In this particular
item, the lead-in can be changed to For which of the following reasons can no conclusion be drawn from these
results? The options can then be edited (ie, A. No followup was made of nonvaccinated children; B. The number of
cases was too small; C. The trial involved only boys, and a
new option can be written for D).

24

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 nonvaccinated children
B. The number of cases (ie, 30 cases over five
years) is too small for statistically meaningful
conclusions
C. No conclusions can be drawn because the trial
involved only boys
D. Vaccine efficacy (%) is calculated as 85-15/100

None of the above is used as an option

The phrase None of the above is problematic in items
Which city is closest to New York City?
where judgement is involved and where the options are not
absolutely true or false. If the correct response is intended to
A. Boston
be one of the other listed options, knowledgeable students
B. Chicago
can be faced with a dilemma because they have to decide
C. Dallas
between a very detailed perfect option and the one that you
D. Los Angeles
have intended as correct. They can often construct an option
that is more correct than the one you intended to be correct.
E. none of the above
Use of none of the above essentially turns the item into a
If students select E, you dont know if they are thinking
true/false item; each option has to be evaluated as more or
about Philadelphia or London.
less true than the universe of unlisted options. It will often be
possible to fix such items by replacing none of the above
by an option that means roughly the same thing but is more specific. For example, in an item asking an examinee to specify the most appropriate pharmacotherapy, replacing none of the above by no drug should be given at this time will eliminate the ambiguity of none of the above.
Stems are tricky or unnecessarily complicated
Sometimes, item writers can take a perfectly easy question
and turn it into something so convoluted that only the most
stalwart will even read it. This item is a sample of that
kind of item. The notation in I: through V: is complex;
having to rank order Roman numerals after working
through that notation is irrelevant and unnecessarily
difficult.

Arrange the parents of the following children with

Downs syndrome in order of 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: 47, XX, -21, +T (21q21q) (parents not karyotyped)
A.
B.
C.
D.
E.

Chapter 3. Technical Item Flaws

III, IV, I, V, II
IV, III, V, I, II
III, I, IV, V, II
IV, III, I, V, II
III, IV, I, II, V

25

Summary of Technical Item Flaws

Issues Related to Testwiseness

Grammatical cues - one or more distractors dont follow grammatically from the stem
Logical cues - a subset of the options is collectively exhaustive
Absolute terms - terms such as always or never are in some options
Long correct answer - correct answer is longer, more specific, or more complete than other options
Word repeats - a word or phrase is included in the stem and in the correct answer
Convergence strategy - the correct answer includes the most elements in common with the other options

Issues Related to Irrelevant Difficulty

Options are long, complicated, or double

Numeric data are not stated consistently
Terms in the options are vague (eg, rarely, usually)
Language in the options is not parallel
Options are in a nonlogical order
None of the above is used as an option
Stems are tricky or unnecessarily complicated
The answer to an item is hinged to the answer of a related item

General Guidelines for Item Construction

Make sure the item can be answered without looking at the options OR that the options are 100% true or false.
Include as much of the item as possible in the stem; the stems should be long and the options short.
Avoid superfluous information.
Avoid tricky and overly complex items.
Write options that are grammatically consistent and logically compatible with the stem; list them in logical or alphabetical order. Write distractors that are plausible and the same relative length as the answer.
Avoid using absolutes such as always, never, and all in the options; also avoid using vague terms such as usually and
frequently.
Avoid negatively phrased items (eg, those with except or not in the lead-in). If you must use a negative stem, use
only short (preferably single word) options.
And most important of all: Focus on important concepts; dont waste time testing trivial facts.

26

Use of Imprecise Terms in Examination Questions

While imprecise terms are used in our everyday speech and in our writing, these terms cause confusion when they are used
in the text of examination items. In a study conducted at the NBME, 60 members of eight test committees who wrote questions for various medical specialty examinations reviewed a list of terms used in MCQs to express some concept related to
frequency of occurrence and indicated the percentage of time that was reflected by each term.
Results (shown below) indicated that the terms do not have an operational definition that is commonly shared, even among
the item writers themselves. The mean value plus or minus one standard deviation exceeded 50 percentage points for more
than half of the phrases. For example, on average, the item writers believed the term frequently indicated 70% of the time;
half believed it was between 45% and 75% of the time; actual responses ranged from 20% to 80%. Of particular note is that
values for frequently overlapped with values for rarely.
The implication of these results for the construction of test
questions varies by item format. Vague terms create far more
severe problems in the various kinds of true/false items (K-,
C- and X-type items) than in one-best-answer (A- and R-type)
items. For example, imprecise terms cause major problems in
true/false items such as this example:

True statements about pseudogout include:

1. It occurs commonly in women.
2. It is often associated with acute pain.
3. It is usually hereditary.
4. Serum calcium levels are frequently increased.

In true/false items, the examinee has to judge whether each option is true or false. When options are not absolutely true or
false, examinees rely on their personal definition of the ambiguous terms or their guesses about what these terms meant to
the item writer. Alternatively, examinee responses may reflect personal response style (the tendency to respond either true
or false when the correct answer is unknown). These response style factors may have more of an effect on whether or not
an examinee answers the item correctly than knowledge of the subject matter and may be part of the reason why true/false
items tend to perform poorly.

Chapter 3. Technical Item Flaws

27

Rewording the options by specifying exact numbers does not correct the problem. For example, the statement, the incidence among women is 1:2000 would not be an appropriate modification of Option 1 in the example shown. The incidence
is not exactly 1:2000, and because a band is not specified, examinees would define their own bands, narrowly or widely, presumably depending on personal response styles. In true/false items, the appropriate treatment of numeric options is either to
generate a comparison (eg, the incidence is greater than that of osteoarthritis) or to specify a range (eg, the incidence is
between 1:1000 and 1:2000).
The issue noted above with true/false items is not as problematic with well-constructed one-best-answer items (ie, those that pose
a clear question and have homogeneous options). For example, the following question includes a vague term in the item stem,
yet, because the task is to select the one-best answer, the question is relatively unambiguous.
Which of the following laboratory values is usually increased in patients with pseudogout?
Problems do arise with one-best answer items that have
vague terms in the options as in this example.
The only way to make such an item more ambiguous would
be to use a fifth option none of the above.

28

Patients with pseudogout have pain:

A. frequently
B. usually
C. often
D. commonly

Box-plot showing distribution of responses for frequency terms. Results are based on responses from 60 members of eight
item-writing committees. The horizontal line in each box indicates the median response; the boxes include the ranges for
50% of the responses. The vertical lines extend to the highest and lowest values indicated. For example, the median response
for frequently indicated 70% of the time; half believed it was between 45% and 75% of the time; actual responses ranged
from 20% to 80%, almost overlapping with rarely.
From: Case SM. (1994) The use of imprecise terms in examination questions: How frequent is frequently? Academic Medicine, 69(suppl):S4-S6.

Chapter 3. Technical Item Flaws

29

Section II
Writing One-Best-Answer Questions
for the Basic and Clinical Sciences

The previous chapters outlined technical issues related to the construction of multiple-choice questions. Section II focuses on item content.

The Basic Rules for One-Best-Answer Items

Each item should focus on an important concept, typically a common or potentially catastrophic clinical problem.
Dont waste testing time with questions assessing knowledge of trivial facts. Focus on problems that would be
encountered in real life. Avoid trivial, tricky, or overly complex questions.

Each item should assess application of knowledge, not recall of an isolated fact. The item stems may be relatively long; the options should be short. Clinical vignettes provide a good basis for a question. For the clinical sciences,
each should begin with the presenting problem of a patient, followed by the history (including duration of signs and
symptoms), physical findings, results of diagnostic studies, initial treatment, subsequent findings, etc. Vignettes may
include only a subset of this information, but the information should be provided in this specified order. For the basic
sciences, patient vignettes may be very brief; laboratory vignettes are also appropriate.

The stem of the item must pose a clear question, and it should be possible to arrive at an answer with the options
covered. To determine if the question is focused, cover up the options and see if the question is clear and if the examinees can pose an answer based only on the stem. Rewrite the stem and/or options if they could not.

All distractors (ie, incorrect options) should be homogeneous. They should fall into the same category as the correct answer (eg, all diagnoses, tests, treatments, prognoses, disposition alternatives). Rewrite any dissimilar distractors. Avoid using double options (eg, do W and X; do Y because of Z) unless the correct answer and all distractors are double options. Rewrite double options to focus on a single point. All distractors should be plausible,
grammatically consistent, logically compatible, and of the same (relative) length as the correct answer. Order the
options in logical order (eg, numeric), or in alphabetical order.

Avoid technical item flaws that provide special benefit to testwise examinees or that pose irrelevant difficulty.

Do NOT write any questions of the form Which of the following statements is correct? or Each of the following statements is correct EXCEPT. These questions are unfocused and have heterogeneous options.
Subject each question to the five tests implied by the above rules. If a question passes all five, it is probably well-phrased
and focused on an appropriate topic.

33

See also:
Swanson DB, Case SM. Assessment in basic science instruction: directions for practice and research. Advances in Health Sciences Education: Theory and Practice. 1997; 2:71-84.

34

Chapter 4
Item Content:
Testing Application of Basic Science Knowledge

Item Content for the Basic Sciences

Traditionally, items are classified by the cognitive processes required to answer the question (eg, recall, interpretation, or problem solving; memory, comprehension, or reasoning). Recall items are thought to test examinees knowledge of isolated facts.
Interpretation items require examinees to review some information (often in tabular or graphical form) and reach some conclusion (eg, a diagnosis). Problem-solving items present a situation and require examinees to take some action (eg, the next
step in patient management). Interpretation and problem-solving items are thought to involve higher order skills, rather than
just rote memory of factual information.
Unfortunately, the cognitive processes required to answer an item are often difficult to determine, because they are as dependent on the background of the examinee as they are on the item content. For example, an item concerning blood flow in a
patient with ventricular septal defect might require simply recall with little or no conscious thought from a pediatric cardiologist or cardiovascular physiologist, but a typical Step 1 examinee might have to reason out the answer from basic principles of hemodynamics. The cognitive processes involved in responding to a question vary by examinee, making this taxonomic approach difficult to use.
A simpler, more objective approach bases item classification on the task of the examinee. If an item requires an examinee
to reach a conclusion, make a prediction, or select a course of action, it should be classified as an application of knowledge
item. If an item tests only rote memory for isolated facts (without requiring their application), it should be classified as a
recall item. All items should require application of knowledge, allowing assessment of both an examinees information base
plus ability to use that information.

Chapter 4. Item Content: Testing Application of Basic Science Knowledge

35

The following pair of item stems illustrate the difference between a question assessing recall of an isolated fact and a question assessing application of knowledge.
Basic Science Recall Item Stem:
What area is supplied with blood by the posterior inferior cerebellar artery?
Basic Science Application of Knowledge Item Stem:
A 62-year-old man develops left-sided limb ataxia, Horners syndrome, nystagmus, and loss of appreciation of facial
pain and temperature sensations. What artery is most likely to be occluded?

It is common to use clinical vignettes as item stems to assess application of basic science knowledge to interpret clinical situations. For example, instead of asking examinees to identify the muscles innervated by a cranial nerve, provide a set of
physical findings and ask examinees to identify the most likely site of the lesion. Instead of asking for a description of respiratory acidosis or alkalosis, provide values for arterial blood gases (and other patient findings as needed) and ask examinees to identify the most likely pathophysiologic explanation. Make sure that examinees can answer the question based on
an understanding of basic science; experience in patient care should not be necessary.
Lab vignettes can also be useful in preparing items that test application of knowledge. These items present lab experiments and require examinees to use their understanding of basic science principles to predict or explain the results. The
vignettes may describe classic experiments in a basic science area, or they may involve less well-known or hypothetical situations. Such items effectively shift the focus of assessment from knowledge of isolated facts to use of basic science principles to solve problems.
Use of patient and lab vignettes to assess application of knowledge has several benefits. First, the face validity of the exam is
greatly enhanced by using problem-solving items. Second, items are more likely to focus on important information, rather than
trivia. Third, it helps to identify those examinees who have memorized a substantial body of factual information, but are unable
to use that information effectively.

36

Guidelines for Basic Science Item Content

Test application of knowledge using experimental and clinical vignettes
Focus items 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, postgraduate medical education, and beyond
Avoid items that only require recall of isolated facts
Avoid esoteric or interesting topics that are not essential

These two items were written to assess the same topic. We recommend that questions be written like the second item, not the
first one.

Acute intermittent porphyria is the result of a defect in

the biosynthetic pathway for
A. collagen
B. corticosteroid
C. fatty acid
D. glucose
*E. heme
F. thyroxine (T4)

An otherwise healthy 33-year-old man has mild weakness and occasional episodes of steady, severe abdominal pain with some cramping but no diarrhea. One
aunt and a cousin have had similar episodes. During
an episode, his abdomen is distended, and bowel
sounds are decreased. Neurologic examination shows
mild weakness in the upper arms. These findings suggest a defect in the biosynthetic pathway for
A. collagen
B. corticosteroid
C. fatty acid
D. glucose
*E. heme
F. thyroxine (T4)

Chapter 4. Item Content: Testing Application of Basic Science Knowledge

37

Item Templates
The overall structure of an item can be depicted by an item template. You can typically generate many items using the same
template. For example, the following template could be used to generate a series of questions related to gross anatomy:
A (patient description) is unable to (functional disability). Which of the following is most
likely to have been injured?
This is a question that could be written using this template:
A 65-year-old man has difficulty rising from a seated position and straightening his trunk, but he has no difficulty
flexing his leg. Which of the following muscles is most likely to have been injured?
*A. Gluteus maximus
B. Gluteus minimus
C. Hamstrings
D. Iliopsoas
E. Obturator internus

Many basic science questions can be presented within the context of a patient vignette. The patient vignettes may include
some or all of the following components:
Age, Gender (eg, A 45-year-old man)
Site of Care (eg, comes to the emergency department)
Presenting Complaint (eg, because of a headache)
Duration (eg, that has continued for 2 days).
Patient History (with Family History ?)
Physical Findings
+/- Results of Diagnostic Studies
+/- Initial Treatment, Subsequent Findings, etc.

38

Additional Templates
A (patient description) has a (type of injury and location). Which of the following structures is most likely to be affected?
A (patient description) has (history findings) and is taking (medications). Which of the following medications is the most likely cause of his (one history, PE or lab finding)?
A (patient description) has (abnormal findings). Which [additional] finding would suggest/suggests a diagnosis of (disease
1) rather than (disease 2)?
A (patient description) has (symptoms and signs). These observations suggest that the disease is a result of the (absence or
presence) of which of the following (enzymes, mechanisms)?
A (patient description) follows a (specific dietary regime). Which of the following conditions is most likely to occur?
A (patient description) has (symptoms, signs, or specific disease) and is being treated with (drug or drug class). The drug acts
by inhibiting which of the following (functions, processes)?
A (patient description) has (abnormal findings). Which of the following (positive laboratory results) would be expected?
(time period) after a (event such as trip or meal with certain foods), a (patient or group description) became ill with (symptoms
and signs). Which of the following (organisms, agents) is most likely to be found on analysis of (food )?
Following (procedure), a (patient description) develops (symptoms and signs). Laboratory findings show (findings). Which
of the following is the most likely cause?
A (patient description) dies of (disease). Which of the following is the most likely finding on autopsy?
A patient has (symptoms and signs). Which of the following is the most likely explanation for the (findings)?
A (patient description) has (symptoms and signs). Exposure to which of the (toxic agents) is the most likely cause?
Which of the following is the most likely mechanism of the therapeutic effect of this (drug class) in patients with (disease)?
A patient has (abnormal findings), but (normal findings). Which of the following is the most likely diagnosis?

See Appendix B for additional examples.

Chapter 4. Item Content: Testing Application of Basic Science Knowledge

39

Types of Questions
Guess my drug
Guess my toxic exposure
Guess my diet
Guess my mood
Predict physical findings
Predict lab findings
Predict sequelae
Identify underlying cause/diagnosis
Identify cause of drug responses
Identify drug to administer

Sample Lead-ins and Option Lists

Which of the following is (abnormal)?
Options sets could include sites of lesions; list of nerves; list of muscles; list of enzymes; list of hormones; types of cells;
list of neurotransmitters; list of toxins, molecules, vessels, spinal segments.
Which of the following findings is most likely?
Options sets could include list of laboratory results; list of additional physical signs; autopsy results; results of microscopic examination of fluids, muscle or joint tissue; DNA analysis results; serum levels.
Which of the following is the most likely cause?
Options sets could include list of underlying mechanisms of the disease; medications that might cause side effects; drugs
or drug classes; toxic agents; hemodynamic mechanisms, viruses, metabolic defects.
Which of the following should be administered?
Options sets could include drugs, vitamins, amino acids, enzymes, hormones.
Which of the following is defective/deficient/nonfunctioning?
Options sets could include list of enzymes, feedback mechanisms, endocrine structures, dietary elements, vitamins.
Given the pedigree, what is the likelihood that the next child (specify gender) will have the disease?

40

Writing the Options: Altering Item Difficulty

The incorrect options in each question are called distractors.
Each distractor should be selected by some examinees; therefore, each distractor should be plausible and none should
stand out as being obviously incorrect. Common misconceptions and faulty reasoning provide a good source of plausible distractors. Distractors directly affect the difficulty of a
question. Consider the question to the right.

Who was the primary author of the Declaration of

Independence?
A. Abraham Lincoln
B. Thomas Jefferson
C. Franklin Roosevelt
D. King George II
E. Catherine the Great

In the example above, the options are quite divergent and Thomas Jefferson is easily identified as the correct answer. Someone who knows relatively little about American history could answer this correctly.
Now consider the same question with a different set of options.
In this example, the question becomes more difficult; the
options are all plausible answers to someone who has limited
knowledge. For some content areas, options like those in the
first example might be appropriate; for others, those in the second example are more appropriate.

Who was the primary author of the Declaration of

Independence?
A. George Washington
B. Thomas Jefferson
C. Alexander Hamilton
D. Benjamin Franklin
E. James Madison

When writing your options, make sure that they are:

Homogeneous in content (eg, all are diagnoses; all are next steps in patient care)
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

Chapter 4. Item Content: Testing Application of Basic Science Knowledge

41

Item Shape
An appropriately shaped item includes as much of the item as possible in the stem; the stem should be relatively long and
the options should be relatively short. The stem should include all relevant facts; no additional data should be provided in
the options.
Appropriately Shaped Item:

Long Stem

A.
B.
C. Short Options
D.
E.

Poorly Shaped Item:

Short Stem
A.
B.
C. Long Options
D.
E.

42

Problem-Based Learning and Use of Case Clusters

An increasing number of medical schools have adopted problem-based learning (PBL) as an instructional strategy for portions of the basic science curriculum. Although each schools approach to PBL is somewhat unique, all involve the use of
written patient cases (problems) in basic science instruction. Problems are designed to stimulate learning of material from
traditional basic science disciplines (eg, anatomy, physiology, biochemistry) from a clinical perspective, and application of
basic science principles to clinical situations is stressed. Material is typically covered through independent study and discussed in small groups with a faculty tutor.
PBL courses and curricula typically emphasize the learning process, learning how to learn, responsibility of students for their
own learning, and preparation for lifelong learning. However, there are important variations among programs that have
implications for assessment. The Open Discovery approach emphasizes the learning process: students have responsibility
for determining what to learn, as well as when and how to learn it. Learning to apply broad principles in problem-solving
situations is viewed as most important, with minimal guidance provided by instructors and maximum opportunity for exploration by students. In contrast, in the Guided Discovery approach, curriculum developers identify specific learning objectives for each problem, and these objectives are provided to instructors who use them to organize group discussion and student learning. These curricula can be highly structured, with careful sequencing of instructional experiences. Students may
or may not be aware of the structure and the specific objectives: their experience may be quite similar to students in programs using the Open Discovery approach. In practice, the Open and Guided Discovery approaches are probably best
viewed as opposite ends of a continuum. Programs vary along the continuum, and, within a program, problems (and groups)
also vary.
Assessment in programs using the Open Discovery approach often focuses on process variables such as self-directedness, motivation, effort, problem-solving, and attitudes. Assessment of learning outcomes is genuinely problematic, because each student
is encouraged to pursue a somewhat different course of study. Use of traditional multiple- choice tests, in particular, is often
viewed as inappropriate, because they may cause students to study to the test, thus discouraging students from self-determination of the material to be learned and the process for learning it.
Assessment of learning outcomes poses fewer problems when the Guided Discovery approach is used, since the same learning objectives that guide problem development and use can also guide test development. To achieve congruence with curricular goals, assessment should focus on students understanding of basic mechanisms of health, disease and treatment.
Well-written multiple-choice tests can play a major role in assessment, as long as they stress application of basic science

Chapter 4. Item Content: Testing Application of Basic Science Knowledge

43

knowledge to patient care. Tests using case clusters multiple-choice questions associated with the same patient presentation are particularly appropriate for PBL courses.
An example of a simple case cluster is shown below. It consists of a brief case presentation, followed by a series of three
multiple choice questions. Each question addresses a somewhat different aspect of the case, looking at the clinical situation
from a variety of perspectives. Like PBL more generally, use of test material like this emphasizes learning of basic science
information so that it is organized to be useful in provision of patient care.

A 34-year-old woman has had severe watery diarrhea for the past four days. Two months earlier she had infectious mononucleosis. She abuses drugs intravenously and has antibodies to HIV in her blood. Physical examination shows dehydration and marked muscle weakness.
1. Laboratory studies are most likely to show
A. decreased serum K+ concentration
B. decreased serum Ca2+ concentration
C. increased serum HCO3- concentration
*D. increased serum Na+ concentration
E. increased serum pH

2. In evaluating the cause of the diarrhea, which of the

following is most appropriate?
A. Colonic biopsy to identify Giardia lamblia
B. Culture of the oral cavity for Candida
albicans
C. Duodenal biopsy to identify Entamoeba
histolytica
D. Gastric aspirate to identify
Mycobacterium avium-intracellulare
*E. Stool specimen to identify Cryptosporidium

44

3. Further studies to evaluate her HIV infection show

the ratio of helper T lymphocytes to suppressor T
lymphocytes to be 0.3. This occurs because HIV
A. induces proliferation of helper
T lymphocytes
B. induces proliferation of suppressor
T lymphocytes
*C. infects cells with CD4 receptors
D. infects macrophages
E. stimulates the synthesis of leukotriene

In addition to principles described earlier in this manual, there are two more considerations required in preparing case clusters: cueing and hinging. First, it is desirable to avoid cueing providing hints at the answers to earlier questions in later
questions. Students are very likely to read ahead for these clues, and item writers should avoid providing them. For example, in a cluster describing a patient with chest pain, if the first question addresses the most likely cause of the pain and the
second requires selection of the most appropriate drug treatment, it is important that each of the diagnoses associated with
the first question have a matching drug in the second (and vice versa); testwise examinees can rule out diagnoses (and
drugs) simply by comparing the option lists.
Second, it is desirable to avoid hinging creating questions where students must know the answer to one question in order
to answer other questions unless the topic to be tested is so important that the item writer is willing to have students
receive either all of the points or none of the points associated with a cluster. The cluster on the next page, prepared by Drs.
David Felten and Ralph Jozefowicz for the final examination in the University of Rochester first-year Neural Science course,
illustrates one strategy to avoid hinging.
Each of the first three items focuses on a different aspect of the patient presentation, and students are likely to respond correctly to some and incorrectly to others, receiving partial credit for partial knowledge. The last item is probably slightly
hinged on the preceding items, since it requires students to put the whole picture together in order to respond correctly, but
this seems reasonable, given the importance of the latter.
It can be difficult for a single faculty member to prepare case clusters where the items draw on information from several basic
science disciplines this requires substantial breadth of knowledge. One strategy for coping with this problem is to adopt
a team approach to preparation of test material analogous to the method generally used for preparation of problems for use
in PBL instruction. For example, a clinician member of a team can prepare the patient description with which the cluster
begins, along with questions related to pathophysiology. Faculty members from relevant basic science disciplines can contribute items that address various aspects of the patient situation from the perspective of their discipline.
Use of this kind of material is not, of course, restricted to curricula and courses taught using a PBL approach. It is completely appropriate any time it is desirable to stress clinical application of basic science information in teaching, learning and assessment. In our view, this includes most basic science courses even those taught in the first year. As the neural science example on the next page illustrates quite well, it is straightforward and appropriate to test basic knowledge of anatomy and physiology in the context of patient care in a traditionally taught course.

Chapter 4. Item Content: Testing Application of Basic Science Knowledge

45

An unresponsive 58-year-old woman is brought to the emergency department after collapsing at a local shopping
mall. Her family reports that she felt well that morning but developed a headache that progressively worsened
while she was shopping. She has had hypertension and atrial fibrillation and is taking an antihypertensive medication and an oral anticoagulant. Her blood pressure is 220/130 mm Hg and her respiratory pattern is one of
apnea alternating with hyperpnea. She responds only to noxious stimuli with extensor posturing involving the
right arm and leg. Fundoscopic examination reveals papilledema involving the left optic disc. Pupils are 3.0/7.0
(R/L) with no reaction to light on the left. There is a left gaze preference. There is diffuse hyperreflexia (R > L)
and Babinskis sign is present bilaterally.
1. The dilated, unreactive left pupil is most consistent
with injury to the left
A.
B.
*C.
D.
E.

optic nerve
optic tract
oculomotor nerve
lateral geniculate nucleus
superior colliculus

2. The extensor posturing on the right is most consistent with injury to the left
A.
B.
*C.
D.
E.

telencephalon
diencephalon
midbrain
pons
medulla

3. Her respiratory pattern is best described as

A.
*B.
C.
D.
E.

normal
Cheyne-Stokes
central neurogenic hyperventilation
apneustic
ataxic

4. Which of the following herniation syndromes is

most consistent with her clinical presentation?
A.
*B.
C.
D.
E.

Cingulate gyrus beneath the falx

Temporal lobe uncus across the tentorium
Diencephalon through the tentorial notch
Brain stem through the tentorial notch
Cerebellar tonsils through the foramen
magnum

Additional discussion of assessment in PBL courses and curricula can be found in:
Swanson DB, Case SM, and van der Vleuten CM. Strategies for student assessment. In: Boud, Feletti, eds. The Challenge of Problem-Based Learning
- Second Edition. London: Kogan Page Ltd; 1997:269-282.

46

Sample Items for the Basic Sciences

1. Several contiguous cells are labeled with a fluorescent
dye that cannot cross cell membranes. One cell is experimentally bleached with light that destroys the dye, but
soon recovers dye fluorescence. This recovery is best
explained by the presence of which of the following
structures between the bleached cell and its fluorescent
neighbors?

3. During an operation, the arterial PCO2 and pH of an

anesthetized patient are monitored. The patient is being
ventilated by a mechanical respirator, and the initial values are normal (PCO2 = 40 mm Hg; pH = 7.42). If the
ventilation is decreased, which of the following is most
likely to occur?
Arterial PCO2 pH

A.
B.
*C.
D.
E.

A basal lamina
Desmosomes (maculae adherentes)
Gap junctions
Glycosaminoglycans
Tight junctions (zonulae occludentes)

A.
B.
C.
*D.
E.
F.

Decrease
Decrease
Decrease
Increase
Increase
Increase

decrease
increase
no change
decrease
increase
no change

2. A 30-year-old man has loss of pain and temperature

sensation from the neck down on the right side of the
body and on the left side of the face; partial paralysis of
the soft palate, larynx, and pharynx on the left; and
ataxia on the left. This syndrome is most likely to result
from thrombosis of which of the following arteries?
A.
B.
*C.
D.
E.

Basilar
Right posterior inferior cerebellar
Left posterior inferior cerebellar
Right superior cerebellar
Left superior cerebellar

Chapter 4. Item Content: Testing Application of Basic Science Knowledge

4. In the branched metabolic pathway, a different single

enzyme catalyzes each of the individual steps. The
enzyme that would be expected to be most severely
inhibited by compound V is enzyme
A.
*B.
C.
D.
E.

A
B
C
D
E

47

5. A patient with posthepatitic cirrhosis develops rapid

enlargement of the liver associated with deterioration of
hepatic function. Serum concentration of which of the
following is most likely to be abnormal?
A.
B.
C.
*D.
E.

"1-Antitrypsin
Carcinoembryonic antigen
Chorionic gonadotropin
"-Fetoprotein
Gastrin

6. The first-born infant of an Rh-negative 26-year-old

woman who had two previous second trimester abortions
has severe hemolysis and circulatory failure. This condition could have been prevented by treating the mother
with
A. anti-RhD IgG during the most recent
pregnancy
*B. anti-RhD IgG on termination of each of the first
two pregnancies
C. anti-RhD IgM during the most recent
pregnancy
D. anti-RhD IgM on termination of the first
pregnancy

48

7. Laboratory tests on an edematous 35-year-old man show

a normal serum concentration of complement and an
increased serum concentration of cholesterol. Urinalysis
shows 4+ protein, 0-5 erythrocytes/hpf, and several hyaline casts. Examination of tissue obtained on renal biopsy is most likely to show
A. acute poststreptococcal (proliferative)
glomerulonephritis
B. membranoproliferative glomerulonephritis
*C. membranous glomerulonephritis
D. minimal change disease (lipoid nephrosis)
E. rapidly progressive glomerulonephritis

8. Genes on the bacterial chromosome have the following

linkages in conjugal transfer: x and y, 25% of the time;
y and z, 50% of the time. If the gene order is x-y-z,
approximately what percentage of the time will x and z
be transferred together?
A.
B.
*C.
D.
E.

1% of the time
5% of the time
13% of the time
20% of the time
40% of the time

9. At a banquet, the menu included fried chicken, homefried potatoes, peas, chocolate eclairs, and coffee.
Within 2 hours, most of the diners became violently ill,
with nausea, vomiting, and abdominal pain. Analysis
of the contaminated food is most likely to yield large
numbers of which of the following organisms?
A.
B.
C.
*D.
E.

Escherichia coli
Proteus mirabilis
Salmonella typhimurium
Staphylococcus aureus
Streptococcus faecalis

10. Drug Y has a volume of distribution (Vd) of 75 L in

both younger and older adult men. In younger adults, it
has a clearance rate of 15 L/h, 50% of which is via the
liver and 50% via the kidneys. For younger men, the
maintenance regimen is 100 mg every 6 hours. Which
of the following regimens will produce essentially the
same steady-state concentration in an older man, whose
creatinine clearance is reduced to half that of younger
men, but whose hepatic function is unimpaired?
A.
*B.
C.
D.
E.
F.

75 mg every 3 hours
75 mg every 6 hours
75 mg every 9 hours
100 mg every 3 hours
100 mg every 6 hours
100 mg every 12 hours

Chapter 4. Item Content: Testing Application of Basic Science Knowledge

11. A patient seen in the emergency department does not

know which heart drug he is taking. His heart rate is
greater than 80/min, and the PR and QRS intervals on
an ECG are prolonged. The patient reports ringing in
his ears. Which of the following drugs has the patient
most likely been taking?
A.
B.
C.
D.
*E.

Digoxin
Lidocaine
Phenytoin
Propranolol
Quinidine

12. An 8-year-old boy needs to be coaxed to go to school,

and often, while there, he complains of severe
headaches or stomach pain. Sometimes his mother has
to take him home because of his symptoms. At night,
he tries to sleep with his parents. When they insist he
sleep in his own room, he says there are monsters in his
closet. These findings are most consistent with which
of the following diagnoses?
A.
B.
*C.
D.
E.

Childhood schizophrenia
Normal concerns of latency-age children
Separation anxiety disorder
Socialized conduct disorder
Symbiotic psychosis

49

Chapter 5
Item Content:
Testing Application of Clinical Science Knowledge

Methods for Assessment

Despite continued debate about the appropriateness of multiple-choice tests, all three Step exams of the USMLE continue to
include multiple-choice questions (MCQs). In a quest for improved assessment instruments, the NBME has conducted continual research on other testing formats. For the past 25 years, a major focus of this research has been the Computer Based
Examination (CBX) project, now termed Computer-based Case Simulations (CCS), which were introduced as a component
of Step 3 in 1999. Since the mid-1970s, a second area of research has focused on standardized patients (SPs), which are
scheduled for inclusion in the licensing examination sequence in 2004 or 2005. As with other forms of more authentic
assessment, CCS and SP-based examinations appear to have significant advantages for assessment of aspects of clinical
competence because they pose tasks for the examinee in a realistic way.
Other projects have focused on enhancing the multiple-choice format. As a result of test development research, MCQs today
appear very different from those used in the past. For both content and psychometric reasons, true/false MCQ formats, such
as K-types (multiple true/false) and C-types (A, B, Both, Neither), are no longer used on the licensure exams. While most of
the questions on Step 2 have the traditional five options, both A-type questions and extended-matching questions can include
as many as 26 options, pushing the examinee task to something closer to uncued free-response. Virtually every item on Step
2 provides a patient vignette that focuses on a task that is relevant to a new intern, such as determining the diagnosis or the
next step in patient care. These items require interpretation and synthesis of the data that are provided; they also require application of knowledge to familiar or unfamiliar situations (depending on the experiences of the examinee). Like CCS and SPbased cases, modern multiple-choice items framed as brief patient vignettes present examinees with low-fidelity simulations
of medical decision-making problems.

Chapter 5. Item Content: Testing Application of Clinical Science Knowledge

51

General Issues Regarding What to Test

There are several tensions that influence the construction of each Step exam which may be relevant to you as you consider
what to include on your exams. As dictated by the purpose statements, the USMLE examination system is designed to be
an examination for general licensure; Step 2, for example, is designed to assess the application of knowledge required for
beginning the first post-medical school year, regardless of specialty. The focus on content that is necessary for practice rather
than explicitly on content that has been taught (if it were possible to catalog such a body of information) means that questions might be included on the exam that assess knowledge not uniformly taught in medical school. Conversely, topics taught
in some medical schools might be omitted from the examination. In reality, there is a close association between what is
taught and what is included on the examination, but the examination is designed to be an independent assessment of what
students need to know as they begin their internship, regardless of whether or not it is taught. The analogous issue for individual schools is the extent to which it is appropriate to include content on an exam that has not been explicitly taught. For
example, you need to decide to what extent you want to hold students responsible for independent learning beyond what has
been covered in lectures.
A second tension on Step 2 arises from the focus on knowledge that is required by the general undifferentiated physician.
When critics have questioned the appropriateness of a general examination in an era of specialization, we have countered by
noting that the medical license is a general license, not a specialty-specific license, which we believe mandates that the examination be general. The generalist initiative has reduced comment in this area and has made us appear somewhat prescient
not something the NBME is often accused of. The analogous issue for individual schools is the extent to which clerkships should focus exclusively on their discipline, without an attempt to integrate across disciplines. In addition, faculty
must decide on the extent to which clerkships should serve as a pre-internship experience for students, as opposed to providing an overview of topics that are relevant to all practicing physicians regardless of specialty.
The focus on questions that are appropriate for all graduating students, rather than those who are entering specific specialties has had a considerable influence on the content of Step 2 items. For example, the surgery committee is more likely to
write items on patient management situations where immediate intervention is essential, or where it is important to triage the
patient to a surgical floor rather than discharge him from the emergency department than to write questions related to surgical techniques that would not be considered essential knowledge for non-surgeons. The obstetrics and gynecology committee is less likely to write questions on the management of unusual high-risk pregnancies (even if most students have been
exposed to these cases in the clerkship) than on the diagnosis of ectopic pregnancy something every new intern, regardless of specialty, should recognize. Psychiatry items are unlikely to cover inpatient psychiatry but are more likely to assess
ability to differentiate psychiatric from nonpsychiatric illnesses in patients who present with bizarre behavior. All questions

52

on Step 2 must be accepted by the entire discipline-specific committee; in addition, they must be accepted by an interdisciplinary committee. This discipline-specific review followed by interdisciplinary review helps to achieve content balance on
the exam. In your own schools, it seems important to have test questions reviewed by other members of your own department. It is likely to be informative to have test questions reviewed by faculty members outside your department, though the
logistics of implementing this procedure may be daunting.

Testing Recall of Isolated Facts or Application of Knowledge

In addition to thinking about the topics that are important to include on a test, you should think about how to structure those
questions to test more than recall of isolated facts. Traditionally, test questions have been classified as requiring recall, interpretation, or problem solving (memory, comprehension, and reasoning) depending on the cognitive processes required to
answer the question. Typical definitions refer to Recall Questions as those which assess examinee knowledge of definitions or isolated facts. Interpretation Questions require examinees to review some information, often in tabular or graphic
form, and reach some conclusion (eg, a diagnosis). Problem-Solving Questions present a situation and require examinees
to take some action (eg, the next step in patient management). The difficulty with these classifications is that the cognitive
processes required to answer a question are as dependent on the background of the examinee as they are on the question content. Experts in a content area may simply recall an answer with little or no conscious thought, whereas others may need to
reason out the answer from basic principles. The cognitive processes involved in responding to a question are examinee-specific, making the taxonomic approach difficult to use.
An alternate approach divides items into two categories: application of knowledge or recall of an isolated fact. If a question requires an examinee to reach a conclusion, make a prediction, or select a course of action, it is classified as an application of knowledge question. If a question assesses only rote memory of an isolated fact (without requiring its application),
it is classified as a recall question.
Questions asking for recall of isolated facts often begin by
Which of the following findings is most likely to be seen
citing a disease and then asking what patient findings are
in postsurgical patients with pulmonary embolism?
expected. These questions are structured similarly to most
textbooks; the examinee could look up the disease and find
the answer in a single paragraph. The flaw with these items is that they seem clinically backward. Patients rarely tell their
physician what disease they have and then ask the physician what their signs and symptoms are.

Chapter 5. Item Content: Testing Application of Clinical Science Knowledge

53

Another type of question posing an inappropriate task is

referred to as a waiting room item. In this item, the examinee is asked to select one of five patients for whom fetal
karyotyping is most appropriate, almost as if the examinee is
charged with performing fetal karyotyping on someone and
he has only to look into the waiting room and select the
patient who is most appropriate.

In contrast, the following item describes a patient and asks

which study is most appropriate, a more reasonable task.

Which of the following is an indication for fetal

karyotyping in a 28-year-old woman?
A.
B.
C.
D.
E.

Paternal age 55
Fetal cystic hygroma on ultrasound exam
Previous child with spina bifida
Previous miscarriage of a triploid fetus
Trisomy 21 in the womans brother

A healthy 28-year-old teacher is at 11 weeks gestation.

Family history is unremarkable except that both of her
brothers have severe mental retardation, her mother
died at 55 years of age of breast cancer, and her father
is estranged. No family health records are available.
Which of the following studies is appropriate?
A. Blood test for fragile X carrier status
B. Blood test for phenylketonuria carrier status
C. Chorionic villus sampling for Duchennes
muscular dystrophy
D. Chorionic villus sampling for chromosome
analysis
E. Amniocentesis for "-fetoprotein

Questions assessing application of knowledge are structured

in a clinically more realistic manner, for example, by giving
the findings and asking the examinee to indicate the underlying disease. Typically, examinees would need to be able
to synthesize information from several pages of a textbook
to answer these questions.

54

A 62-year-old man develops acute shortness of breath

and pleuritic chest pain 4 hours after undergoing
cholecystectomy. Which of the following is the most
likely diagnosis?

Use of questions with clinical vignettes as item stems has several benefits. First, the face validity of the examination is
greatly enhanced by using questions that require examinees to solve clinical problems. Second, questions are more likely
to focus on important information, rather than trivia. Third, these questions help to identify those examinees who have memorized a substantial body of factual information, but are unable to use that information effectively in clinical situations. Questions with clinical vignettes are generally more appropriate for higher level examinations.
Writing application of knowledge questions is relatively straightforward in medicine. When you describe a patient and ask
a question related to that patient, you are assessing application of knowledge. The one instance in which use of a clinical
vignette involves simply recall of an isolated fact is if the vignette describes a patient identical to one the student has read
about before (eg, you use a patient vignette from a textbook or one discussed in class).

Guidelines for Clinical Science Item Content

Test application of knowledge using clinical vignettes to pose medical decisions in patient care situations.
Focus items on common or potentially catastrophic problems; avoid zebras and esoterica.
Pose clinical decision-making tasks that would be expected of a successful examinee.
Avoid clinical situations that would be handled by a (sub)specialist.

Questions should focus on specific tasks that the successful examinee must be able to undertake at the next stage of training
(eg, determine the most likely diagnosis; indicate what additional laboratory studies should be ordered; formulate the next
step in management; predict the most likely additional finding). For each topic, the areas in which mistakes are commonly
made should be the focus of a question.

Chapter 5. Item Content: Testing Application of Clinical Science Knowledge

55

Writing One-Best-Answer Items

Constructing the Stem
The vast majority of questions should be written with a clinical vignette. The stem should begin with the presenting problem of a patient, followed by the history (including duration of signs and symptoms), physical findings, results of diagnostic studies, initial treatment, subsequent findings, etc. Vignettes may include only a subset of this information, but the
information should be provided in this specified order. The stem should consist of a single, clearly formulated problem.
The lead-in of the stem must pose a clear question so that the examinee can pose an answer without looking at the options.
Satisfying the cover-the-options rule is an essential component of a good question.
Good stem: This stem provides sufficient information and can be answered without referring to the options.
A 52-year-old man has had increasing dyspnea and cough productive of purulent sputum for 2 days. He has smoked
one pack of cigarettes daily for 30 years. His temperature is 37.2 C (99 F). Breath sounds are distant with a few
rhonchi and wheezes. His leukocyte count is 9000/mm3 with a normal differential. Grams stain of sputum shows
numerous neutrophils and gram-negative diplococci. X-ray films of the chest show hyperinflation. Which of the following is the most likely diagnosis?
Stem testing isolated facts: The following stem contains insufficient information; in order to answer the question, the examinee must use the options as a frame of reference.
Which of the following is true about pseudogout?

Patient vignettes should include some or all of the following components in the order indicated:
Age, Gender (eg, A 45-year-old man)
Site of Care (eg, comes to the emergency department)
Presenting Complaint (eg, because of a headache)
Duration (eg, that has continued for 2 days).
Patient History (with Family History ?)
Physical Findings
+/- Results of Diagnostic Studies
+/- Initial Treatment, Subsequent Findings, etc.

56

Make sure that your stem:

Focuses on important concepts rather than trivial facts
Can be answered without looking at the options
Includes all relevant facts; no additional data should be provided in the options
Is not tricky or overly complex
Is not negatively phrased (ie, avoid using except or not in the lead-in)

Fine Points on Item Stems

Use of Real Patients. We believe it is generally better not to base multiple-choice questions on real patients, particularly
for tests aimed at students. As a general rule, real patients are too complicated, and the elements that are complicated are
not necessarily those that are important for assessment. As noted earlier, we do include window dressing (ie, incidental findings), but do not include red herrings (ie, information that is intended to lead examinees away from the correct answer).
Unfortunately, real patients often have red herrings among their findings.
Use of Reference Materials. We believe that it is appropriate to provide information in a test question if, in real life, someone would be likely to refer to a reference source to obtain the information. For example, in many instances, we believe it
is appropriate to provide a table of normal laboratory values or a chart showing a recommended schedule of screening tests
or immunizations. Of course, you might not just ask questions that require examinees to simply look up information in the
chart provided, but you might, for example, ask about immunization of a 6-year-old child who had never been immunized.
Use of Patients or Physicians Own Words. We generally do not believe it is useful to include the patients own words,
particularly if the examinee task is to interpret nuances of language that might be affected by tone. On the other hand, it may
be useful to ask the examinee to select the most appropriate physician response to a patient by asking the examinee to choose
among options phrased as open-ended, closed, or leading questions.
Patients Who Lie. We believe all multiple-choice patients should tell the truth, or the physicians interpretation of the
patients story should be provided. Physicians use multiple cues to determine how truthful a patient is and many of these cues
cannot be translated into written form. Thus, our items would describe a patients alcohol consumption as The patient drinks
16 oz of beer with dinner each night or The patients description of his alcohol consumption is contradictory. We would
not write something ambiguous, such as The patient claims to drink only one bottle of beer each night.

Chapter 5. Item Content: Testing Application of Clinical Science Knowledge

57

Verbosity, Window Dressing, and Red Herrings: Do They Make a Better Test Item?
Most educators stress the importance of writing item stems that are as short as possible, avoiding verbosity (ie, extra words),
window dressing (ie, extraneous material), and red herrings (ie, information designed to mislead the examinee). Somewhat in opposition to this advice, we have emphasized use of clinical vignettes in item writing efforts. For USMLE Step 2,
these vignettes consist of paragraph-length descriptions of clinical situations, generally followed by a question related to the
diagnosis or next step in patient care. Such items stress application of knowledge by asking examinees to make clinical decisions, rather than to simply recall isolated facts. They are designed to reflect real life tasks by challenging examinees to first
identify the findings that are important, then integrate those findings into a diagnosis or clinical action. Such items often require
multiple steps in the thinking process. We have found that vignette items tend to have fewer technical item flaws than typical
non-vignette items, presumably because vignettes follow a standard structure and pose questions that are clinically natural.
Despite these advantages, some have challenged the use of vignettes, believing that a vignette only makes an item more cumbersome by wrapping window dressing around the real question. Some advocate avoiding vignettes altogether; others advocate
using short vignettes and including only relevant positive findings expressed concisely; the rest advocate use of long vignettes
that include more complete information that the examinee must review and synthesize.
Several studies1 were conducted to compare the psychometric characteristics of items developed in three formats: nonvignette, short vignette, and long vignette. The progression was designed to require increasing levels of interpretation, analysis, and synthesis of findings (see sample item in three formats below). As expected, items became more difficult as patient
findings were presented in a less interpreted form; however, the differences in discrimination were not statistically significant. Regardless of the mixed psychometric results, we believe vignette items are generally more appropriate because they
test application of knowledge to patient situations and pose appropriate clinical challenges; such items might be viewed as
low fidelity clinical simulations that improve the content validity of the examinations.
An item written in a non-vignette format typically is written from a top-down perspective (ie, given a disease, what are the
associated findings). To an expert, items written in this manner may appear identical to items written with a patient vignette.
1From: Case SM, Swanson DB, Becker DF. Verbosity, window dressing, and red herrings: do they make a better test item? Academic Medicine.

1996;71:528-530.

58

The following trio of items indicate that, to the low-performing student, the items are not identical.
Each item was administered to senior medical students as part of the licensing examination. The grid under each item shows
the percentage of Hi and Lo students (ie, those who performed in the top and bottom 20% of the examination overall)
who selected each option. Almost all of the Hi group (99%) and the Lo group (90%) selected the correct option in the nonvignette format. The short- and long-vignette formats were not markedly more difficult for the Hi group, but were for the
Lo group; the correct answer was selected by 82% in the short-vignette format and 66% in the long-vignette format.

Non-Vignette

The most likely renal abnormality in children with nephrotic syndrome and normal
renal function is
A. acute poststreptococcal glomerulonephritis
B. hemolytic-uremic syndrome
*C. minimal change nephrotic syndrome
D. nephrotic syndrome due to focal and segmental glomerulosclerosis
E. Schnlein-Henoch purpura with nephritis

A B C D E
Hi

0 99 0

Lo

1 90 1

Short Vignette
A 2-year-old boy has a 1-week history of edema. His blood pressure is 100/60 mm
Hg, and there is a generalized edema and ascites. Serum concentrations are: creatinine 0.4 mg/dL, albumin 1.4 g/dL, and cholesterol 569 mg/dL. Urinalysis shows
4+ protein and no blood. The most likely diagnosis is (same option list followed).

Chapter 5. Item Content: Testing Application of Clinical Science Knowledge

A B C D E
Hi

0 98 2

Lo

2 82 8

59

Long Vignette
A 2-year-old black child developed swelling of his eyes and ankles over the
past week. Blood pressure is 100/60 mm Hg, pulse 110/min, and respirations
28/min. In addition to swelling of his eyes and 2+ pitting edema of his
ankles, he has abdominal distention with a positive fluid wave. Serum concentrations are: creatinine 0.4 mg/dL, albumin 1.4 g/dL, and cholesterol 569
mg/dL. Urinalysis shows 4+ protein and no blood. (Same lead-in and option
list followed).

A B C D E
Hi

1 98 1

Lo 10 9 66 10 5

Although the item listed above is labeled long vignette, it is quite short in comparison to most items on USMLE Step 2.
We believe that new graduates from medical school need to demonstrate proficiency in sorting through patient information, synthesizing the important findings, and reaching a conclusion. As a result, our items tend to have a mix of important and unimportant findings. On the other hand, we sometimes synthesize findings with a statement such as the family
history is noncontributory.

60

Writing Items Related to Physician Tasks

Each topic requires a slightly different approach to item writing. We provide some sample lead-ins and other tips to guide
your item-writing efforts for each physician task.

Health and Health Maintenance

Items in this topic area assess ability to evaluate risk factors, understand epidemiologic data, and apply preventive measures.
Health and health maintenance items commonly fall into one of the following categories: 1) screening tests; 2) constructive
interference; 3) immunizations/travel medicine; or 4) emergency intervention.
In general, begin the items with a clinical vignette that describes a patient. In addition to history and physical examination
findings, these vignettes may include information about immunization history, risk factors, and family history. Information
about the community may be relevant and therefore included, but the question should focus on the individual patient. Questions should NOT focus on the direct assessment of isolated facts. For example, avoid asking about the leading cause of
death in some subpopulation; instead, focus on the applications of this knowledge. In asking about immunizations or screening tests, consider providing a chart of customary practices to avoid memorization of conflicting recommendations.
The following lead-ins are examples of those used in this category:
Which of the following immunizations should be administered at this time?
Which of the following is the most appropriate screening test?
Which of the following tests would have predicted these findings?
Which of the following is the most appropriate intervention?
For which of the following conditions is the patient at greatest risk?
Which of the following is most likely to have prevented this condition?
Which of the following is the most appropriate next step in management to prevent [morbidity/mortality/disability]?
Which of the following should be recommended to prevent disability from this injury/condition?
Early treatment with which of the following is most likely to have prevented this patients condition?
Supplementation with which of the following is most likely to have prevented this condition?

Chapter 5. Item Content: Testing Application of Clinical Science Knowledge

61

A 15-year-old boy has had two episodes of severe anaphylactic shock following bee stings. Which of the
following is the most appropriate intervention?
A.
Administration of corticosteroids during
the summer
B.
Long-term prophylactic antihistamine therapy
C.
Protective clothing
*D.
Desensitization with bee venom extract
E.
Restrict him to the house during the
summer months

A 33-year-old woman, gravida 1, para 1, spontaneously

delivers a 2460-g (5 lb 7oz) female newborn at 38 weeks
gestation. The newborn has hepatosplenomegaly, patent
ductus arteriosus, and cataracts. At 8 weeks gestation,
the mother developed a maculopapular rash, enlarged
cervical lymph nodes, sore throat, and arthralgias that
spontaneously resolved in 1 week. The subsequent prenatal course was uncomplicated. Which of the following
tests during pregnancy is most likely to have predicted the
findings in the fetus?
A.
Amniocentesis to determine karyotype
B.
Culture for herpes simplex virus
*C.
Serial rubella titers
D.
Urinalysis for cytomegalovirus
E.
VDRL test

A healthy moderately active 75-year-old woman is

found on routine screening to have a total serum cholesterol concentration of 208 mg/dL and serum HDLcholesterol concentration of 70 mg/dL. ECG shows
no abnormalities. Which of the following dietary recommendations is most appropriate?
A.
Decreased intake of cholesterol
B.
Decreased intake of saturated fat
C.
Decreased intake of simple carbohydrates
D.
Increased intake of fiber
*E.
No change in diet

An asymptomatic 33-year-old man has a blood pressure of 166/112 mm Hg. Serum electrolyte levels are
within normal limits. Effective antihypertensive treatment is most likely to reduce the likelihood of which
of the following?
A.
Aortic aneurysm
B.
Congestive heart failure
C.
Myocardial infarction
D.
Renal failure
*E.
Stroke

62

Mechanisms of Disease
These items should test examinees knowledge of pathophysiology in its broadest sense, including etiology, pathogenesis,
natural history, clinical course, associated findings, complications, severity of illness, and intended or unintended effects of
therapeutic interventions. Mechanisms questions should be framed in a clinical context.
In general, begin your mechanisms items with a clinical vignette of a patient and his/her symptoms, signs, history, lab study
findings, etc. Then ask a question such as one of these:
Which of the following is the most likely explanation for these findings?
Which of the following is the most likely location of the patients lesion?
Which of the following is the most likely pathogen?
Which of the following findings is most likely to be increased/decreased?
A biopsy is most likely to show which of the following?

A 10-year-old girl develops gross hematuria 14 days

after a sore throat. She has a blood pressure of
170/100 mm Hg and 2+ pedal and pretibial edema.
Serum urea nitrogen (BUN) level is 3.2 mg/dL.
Which of the following is the most likely cause?
A.
Coarctation of the aorta
B.
Decreased production of endothelial-derived
relaxant factor
C.
Increased production of aldosterone
D.
Increased production of catecholamine
*E.
Intravascular volume of expansion

Chapter 5. Item Content: Testing Application of Clinical Science Knowledge

A 32-year-old man has a purulent urethral discharge.

A culture grows Neisseria gonorrhoeae sensitive to
penicillin. One week after cessation of penicillin therapy, the patient has a recurrence of the urethral discharge. A culture again shows N. gonorrhoeae sensitive to penicillin. Both the patient and his sexual
partner are HIV negative. Examination of the
patients sexual partner shows an anal fissure; urethral culture does not grow N. gonorrhoeae. Which of
the following is the most likely cause of the recurrence of urethral infection?
A.
Concurrent herpesvirus infection
B.
Emergence of bacterial resistance
C.
Inadequate treatment with penicillin
*D.
Reinfection from the partner

63

Diagnosis
For this category, write items that require examinees to interpret history, physical findings, and results of laboratory, imaging, and
other studies in order to determine the most likely diagnosis (differential diagnosis) or the next step in diagnosis (diagnostic testing). As you write questions in this area, think about whether you want to assess ability to integrate knowledge across clerkships.
The classic diagnosis item begins with a patient description (including age, gender, symptoms and signs and their duration,
history, physical findings on exam, findings on diagnostic and lab studies) and ends with a question:
Which of the following is the most likely diagnosis?
Which of the following is the most appropriate next step in diagnosis?
Which of the following is most likely to confirm the diagnosis?
A 52-year-old man has had increasing dyspnea and
cough productive of purulent sputum for 2 days. He
has smoked one pack of cigarettes daily for 30 years.
His temperature is 37.2 C (99 F). Breath sounds are
distant with a few rhonchi and wheezes. His leukocyte count is 9000/mm3 with a normal differential.
Grams stain of sputum shows numerous neutrophils
and gram-negative diplococci. X-ray films of the
chest show hyperinflation. Which of the following is
the most likely diagnosis?
A.
Asthma
B.
Bronchiectasis
*C.
Bronchitis
D.
Pulmonary embolism
E.
Streptococcal pneumonia

64

A 28-year-old woman has palpitations that occur

approximately once a week, last 1-5 minutes, and consist of rapid, regular heart pounding. The episodes
start and stop suddenly and have not been associated
with chest discomfort or dyspnea. There is no history
of heart problems. She drinks two to three cups of coffee daily. She rarely drinks alcohol and does not
smoke. Her blood pressure is 120/88 mm Hg, and
pulse is 96/min and regular. A stare and lid lag are
noted. The thyroid gland is firm and 1.5 times larger
than normal. There is a midsystolic click at the apex
and a grade 2/6, early systolic murmur at the left upper
sternal border. An ECG is normal except for evidence
of sinus tachycardia. Which of the following is the
most appropriate next step in diagnosis?
A.
Ambulatory ECG monitoring
B.
Measurement of serum thyroid-stimulating
hormone level
C.
Measurement of urine catecholamine level
D.
MUGA scan
E.
Echocardiography

Management
These items assess principles of chronic and acute care in inpatient and outpatient settings. When writing management items,
it is especially important to focus on aspects of care relevant to the level of practice of the examinee (supervised, limited supervision, independent practice, subspecialist). For Step 2, we focus on aspects of care that would be appropriate for all new
interns regardless of specialty, and middle-of-night urgent care when help may be unavailable. Questions cover pharmacotherapy decisions, more general treatment decisions where options include a mix of pharmacotherapy and other treatments,
and management decisions where options include a mix of treatments and other things such as diagnostic testing.
Questions to ask include:
Which of the following is the most appropriate initial or next step in patient care?
Which of the following is the most effective management?
Which of the following is the most appropriate pharmacotherapy?
Which of the following is the first priority in caring for this patient? (eg, in emergency department)

A hospitalized 55-year-old woman with decompensated cirrhosis of the liver is being treated with spironolactone, potassium chloride elixir, and furosemide.
She is now barely responsive and hypotensive without
respiratory distress. She has signs consistent with
chronic hepatic disease, ascites, and minor peripheral
edema. ECG shows a regular, slow (55/min) rhythm,
no P waves, and a wide, slurred QRS complex running into a wide, slurred ST and T wave. Which of the
following should be administered intravenously?
A.
Calcium
B.
Lidocaine
C.
Magnesium
D.
0.9% Saline
*E.
Potassium

Chapter 5. Item Content: Testing Application of Clinical Science Knowledge

A previously healthy 15-year-old boy has cramping periumbilical pain; after several hours, the pain shifts to the
right lower quadrant and becomes constant. He vomits
several times and is brought to the emergency department. The abdomen is tender on deep palpation of the
right lower quadrant. Findings on chest and abdominal
x-ray films are normal. Leukocyte count is 15,000/mm3.
Urinalysis shows 3 leukocytes/hpf. Which of the following is the most appropriate initial management?
A.
Supportive treatment at home; return at once if
the pain increases
B.
Barium enema
C.
CT scan of the abdomen
D.
Intravenous pyelography and cystography
*E.
Surgical exploration of the abdomen

65

Writing Items on Difficult Topics

One of the common beliefs is that many topics do not lend themselves to a multiple-choice format. We have had reasonable
success in generating items in many of these areas and recommend the following strategy.
1. After you identify a topic that youre having difficulty with, look through all sources of test material and select any
questions on the topic that you think are acceptable.
2. Identify the key features of these items and try to develop a template that would enable faculty to write similar items.
3. For topics where no sample items are available, think about what you want to assess. Go beyond the list of topics
by outlining tasks related to the topic that are essential for medical students to know (ie, each element of the list
should include a verb).
To illustrate this process, the following paragraphs outline the process we used to write Step 2 questions on Medical Ethics
and Jurisprudence. The content outline includes the following topics: 1) Consent and informed consent to treatment (eg,
full disclosure, alternate therapies, risks and benefits); 2) Physician-patient relationship (eg, truth-telling, confidentiality, privacy, autonomy, public reporting); 3) Death and dying (eg, diagnosing death, life-support, autopsy, organ donation, euthanasia, suicide); 4) Birth-related issues (eg, prenatal diagnosis, abortion, maternal-fetal conflict); and 5) Research issues (eg,
consent, placebos, conflict of interest, vulnerable populations).
Authors typically wrote questions such as: Which of the following is the definition of informed consent? Or they would
describe a scenario and ask which ethical principle was illustrated by the scenario. This is a sample legal question from
the past.

These are irreverently referred to as who cares

questions.

66

The legal basis for the eased restrictions on abortions

in the US can be traced most closely to
A.
federal legislation
B.
a federal court ruling
C.
state legislations
D.
state court rulings
E.
AMA rulings

We reviewed the item pool and decided that we were less interested in whether or not students knew the definitions; we wanted to assess whether or not examinees could apply ethical principles in their decisions related to patient care. We then convened a group of item writers who looked through model questions and generated new items for the exam. All questions
involved a patient vignette and asked the student to indicate what the physician should do or asked the student to evaluate
the appropriateness of the physicians actions indicated in the vignette; no questions focused on the definition of terms. The
following are some sample items we wrote.

A nurse is hospitalized for an appendectomy at the

medical center where she is employed. One week after
discharge, the assistant hospital administrator asks
the surgeon what the final diagnosis was. Which of
the following is the most appropriate response on the
part of the surgeon?
A.
Answer, because it will expedite handling of
insurance issues at the medical center
B.
Answer, because as an employee of the medical
center the administrator has access to
information about patients
C.
Answer, because of the possibility of spreading
misinformation about the patient
D.
Decline to answer, because the administrator is
not a medical doctor
*E.
Decline to answer, because the information
is confidential

Chapter 5. Item Content: Testing Application of Clinical Science Knowledge

An 8-year-old boy with acute lymphoblastic leukemia

has experienced three relapses in the past 2 years. The
only available treatment is experimental chemotherapy. Without treatment, the child is unlikely to survive
for more than 6 weeks; with treatment, his prognosis is
unknown. The parents do not want further treatment
for their son and wish to take him home; the child also
says he wants to go home. Which of the following is
the most appropriate course of action?
A.
Discharge the child against medical advice
*B.
Discharge the child routinely
C.
Petition the court for an order for treatment
D.
Report the parents to social services for
medical neglect

67

Section III
Extended-Matching Items

Section III provides information regarding Extended-Matching items.

Chapter 6 presents the Extended-Matching item format where examinees are instructed to select the one-best answer. Chapter 7 presents the
format where examinees are instructed to select some particular number
of options, generally more than one.

Chapter 6
Extended-Matching (R-Type) Items

Extended Matching items are multiple-choice items organized into sets that use one list of options for all items in the set.
A well-constructed Extended-Matching set includes four components:
1. a theme;
2. an option list;
3. a lead-in statement; and
4. at least two item stems, as illustrated below.
Theme:

Fatigue

Options:

A.
B.
C.
D.
E.
F.
G.

Lead-in:

For each patient with fatigue, select the most likely diagnosis.

Stems:

1. A 19-year-old woman has had fatigue, fever, and sore throat for the past week. She has a temperature
of 38.3 C (101 F), cervical lymphadenopathy, and splenomegaly. Initial laboratory studies show a leukocyte count of 5000/mm3 (80% lymphocytes, with many lymphocytes exhibiting atypical features).
Serum aspartate aminotransferase (AST, GOT) activity is 200 U/L. Serum bilirubin concentration and
serum alkaline phosphatase activity are within normal limits.
Ans: E

Acute leukemia
Anemia of chronic disease
Congestive heart failure
Depression
Epstein-Barr virus infection
Folate deficiency
Glucose 6-phosphate dehydrogenase
deficiency

H.
I.
J.
K.
L.
M.
N.

Hereditary spherocytosis
Hypothyroidism
Iron deficiency
Lyme disease
Microangiopathic hemolytic anemia
Miliary tuberculosis
Vitamin B12 (cyanocobalamin)
deficiency

2. A 15-year-old girl has a two-week history of fatigue and back pain. She has widespread bruising, pallor,
and tenderness over the vertebrae and both femurs. Complete blood count shows hemoglobin concentra3
3
tion of 7.0 g/dL, leukocyte count of 2000/mm , and platelet count of 15,000/mm .
Ans: A

Chapter 6. Extended-Matching (R-Type) Items

71

Extended-matching items are written differently than traditional one-best-answer items. Most often, the theme, lead-in, and
options are written first; the item stems are written last. For example, if you want to write some questions related to the diagnosis of fatigue, you would begin by listing the diagnoses that might cause fatigue. You would then write a vignette for each
(or many) of the options in the list. The example above includes vignettes for Epstein-Barr virus infection and for acute
leukemia. Additional items might be written for some of the remaining diagnoses; for common, treatable diagnoses, more
than one item might be prepared. The sample vignettes are moderate in length; shorter, more-focused vignettes could also
be used. Alternatively, examinees could be challenged to identify key diagnostic information, intermingled with incidental
findings, by using longer vignettes.

Avoiding Flaws When You Write Extended-Matching Items for Your Own Examination
The four components (theme, options, lead-in, and stems) are all essential for the construction of a good quality extendedmatching set. Sets without lead-ins (or with nonspecific lead-ins, such as Match each item with the best option) should NOT
be used, because they generally pose inconsistent or ambiguous tasks for examinees. The following set is flawed. The options
are heterogeneous; there is no lead-in; the stems cannot be answered without reading the options. Rules for extended-matching items are completely analogous to those for one-best answer items.

Sample Extended-Matching Set - Flawed

72

A.
B.
C.
D.
E.
F.
G.
H.

is motion sickness
have no effects on people
indirectly increase CO2
cause death
increased odor sensitivity
is a reduction in visibility
esthetics, economics, health
products of fossil fuel combustion

I.
J.
K.
L.
M.
N.

1.
2.
3.

Factors that people consider when evaluating air quality

A principal effect of particulate matter in air
The products of photochemical smog

O.

are completely controlled

cause plant and eye damage
are negligible
increase risk of skin cancer
cannot be controlled
excess acute respiratory
illness among children
contrary to public opinion

After reading the stem in Item #1, examinees have only the vaguest idea what the question is about. In an attempt to determine the best answer, the examinees have to decide whether is motion sickness is more or less true than have no effects
on people. The task is not do-able. Under these circumstances, unless an option is absolutely 100% true or false, it cannot
be rank-ordered with the other options. The stem of item #1 by itself is not clear; the item cannot be answered without looking at the options.
As with one-best-answer items, the stems should be long; the options should be short. There MUST be a lead-in that establishes the relationship between the items and the options. There should be NO verbs in the options. The cover-the-options
rule is as relevant for extended-matching items as it is for one-best-answer items.

Chapter 6. Extended-Matching (R-Type) Items

73

Sample Lead-ins and Topics for Option Lists

Patient vignettes provide an excellent structure for stems, not only in the clinical sciences, but also to assess knowledge in
the basic sciences. Lead-ins generally begin with a phrase such as For each of the following patients. Often sets are
organized around chief complaints or some other factor that allows a more specific introductory phrase such as For each
of the following patients with fatigue, or For each of the following patients with an enzyme deficiency. The second part
of the lead-in describes the task and the option set: select the most likely diagnosis; select the protein that is most likely to be defective.
The following are some additional sample lead-ins and some suggested topics for option lists.

74

For each of the following patients, select the [eg, nerve] that is most likely to be [abnormal/defective/deficient/nonfunctioning].
Options sets could include list of nerves; list of muscles; list of enzymes; list of hormones; list of proteins; list of
types of cells; list of neurotransmitters; list of pathologic processes.

For each of the following patients, select the [finding] that would be expected.
Options sets could include list of laboratory results; list of additional physical signs; autopsy results; results of microscopic examination of fluids, muscle or joint tissue; DNA analysis results; hormone levels.

For each of the following patients, select the most likely [cause].
Options sets could include list of underlying mechanisms of the disease; medications that might cause side
effects; list of drugs or drug classes; toxic agents; hemodynamic mechanisms.

For each of the following patients, select the [eg, drug] that should be administered.
Options sets could include list of drugs, vitamins, amino acids, enzymes, hormones.

For each of the following patients with [chief complaint], select the most likely diagnosis.
Options sets could include list of diagnoses, most often organized around a chief complaint such as diseases that
cause chest pain or diseases that cause fever.

For each of the following patients, select the most appropriate next step in patient care.
Options sets could include list of pharmacologic therapies, list of laboratory studies, disposition alternatives, or
the options could include a mixed set of treatments and additional studies to assess whether the student knows
when sufficient data have been gathered.

More on Options for R-Sets

Generally, anything that can be listed can form the basis for options in an R-set. Below are some topics that have been used
as the basis for option lists.
Arteries
Nerves
Muscles
Amino Acids
Peptides
Hormones
Enzymes
Cell Components
Cell Types
Blood Components
Molecules
Karyotypes
Proteins
Lipids
Pathogens/Bacteria/Fungi
Viruses
Cytokines
Toxins
Vitamins/Minerals
Diagnoses

Connective Tissue Types

Anatomic Structures
Endocrine Structures
Neurotransmitters
Metabolic Defects
Immune Disorders
Motor System Components
Cardiac Structures
Organelles
Congenital Anomalies
Segments of the Spinal Cord
Central Nervous System Components
Secretory Products
Extracellular Matrix Components
Management Alternatives
Drugs/Drug Classes
Pathologic Processes
Pathophysiologic States
Electrolyte Abnormalities
Diagnostic Tests

The list of options should be single words or very short phrases. They must be homogeneous (all diagnoses, all management options, all anatomical sites, all vitamins, etc). They can be labeled areas in a graph or in pictorial material. Options,
especially those involving laboratory values, are often expressed in tabular form (see physiology example). Include all relevant options that are appropriate for the examinees; subtle distinctions and uncommon diagnoses may be inappropriate.
For some topics, as few as three options might be appropriate; for others, a list of 26 (one for each letter in the alphabet)
might be required.

Chapter 6. Extended-Matching (R-Type) Items

75

Writing the Item Stems

Patient vignettes provide an excellent structure for stems both in the basic and the clinical sciences. In the clinical sciences,
the vignette commonly provides the patients age, gender, chief complaint, and site of care, followed by personal history, family history (if relevant), then physical examination information, then laboratory data (if provided). Depending upon the purpose of the set, vignettes can be brief, prototypic presentations or fuller descriptions that challenge examinees to identify key
information. Generally, these items would include at least the patients age, gender, chief complaint, and related history. Items
to assess knowledge of the basic sciences, particularly for courses taught in the first year of medical school, might include less
detailed prototypical descriptions.
Each patient description should be similar in structure to the others in the set. For example, if race, ethnicity, or occupation is
included in one item, it should be included in all items; if laboratory data are included for one item, include them in all items.
It is advisable not to mix adults and pediatric cases in the same set too often the age alone provides too much cueing and
eliminates large numbers of options from consideration.
One advantage of the use of patient vignettes is that it helps to assure that the content assesses application of knowledge. These
items should not resemble crossword puzzles, where both the options and the stems are single words or short phrases. Avoid
reconstructing those items you were faced with in junior high school where you had to draw a line from something in column
A to the matching option in column B.
It is particularly important that the items be straightforward. There is no reason to make them tricky; the extended option list
makes them difficult enough to allow you to distinguish the knowledgeable student from the other students without resorting
to trickery. As with well-constructed A-type questions, the cover-the-options rule is paramount. Knowledgeable students
should be able to generate an answer to the question and then find that answer in the alphabetical list of options.
An item should be prepared for most of the options; for common or important options, more than one item can be written. In
constructing an examination assessing general competence, to avoid overemphasizing a topic, all of the options, but only two
or three of the items, would be used; the remaining items are retained for subsequent exams. On the other hand, if you want
to assess knowledge in greater depth on a smaller number of topics, 10 to 20 items can be included for each set, with a subscore calculated for each topic.
In reviewing the items, check to make sure that there is only a single best answer for each question. Also make sure that
there are at least four reasonable distractors for each item. As a final check, it is recommended that you ask a colleague to
review the items (without the correct answer indicated). If the colleague has difficulty determining the correct answer, modify the option list or the item to eliminate the ambiguity.

76

Sample Good and Bad Item Stems Using the Same Option List
The following is a good microbiology set. The options are a homogeneous list of pathogens; including both viruses and bacteria makes sense. There is a lead-in that presents a clear task for the examinee. There are two item stems that require students to apply their basic science knowledge of microbiology to arrive at the most likely cause of each patients illness.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Adenovirus
Aspergillus fumigatus
Bacillus anthracis
Candida albicans
Chlamydia psittaci
Coccidioides immitis
Coronavirus
Corynebacterium diphtheriae
Coxiella burnetii
Coxsackievirus
Epstein-Barr virus

L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.

Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium tuberculosis
Mycoplasma pneumoniae
Neisseria gonorrhoeae
Neisseria meningitidis
Pneumocystis carinii
Rhinovirus
Streptococcus pneumoniae
Streptococcus pyogenes
(group A)

For each patient with fever, select the pathogen most likely to have caused his/her illness.
1. A 7-year-old girl has a high fever and a sore throat. There is pharyngeal redness, a swollen right tonsil with creamy
exudate, and painful right submandibular lymphadenopathy. Throat culture on blood agar yields numerous small $hemolytic colonies that are inhibited by bacitracin.
Ans: U
2. For the past week, an 18-year-old man has had fever, sore throat, and malaise with bilaterally enlarged tonsils, tonsillar
exudate, diffuse cervical lymphadenopathy, and splenomegaly. There is lymphocytosis with atypical lymphocytes. The
patient tests positive for heterophil antibodies.
Ans: K
The following stem, developed for the same set, assesses recall of isolated facts rather than application of knowledge. It
looks more like a crossword puzzle question than a question for a medical school examination.
3. An encapsulated gram-positive organism that usually grows in pairs or short chains.

Chapter 6. Extended-Matching (R-Type) Items

Ans: T

77

The following set includes two item stems. The first requires that the examinee synthesize information in order to determine a diagnosis; the second requires only recall of an isolated fact.
A.
B.
C.
D.
E.
F.
G.
H.

Vitamin A
Vitamin B1
Vitamin B2
Vitamin B6
Vitamin C
Vitamin D
Vitamin E
Vitamin K

I.
J.
K.
L.
M.
N.
O.
P.

Biotin
Copper
Folate
Iodine
Iron
Magnesium
Niacin
Zinc

For each patient with clinical features caused by metabolic abnormalities, select the vitamin or mineral that is most likely
to be involved.
1. A 70-year-old widower has ecchymoses, perifollicular petechiae, and swelling of the gingiva. His diet consists mostly of cola and hot dogs.
Ans: E
2. Involved in clotting factor synthesis.
Ans: H

78

The following set includes two item stems. The first item stem requires that the examinee synthesize information to determine the diagnosis of trisomy 21; the second item provides this information. When you develop item stems, you need to
decide the level of synthesis you will provide.
A.
B.
C.
D.

Atrial septal defect

Coarctation of the aorta
Complete transposition of the great arteries
Endocardial cushion defect

E.
F.
G.
H.

Patent ductus arteriosus

Pulmonic valve stenosis
Tetralogy of Fallot
Ventricular septal defect

For each patient, select the most likely congenital heart defect.
1. A 3090-g infant is born at term. Physical examination shows the child to be hypotonic with a weak suck. There is
no cyanosis. Prominent epicanthal folds, a large tongue, and small incurved 5th digits on the hands are present. There
is a loud holosystolic murmur over the entire precordium and a palpable thrill at the upper left sternal border in the
2nd through 4th intercostal spaces.
Ans: D
2. An infant with trisomy 21 has clefts of the right and left atrioventricular valves; there is no cyanosis.
Ans: D

Chapter 6. Extended-Matching (R-Type) Items

79

This set poses a task that is clinically backward. The examinee is given a vaccine and asked to select the best patient for this
vaccine. A more appropriate task would be for the examinee to be given a patient and asked for the most appropriate next
step in patient care (ie, describing a patient in each item stem; using For each patient, select the most appropriate next step
in patient care; and using things such as vaccines as options). A second problem with the set is that insufficient information is provided about each patient. For example, the examinee would want the immunization history for a patient before
deciding which immunizations to provide.

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

Birth
Year

Gender

Occupation

Pregnant

Childhood
Disease

Medical
History

Allergy

1980
1975
1970
1965
1960
1955
1950
1945
1940
1935

Male
Female
Female
Female
Male
Female
Female
Male
Male
Female

Student
Painter
Teacher
Lawyer
Painter
Clerk
Nurse
Executive
Driver
Homemaker

Yes
Yes
No
No
No
No

None
None
None
None
Measles
Mumps
Varicella
Measles
Rubella
Unknown

None
None
None
None
None
Diabetes
None
Hypertension
Splenectomy
Gastritis

Egg products
Penicillin
None
Gelatin products
Tetanus toxoid
None
None
None
None
Sulfonamides

For each vaccination, select the patient profile that represents its most appropriate use.
1.

Measles vaccine

2.

Meningococcal vaccine

80

Overview of the Steps for Writing Extended-Matching Items

1. Identify the theme for the set. The theme can be a chief complaint (eg, chest pain, fatigue), a disposition situation
(eg, admission/discharge from the emergency department), a drug class (eg, antihypertensive agents, antibiotics).
2. Write the lead-in for the set (eg, For each patient described below, select the most likely diagnosis). The lead-in
indicates the relationship between the stems and options, clarifying the question posed for examinees. It is an essential component of an Extended-Matching set.
3. Prepare the list of options. The list of options should be single words or very short phrases. List the options in
alphabetical order unless there is a logical order.
4. Write the items. The items within a set should be similar in structure. Most often, patient vignettes are appropriate.
5. Review the items. Check to make sure that there is only a single best answer for each question. Also make sure
that there are at least four reasonable distractors for each item. As a final check, it is recommended that you ask a
colleague to review the items (without the correct answer indicated). If the colleague has difficulty determining the
correct answer, modify the option list or the item to eliminate the ambiguity.

Additional information on writing Extended-Matching items can be found in:

Case SM, Swanson DB. Extended-matching items: a practical alternative to free-response questions. Teaching and Learning in Medicine.
1993;5(2):107-115.
Case SM, Swanson DB, Woolliscroft JO. Assessment of diagnostic pattern recognition skills in medicine clerkships using a written test. In: Harden R, Hart I, Mulholland H, eds. Approaches to Assessment of Clinical Competence. Norwich, England: Page Brothers; 1992:452-458.

Chapter 6. Extended-Matching (R-Type) Items

81

Sample Extended-Matching Sets

Sample Anatomy Set
A.
B.
C.
D.

Left anterior cerebral artery

Right anterior cerebral artery
Left middle cerebral artery
Right middle cerebral artery

E.
F.
G.
H.

Left posterior cerebral artery

Right posterior cerebral artery
Left lenticulostriate arteries
Right lenticulostriate arteries

For each patient with neurologic abnormalities, select the artery that is most likely to be involved.
1. A 72-year-old right-handed man has weakness and hyperreflexia of the right lower limb, an extensor plantar
response on the right, normal strength of the right arm, and normal facial movements.
Ans: A
2. A 68-year-old right-handed man has right spastic hemiparesis, an extensor plantar response on the right, and paralysis of the lower two-thirds of his face on the right. His speech is fluent, and he has normal comprehension of verbal and written commands.
Ans: G

82

Sample Pharmacology Set

A.
B.
C.
D.
E.
F.
G.
H.
I.

Acetaminophen
Amiodarone
ACE inhibitors
Aspirin
Atenolol
Bleomycin
Cytosine arabinoside
Furosemide
Metronidazole

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Nalidixic acid
Nitrofurantoin
Penicillin
Prednisone
Procainamide
Propranolol
Sulfasalazine
Tetracycline
Verapamil

For each patient, select the drug most likely to have caused the adverse effect.
1. A 56-year-old man with recurrent ventricular arrhythmias began taking an antiarrhythmic drug 5 months ago. He
now has progressive dyspnea, cough, and low-grade fever. Erythrocyte sedimentation rate is increased. X-ray film
of the chest shows a diffuse interstitial pneumonia. Pulmonary function tests show that diffusing capacity for carbon monoxide is decreased.
Ans: B
2. A 62-year-old man with chronic obstructive pulmonary disease begins therapy with an antihypertensive drug. Two
weeks later, he has marked worsening of dyspnea and clearly audible wheezing.
Ans: O

Chapter 6. Extended-Matching (R-Type) Items

83

Sample Physiology Set Clinical Features (Which additional findings are likely?)
pH
A.
B.
C.
D.
E.
F.
G.

7.15
7.15
7.30
7.40
7.50
7.50
7.50

PO2 mm Hg
98
98
56
100
100
100
56

PCO2 mm Hg

HCO3 - mEq/L

33
24
80
40
33
24
33

11
8
38
25
25
18
25

For each patient described below, select the most likely arterial blood gas findings.
1. A 22-year-old man with a 3-week history of polyuria and polydipsia has had nausea, vomiting, and decreased responsiveness for the past 12 hours. Urinalysis (dipstick) shows 4+ glucose and 4+ ketones.
Ans: B
2. A 25-year-old woman is brought to the emergency department 12 hours after a suicide attempt. She took approximately 100 500-mg aspirin tablets.
Ans: F

84

Sample Diagnosis Set

A.
B.
C.
D.

Ankylosing spondylitis
Intervertebral disc infection
Multiple myeloma
Myofascial pain

E.
F.
G.
H.

Osteoporosis
Spinal stenosis
Spondylolysis
Tuberculosis of the spine

For each patient with back pain, select the most likely diagnosis.
1. A 26-year-old man has insidious onset of low back pain and early morning stiffness. The pain alternates from side
to side and occasionally radiates into the buttocks and back of the thighs, but not below the knees. The patient has
acute anterior uveitis, diffuse low back and sacroiliac tenderness, and restricted range of motion at the hips. His erythrocyte sedimentation rate is 40 mm/h; latex fixation test is negative; and mild hypoproliferative anemia is present.
Ans: A
2. Twelve hours after being struck from the rear while driving her car, a 28-year-old woman has vague cervical and
lumbar pain associated with headache and restricted cervical mobility. She is now very anxious. Rope-like bands
of muscle are present in the lumbar area and over the left buttock; the bands are painful
Ans: D
Additional items would cover some of the remaining diagnoses. The sample vignettes are of average length; shorter, more
focused vignettes may also be used. Alternatively, examinees could be challenged to identify key diagnostic information by
using longer vignettes.

Chapter 6. Extended-Matching (R-Type) Items

85

Sample Diagnosis Set

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

Abdominal aneurysm
Appendicitis
Bowel obstruction
Cholecystitis
Colon cancer
Constipation
Diverticulitis
Ectopic pregnancy ruptured
Endometriosis
Hernia

K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.

Kidney stone
Mesenteric adenitis
Mesenteric artery thrombosis
Ovarian cyst ruptured
Pancreatitis
Pelvic inflammatory disease
Peptic ulcer disease
Perforated peptic ulcer
Pyelonephritis
Torsion

For each patient with abdominal pain, select the most likely diagnosis.
1. A 25-year-old woman has sudden onset of persistent right lower abdominal pain that is increasing in severity. She
has nausea without vomiting. She had a normal bowel movement just before onset of pain. Examination shows
exquisite deep tenderness to palpation in right lower abdomen with guarding but no rebound; bowel sounds are present. Pelvic examination shows a 7-cm, exquisitely tender right-sided mass. Hematocrit is 32%. Leukocyte count
is 18,000/mm3. Serum amylase activity is within normal limits. Test of the stool for occult blood is negative.
Ans: B
2. An 84-year-old man in a nursing home has increasing poorly localized lower abdominal pain recurring every 3-4 hours
over the past 3 days. He has no nausea or vomiting; the last bowel movement was not recorded. Examination shows
a soft abdomen with a palpable, slightly tender, lower left abdominal mass. Hematocrit is 28%. Leukocyte count is
10,000/mm3. Serum amylase activity is within normal limits. Test of the stool for occult blood is positive.
Ans: E

86

Sample Management Set: Disposition

A.
B.
C.
D.
E.
F.

Observe in emergency department

Admit for surgery
Admit for medical management
Admit for endoscopy
Admit for laparoscopy
Order contrast studies

G.
H.
I.
J.
K.

Order MRI
Order CT scan
Order ultrasonography
Send home with analgesics
Send home for follow-up by
personal physician

For each of the following patients, select the most appropriate next step in patient care.
Items might describe patients with appendicitis, ectopic pregnancy, endometriosis, Crohns disease, diverticulitis, pelvic
abscess, sickle cell crisis, renal lithiasis, twisted ovarian cyst, or other problems that commonly present as emergencies.
Other disposition sets might focus on telephone triage, hospital transfer/discharge decisions, etc.

Chapter 6. Extended-Matching (R-Type) Items

87

Sample Management Set: Diagnostic Testing

A.
B.
C.
D.
E.
F.
G.

Test of the stool for occult blood

Fasting serum glucose level
Hemoglobin level
Prostate-specific antigen level
Serum cholesterol level
Serum iron level
Thyroid function tests

H.
I.
J.
K.
L.
M.

Exercise tolerance test

Digital prostate examination
ECG
Spirometry
X-ray film of the chest
Sigmoidoscopy

For each patient who comes to the physician for a health maintenance examination, select the most appropriate diagnostic study.
1. A 22-year-old man who weighs 89 kg (196 lb) and is 175 cm (69 in) tall has smoked one pack of cigarettes daily for
8 years; he does not exercise. His last examination was 5 years ago. His father had a myocardial infarction at the
age of 48 years. Physical examination shows no abnormalities.
Ans: E
2. A 28-year-old woman who weighs 70 kg (154 lb) and is 173 cm (68 in) tall has smoked one pack of cigarettes daily
for 12 years; she does not exercise. Her last examination was 5 years ago, though she had a Pap smear 9 months ago
that showed normal results. Her father had a myocardial infarction at the age of 48 years. Her grandmother was
diagnosed with colon cancer at the age of 62 years. Physical examination shows no abnormalities.
Ans: E

Sample Option List for Electrolyte Abnormalities

A.
B.
C.
D.

Hypocalcemia
Hypokalemia
Hypomagnesemia
Hyponatremia

E.
F.
G.
H.

Hypercalcemia
Hyperkalemia
Hypermagnesemia
Hypernatremia

For each of the following patients, select the electrolyte abnormality most likely to be present.

88

Sample Behavioral Sciences/Pediatrics Option List

A.
B.
C.
D.
E.
F.
G.
H.

Cognitive/
Language Skills

Gross Motor
Skills

Social
Skills

Normal
Normal
Normal
Normal
Delayed
Delayed
Delayed
Delayed

Normal
Normal
Delayed
Delayed
Normal
Normal
Delayed
Delayed

Normal
Delayed
Normal
Delayed
Normal
Delayed
Normal
Delayed

For each child, select the best description of development.

Sample Nutrition/Biochemistry Option List

A.
B.
C.
D.
E.
F.
G.
H.

Vitamin A
Vitamin B1 (thiamine)
Vitamin B2 (riboflavin)
Vitamin B6
Vitamin C
Vitamin D
Vitamin E
Vitamin K

I.
J.
K.
L.
M.
N.
O.
P.

Folate
Biotin
Niacin
Iron
Magnesium
Copper
Zinc
Iodine

For each child with a metabolic abnormality, select the vitamin or mineral that is most likely to be involved.
See Appendix B for additional examples.

Chapter 6. Extended-Matching (R-Type) Items

89

Steps for Organizing a Group to Write Clinical R-Sets

The following steps may be followed to utilize a group in writing clinical R-sets. Some groups have met over dinner; followed the steps below; and generated a first draft of a dozen or more items from each attendee. Others have scheduled this
as a full-day off-campus retreat, with the goal of generating a pool of near-final items.
The organizer of the item writing party should think about how the participants time can best be spent. The yield will be
substantially greater in terms of both quality and quantity if some work is done in advance. For example, there will be significantly smaller yield if the participants are expected to decide what topics to write on; time will be saved if the topics for
each set are defined in advance of the meeting (Step #1 below). Similarly, more items will be developed if a draft of the
options for each set is developed in advance (Step #3 below). More items will also be developed if a sample item is written
as a model for each set (Step #4 below). There are situations where it is best to allow item writers considerable flexibility
in determining what to write. In these circumstances, providing one or more option sets and allowing them to generate one
or more options sets on their own might be workable.
Decisions will also need to be made about the composition of the pairs of item writers. In some circumstances, it might be
best to allow participants to self-select their partners. In other circumstances, it might be best to assign the pairs. We have
had the most success assembling item-writing pairs with similar interests, but including individuals with more diverse expertise as reviewers. If the goal is to generate interdisciplinary items for an exam, the same list of options may be provided to
several pairs of item writers. For example, options related to abdominal pain could be given to a pair of gynecologists; a pair
of surgeons; and a pair of internists. In constructing the exam, one or more items from each discipline could be merged into
the same set, requiring that examinees think across disciplines in determining the most likely diagnoses of the patients.
Significant time can be saved if participants write their items on computers. This saves many hours of trying to decipher the
handwriting of the item writers. We typically have two item writers work at one computer (we have found that someone
automatically assumes control of the keyboard). Then, several approaches are possible for the review: reviewers may congregate around the computer to read the items on screen; the item author can read the item aloud to the reviewers who do
not have a copy of the items; or hard copies can be printed for everyone to use in the review session.

90

1. Define the content domain of the exam. For example, in developing an exam to test the ability to diagnose common clinical problems, you might define the domain by a list of the chief complaints. Time will be saved if this is
done in advance of the item-writing meeting.
Abdominal mass
Abdominal pain
Anemia
Ascites
Back pain
Chest pain
Confusion
Cough
Developmental delay
Diarrhea

Dizziness
Easy bruising
Fatigue
Fever
Gastrointestinal bleeding
Headache
Hematemesis/Melena
Itching
Jaundice
Joint pain

Lymphadenopathy
Movement abnormalities
Nausea
Palpitations
Sexual dysfunction
Shortness of breath
Skin lesion
Syncope
Weight change
Wheezing

2. Train a group of faculty members to serve as item writers. Training should include a brief discussion of the purpose of the exam, some sample items, and the procedures to be followed during item writing.
3. Divide the group into pairs to write items. Each pair is assigned to write on 2-4 chief complaints; they generate
(or modify) a list of diagnoses for each assigned complaint and write one or more patient descriptions for the diagnoses they included in their option list. Expect 20 to 60 item stems from each pair (10 to 20 per complaint). Use of
computers will save considerable time in the long run.

Chapter 6. Extended-Matching (R-Type) Items

91

4. Stress the following guidelines for writing stems.

Each item should describe a patient with one of the diagnoses in the option list, beginning with the patients age, gender, chief complaint, and site of care, followed by personal history, family history (if relevant), then physical examination information, then laboratory data (if provided).
Depending upon the purpose of the set, vignettes can be brief prototypic presentations or fuller descriptions that challenge examinees to identify key information.
Each patient description should be similar in structure to the others in the set. For example, if race, ethnicity, or
occupation is included in one item, include it in all items; if laboratory data are included for one item, include them
in all items.
5. Merge the pairs into a larger group to review the items. One approach is to have the author read the item aloud;
others attempt to provide the correct answer. The group reviews the option list and modifies the item or the option
list to eliminate any ambiguity. Other approaches are outlined above.
6. Type, edit, and subject the items to external review. Items should be reviewed without the correct answer indicated after they are in their final form.
7. Construct the test. Select a sample of items from each complaint; save the remaining items for subsequent exams.
Items can be converted into one-best-answer items by adding a lead-in and the best five (or more) options from the
option list.

92

Form for Writing R-Sets

Theme: _________________________________________________________________
(eg, a presenting complaint)
Lead-In:_________________________________________________________________
(eg, For each patient with fever, select the most likely diagnosis.)

Options
A
B
C
D
E
F
G
H
I
J
K
L
M

N
O
P
Q
R
S
T
U
V
W
X
Y
Z

(Write items on separate pages)

Chapter 6. Extended-Matching (R-Type) Items

93

Sample SPSSX Code to Score Multiple-Choice Tests, including Extended-Matching Items

The following SPSSX code can be used as a model for scoring a hypothetical test including up to 100 multiple-choice items;
each item may have up to 26 options but only one correct answer. It is straightforward to alter the code for any test length.
It is assumed that:
the answer key is in a file named KEY.DAT (format: an eight-character exam ID, followed by a space and the 100
correct answers);

the examinee responses are in a file named RESPONSE.DAT (format: social security number or any nine-digit examinee ID, a space, the eight-character exam ID, a space, the examinees responses to the 100 items);

the item analysis output shows the distribution of responses to each item, plus a reliability coefficient (coefficient
alpha); and

score reports with the examinee ID number, plus percent correct and standard scores (placed in a file named
REPORT.LIS). REPORT.LIS can be imported into a word processor to enhance its appearance.

For experienced SPSSX users, the code should be easy to understand. SPSSX provides some file management facilities that
vaguely resemble those in relational data bases (illustrated in the AGGREGATE and MATCH FILES commands); these join
the answer key to each examinee record, calculate a mean and SP, and join these to each examinee record.
It is straightforward to generalize the code to handle subscores, more complicated scoring algorithms, etc.

94

TITLE
SUBTITLE
SET
COMMENT
FILE HANDLE
DATA LIST
FILE HANDLE
SAVE
COMMENT
FILE HANDLE
DATA LIST

COMMENT
MATCH FILES
COMMENT
COMMENT
VECTOR
DO REPEAT
COMPUTE
IF
END REPEAT
COMMENT
TABLES

COMMENT
RELIABILITY

COMMENT
COMPUTE
COMMENT
FILE HANDLE
AGGREGATE
MATCH FILES
COMPUTE
COMMENT
FILE HANDLE
WRITE

SAMPLE SPSSX SETUP FOR SCORING A HYPOTHETICAL 100-ITEM

MULTIPLE CHOICE TEST DAVE SWANSON, SEPTEMBER 6, 1991
LENGTH=64/WIDTH=132
READ IN AND SAVE THE ANSWER KEY
KEYDAT/NAME=KEY.DAT
FILE=KEYDAT/
EXAMCODE,KEY1 TO KEY100
(A8,1X,100A1)
KEYSYS/NAME=KEY.SYS
OUTFILE=KEYSYS
READ IN EXAMINEE RESPONSE STRINGS
RESPDAT/NAME=RESPONSE.DAT
FILE=RESP/
SSN,EXAMCODE,RESP1 TO RESP100
(F9.0,1X,A8,1X,100A1)
ADD THE ANSWER KEY TO RESPONSE STRING RECORDS
FILE=*/TABLE=KEYSYS/BY EXAMCODE
COMPARE THE KEY TO RESPONSES AND CREATE A 0/1 VECTOR OF
INCORRECT/CORRECT ANSWERS
SCORE(100,F1.0)
K=KEY1 TO KEY100/R=RESP1 TO RESP100/S=SCORE1 TO SCORE100
S=0
(K EQ R) S=1
PRINT A CROSSTABULATION OF RESPONSES FOR EACH ITEM
FORMAT=CWIDTH(10,3) NSPACE LIGHT/
TABLE= RESP1 +
RESP2 +
... + (youd actually need to type all of these in)
RESP100 BY (LABELS)/
STATISTICS=COUNT((F3.0) )
GENERATE RELIABILITY STATISTICS
VARIABLES=SCORE1 TO SCORE100/
SCALE(TOTAL)=SCORE1 TO SCORE100/
STATISTICS=DESCRIPTIVE,SCALE,ANOVA/
SUMMARY=ALL
CALCULATE A PERCENT CORRECT SCORE FOR THE TOTAL TEST
PCSCORE=100*MEAN(SCORE1 TO SCORE100)
CALCULATE A STANDARD SCORE FOR THE TOTAL TEST
MEANSD/NAME=MEANSD.TMP
OUTFILE=MEANSD/BREAK=EXAMCODE/
PCMEAN=MEAN(PCSCORE)/PCSD=SD(PCSCORE)
FILE=*/TABLE=MEANSD/BY EXAMCODE
STDSCORE=500+100*(PCSCORE-PCMEAN)/PCSD
WRITE OUT A SCORE REPORT
REPORT/NAME=REPORT.LIS
OUTFILE=REPORT/
SSN,PCSCORE,STDSCORE
(3F9.0)

EXECUTE
FINISH

Chapter 6. Extended-Matching (R-Type) Items

95

Comparison of Items in Five-Option and Extended-Matching Format

In several studies to investigate the optimal number of options for multiple-choice items, we have consistently found that,
other things being equal, more options are better than fewer options. Based on items used on NBME exams, extendedmatching items are more discriminating than any other format; 5-option A-types are second best; and the various forms of
true/false items are the worst. In controlled studies comparing otherwise equivalent 5-option and extended-matching items,
extended-matching items were found to be more discriminating than 5-option items; comparable levels of reproducibility can
be achieved with the extended-matching format using one-third fewer items than with 5-option items. Extended-matching
items were also found to be more difficult than content-parallel 5-option items: there is a lower probability of guessing the
correct answer, and item writers are not always able to select the most functional distractors in reducing the number of
options to five.
The following table shows examinee responses to a sample item presented in a 5-option format and in a 15-option format.
The item was originally written as a 15-option item; the item writer then reduced the number of options to five by selecting
what he thought were the best distractors (B, F, G, J, N). The item was markedly easier in the 5-option format (p value of
81 vs 59), and the discrimination was markedly lower (not shown). There is an increased probability of examinees selecting the correct answer in the 5-option format, especially because item writers do not uniformly identify the most salient distractors (eg, option D). Tests constructed of extended-matching items tend to spread out the lower ability students; the
extended list of options gives them more opportunity to show what they dont know.
Examinee Responses
Format

5-option
15-option

81
2

59

*
2

13

14
0

O
0

For additional information, see also:

Case SM, Swanson DB, Ripkey DR. Comparison of items in five-option and extended-matching format for assessment of diagnostic skills. Academic Medicine. 1994;69(suppl):S1-S3.
Case SM, Swanson DB. Extended-matching items: a practical alternative to free-response questions. Teaching and Learning in Medicine.
1993;5(2):107-115.
Swanson DB, Case SM. Trends in written assessment: a strangely biased perspective. In: Harden R, Hart I, Mulholland H, eds. Approaches to
Assessment of Clinical Competence. Norwich, England: Page Brothers; 1992:38-53.

96

As to Rs and Back Again

Although research has consistently shown a psychometric advantage of Extended-Matching (R-type) items over five-option
A-type items, there may be circumstances where you need to convert items from one format to another. This should be
straightforward.
For example, the following item was written as a five-option A-type item:
A patient with the classic phenotypic features of trisomy 21 (Down syndrome) has 46 chromosomes on each of 100
metaphase karyotypes. Which of the following is the most likely explanation for this finding?
A.
B.
C.

Deletion
Mosaicism
Somatic mutation

*D.
E.

Translocation
Undetected trisomy

This can easily be transformed into the following extended-matching item. Once in this format, additional stems can be written to expand the set.
A.
B.
C.

Deletion
Mosaicism
Somatic mutation

D.
E.

Translocation
Undetected trisomy

For each patient with genetic abnormalities, select the genetic pattern that is most likely to be involved.
A patient with the classical phenotypic features of trisomy 21 (Down syndrome) has 46 chromosomes on each of 100
metaphase karyotypes.
Additional options could be written to make the examinee task more challenging.
A.
B.
C.
D.
E.

Deletion
Genomic imprinting
Mosaicism
Pleiotropy
Reduced penetrance

F.
G.
H.
I.

Somatic mutation
Translocation
Undetected trisomy
Variable expressivity

For each patient with genetic abnormalities, select the genetic pattern that is most likely to be involved.
Items from this set could be converted back to single A-type items with five or more options.

Chapter 6. Extended-Matching (R-Type) Items

97

Chapter 7
Pick N Items: An Extension of the Extended-Matching Format

The Pick N format may be similar to either the extended-matching or the A-type format; the primary difference is that the
examinee is told to pick 2, 3, 4, or even 5 of the options listed. As with extended-matching sets, the option list may include
up to 26 options. The format was developed to replace negative items or items with double options, particularly in areas
such as Health Maintenance and Disease Prevention. Items might focus on various patients with different risk factors who
come for routine examination; the examinee would be asked to select the laboratory studies or immunizations that should be
ordered for each patient. The format could also be used for emergency management items where several procedures would
be carried out simultaneously; the examinee would be asked to select a specific number of actions from the option list.
The item-writing rules are the same as for extended-matching sets. The options should be short (usually a single word or
very short phrase); the patient vignettes can be long. If the set asks for management decisions, each vignette should contain
all relevant history and physical examination data. As with extended-matching items, the format works well for items that
appear to be extremely easy; tricky or unnecessarily complex vignettes should be avoided.
The Pick N format is designed to specify exactly how many options to select. The rationale for this decision is derived from
the essential difference between true/false and one-best-answer items, where true/false items require the examinee to indicate all responses that are appropriate, and one-best-answer items require the examinee to indicate a specific number of
responses. Specifying the number of options to be selected changes the task from a true/false task to a best-answer task.
Research indicates that partial credit scoring is preferred but logistical considerations might preclude this. If you use all-ornothing scoring, the items may be extremely difficult, and it is best to require examinees to select only two or three options,
rather than more.
For additional information, see also:
Ripkey DR, Case SM, Swanson DB. A new item format for assessing aspects of clinical competence. Academic Medicine. 1996;71
(suppl):S34-S36.

Chapter 7. Pick N Items: An Extension of the Extended-Matching Format

99

A.
B.
C.
D.
E.

Diabetic polyneuropathy
Huntingtons disease
Lateral medullary syndrome
Lead encephalopathy
Medulloblastoma

F.
G.
H.
I.
J.

Multiple sclerosis
Parkinsons disease
Pontine glioma
Tabes dorsalis
Wernickes encephalopathy

A 50-year-old man has the gradual onset of mental confusion, disorientation, and loss of short-term memory. He
has a left footdrop. A blood smear shows microcytosis and basophilic stippling of erythrocytes. (Select the two
most likely diagnoses)
In the example above, there would be disagreement about what diagnoses are likely, but the task becomes clear if the examinee is told to select the two most likely diagnoses. The options can be diagnosed as follows.
F

Least Likely Diagnosis

Most Likely Diagnosis

Sample Pick N Set

A.
B.
C.
D.
E.
F.

Calcium
Fluoride
Folic acid
Iron
Vitamin A
Vitamin B1 (thiamine)

G.
H.
I.
J.
K.

Vitamin B6
Vitamin B12 (cyanocobalamin)
Vitamin C
Vitamin D
Vitamin E

For each child, select the appropriate vitamin or mineral supplements.

1. A 1-month-old infant is brought to the physician for a well-child examination. He has been exclusively breast-fed,
and examination shows normal findings. (SELECT 2 SUPPLEMENTS).
Ans: B, J
2. A 6-year-old girl has cystic fibrosis. She has been taking no medications. (SELECT 3 SUPPLEMENTS).
Ans: E, J, K

100

Sample Pick N Set

A.
B.
C.
D.
E.

Analysis and culture of cerebrospinal fluid

Blood culture
Complete blood count
Examination of the stool for leukocytes
Measurement of serum electrolyte levels

F.
G.
H.
I.

Urinalysis
Urine culture
X-ray film of the abdomen
X-ray film of the chest

For each child with fever, select the appropriate initial diagnostic studies.
1. A previously healthy 1-year-old girl is brought to the emergency department because of fever for 1 day. Her temperature is 41 C (105.8 F). She is otherwise asymptomatic. Physical examination shows no abnormalities.
(SELECT 4 STUDIES).
Ans: B, C, G, I
2. A previously healthy 10-day-old newborn is brought to the emergency department because of fever for 2 hours. He
was born at term after an uncomplicated pregnancy. His temperature is 39 C (102.2 F). Physical examination shows
no abnormalities. (SELECT 6 STUDIES).
Ans: A, B, C, E, G, I
3. A 7-year-old boy with sickle cell disease is brought to the emergency department because of fever for 1 day and chest
pain for 1 hour. His temperature is 39.5 C (103.1 F). Breath sounds are slightly decreased in the right lower lung;
he is not in respiratory distress. (SELECT 3 STUDIES).
Ans: B, C, I

Chapter 7. Pick N Items: An Extension of the Extended-Matching Format

101

PATIENT CHART
Patient History
Sex:
Current age:
Chief complaint:
Social history:
Marital status:
Occupation:
Alcohol:
Smoking:
Exercise prgm:
Medical history:
Childhood:
Immunizations:
Screening:
Family history:
Parents:
Siblings:
Children:
Current medications:
Allergies:

male
28 years
health maintenance examination
single
computer programmer
2-4 beers/weekend
5-10 cigarettes daily from age 16-24
sedentary
obese since grade school
all childhood immunizations; last tetanus toxoid age 15;
no immunizations since childhood
no physician visits since college
father age 57; hypertensive mother age 55; obese and hypertensive
none
none
none
none

Physical Examination
Height:
Weight:
Vital signs:
Blood pressure
Pulse
Respirations
Skin:
Abdominal:
Laboratory studies:

102

178 cm (70 in)

134 kg (295 lb)
148/86 mm Hg
90/min
16/min
erythematous rash in groin
obese
none ordered

1. For the patient whose chart is shown, select the conditions for which he is at increased risk.
(SELECT 4 CONDITIONS)
A.
B.
C.
D.
E.
F.

Alcoholism
Colon cancer
Coronary artery disease
Diabetes mellitus
Hemochromatosis
HIV

G.
H.
I.
J.
K.
L.

Hypertension
Hypothyroidism
Osteoarthritis
Skin cancer
Thyroid cancer
Urinary tract infection

2. For the patient whose chart is shown, select the most appropriate health maintenance interventions.
(SELECT 4 INTERVENTIONS)
A.
B.
C.
D.
E.
F.
G.

Complete blood count

Dietetic counseling
Exercise counseling
Fasting serum lipid profile
Hepatitis B immunization
HIV testing
Influenza immunization

Chapter 7. Pick N Items: An Extension of the Extended-Matching Format

H.
I.
J.
K.
L.

Serum urea nitrogen (BUN) and creatinine

level measurements
Tetanus toxoid vaccine
Thyroid function tests
Urinalysis
X-ray film of the chest

103

Section IV
Additional Issues

This section includes some additional issues that are related to testing.

Chapter 8
Interpretation of Item Analysis Results

Many schools provide faculty with item analysis output following each multiple-choice examination. This output is an excellent source of information about an item and is useful in evaluating the quality of the item, as well as in evaluating the accuracy of the answer key.
The following are sample results from four items; each illustrates a common situation. The students taking the test were
divided into a Hi group and a Lo group, based on their performance on the total test. If you have a small number of examinees, include the top 50% of the students in the Hi group and the bottom 50% in the Lo group. If you have a large number
of examinees, you might include the top 25% in the Hi group and the bottom 25% in the Lo group.
Typically, item analysis output indicates the percentage of students in each group who selected each option. Often, it also
includes some measure of item difficulty (eg, the p-value or the proportion of students who answered the item correctly)
and some measure of discrimination (eg, a biserial or a point biserial). We recommend that attention be focused on the pattern of responses rather than on the difficulty level or discrimination index.

Chapter 8. Interpretation of Item Analysis Results

107

For each sample item below, the percentage of students selecting each option is shown. The total row shows the percentage
of the total group who selected each option. For example, in Item #1, 1% of the Hi group selected Option A; 1% selected
B; 91% selected C; 4% selected D; 1% selected E; and 2% selected F. In the same item, 20% of the Lo group selected Option
A; 6% selected B, etc. The asterisk on Option B indicates that B was the purported correct answer.
Item #1
Group
Hi
Lo
Total

A
1
20
9

p-value: 2

B*
1
6
2

C
91
51
76

D
4
14
8

E
1
6
3

F
2
3
2

discrimination index: -0.21

Interpretation: This is the typical pattern for an item that is miskeyed: if the answer is Option B, the item is very difficult
and the discrimination index is negative. With a key of B, only 2% of the students answered correctly. The correct answer
is almost certainly C, but a content expert should review the item to make sure. If the correct answer is C, the p-value
becomes 76 and the discrimination index becomes 0.46 these are both excellent from a statistical perspective, and there
is no reason to make any changes in item text.

Item #2
Group
Hi
Lo
Total
p-value: 74

A
0
0
0

B
1
1
1

C*
90
60
74

D
3
25
12

E
3
8
7

F
3
6
6

discrimination index: 0.33

Interpretation: 90% of the Hi group and 60% of the Lo group selected the correct answer. These are excellent overall statistics. You could rewrite A and B before you reuse the item because few students selected those options.

108

Item #3
Group
Hi
Lo
Total

A
44
20
32

p-value: 34

B
1
15
7

C*
50
21
34

D
2
22
14

E
1
20
11

F
2
2
2

discrimination index: 0.30

Interpretation: 50% of the Hi group and 21% of the bottom group selected the correct answer. This is a very difficult item
that is probably NOT OK. Too many of the Hi group selected Option A; the item may be poorly worded. Check Option A
for fairness. Make sure Option A is not equally correct.

Item #4
Group
Hi
Lo
Total
p-value: 34

A
18
24
22

B
10
24
17

C*
51
21
34

D
17
25
22

E
2
4
3

F
2
2
2

discrimination index: 0.30

Interpretation: The Hi/Lo group breakdown on option C is identical to Item #3, but this item may be OK. In contrast to Item
#3, those who dont know the correct answer are widely spread across the various distractors. Of course, it would still be
desirable to review options A, B and D for correctness and clarity.

Chapter 8. Interpretation of Item Analysis Results

109

Chapter 9
Establishing a Pass/Fail Standard

Definitions and Basic Principles

Standards may be classified as either relative or absolute. A relative standard is based on the performance of the group taking the test. Examinees pass or fail depending upon how well they perform relative to other examinees taking the test. The
following are examples of relative standards:
Those scoring below 1.2 standard deviations below the mean will fail.
The bottom 20 percent of the group will fail.
In contrast, an absolute standard does not compare the performance of one examinee with the others who are taking the test.
Examinees pass or fail based only upon how well they perform, regardless of the performance of other examinees. All examinees could pass or all could fail. The following is an example of an absolute standard:
Those answering less than 60 percent of the questions correctly will fail.
Unless there are strong reasons to fail a given number of examinees, an absolute standard (based on examinee performance)
is preferred over a relative standard (based on a particular failure rate).

Basic Principles of Setting Standards

Regardless of the procedure used, setting standards requires judgement. Setting standards will always be arbitrary,
but need not be capricious.

Unless there is a specific reason to fail a given number of examinees (eg, there are only a fixed number of slots
available), a standard based on examinee mastery of exam content is preferred over a standard based on a particular failure rate.

Chapter 9. Establishing a Pass/Fail Standard

111

It is wise to involve multiple informed judges in the standard-setting process. Differences of opinion will occur, and
use of multiple judges will reduce hawk/dove effects.

Judges should be provided with data on examinee performance at some point in setting standards. Setting standards
without such data may lead to uninformed standards and unreasonable results.

A helpful how-to reference on standard setting is:

Livingston SA, Zieky MJ. Passing Scores: A Manual for Setting Standards of Performance on Educational and Occupational Tests. Princeton, NJ:
Educational Testing Service; 1982.

Two Standard-Setting Methods Based on Judgements about Items

The Modified Ebel Procedure

112

A group discusses the characteristics of the borderline examinee: an examinee whose skills are just good enough
to allow him/her to pass.

Judges categorize items as Essential, Important, or Indicated.

Judges indicate the number of items in each category that a borderline examinee would obtain.

The pass/fail standard is calculated as the percentage of possible points that a borderline examinee
would obtain.

The Modified Angoff Procedure

A group discusses the characteristics of a borderline examinee.

For each item on the test, the judges estimate the percentage of borderline examinees who would answer the item
correctly.

The pass/fail standard for the test is the average of the percentages for the items.

Common Variations on the Angoff Procedure

Judges may or may not be provided with the correct answers to questions.

Judges may or may not be provided with information concerning the percentage of examinees who answered each
item correctly.

After a period of training, judges may continue to work as a group or may work individually.

Chapter 9. Establishing a Pass/Fail Standard

113

Relative/Absolute Compromise Standards: The Hofstee Method

More recently, several compromise models have been developed that utilize the advantages of both relative and absolute
standard-setting procedures. One of these methods, the Hofstee method, is described below.
1. Judges are asked to review a copy of the exam.
2. Judges then indicate the following values, which define acceptable standards:
Lowest acceptable percentage of failing examinees (minimum failure rate)
Highest acceptable percentage of failing examinees (maximum failure rate)
Lowest score which would allow someone to pass (minimum passing point)
Highest score required for someone to pass (maximum passing point)
3. After test administration, a curve showing the fail
rate as a function of passing score is plotted. (In the
figure shown, the curve extends from bottom left to
top right.)
4. The four values obtained in #2 are drawn, forming a
rectangle. Often the median values of the group of
judges are used. In the example, the appropriate
failure rate was judged to be between 0 and 20%
(see horizontal lines); the appropriate pass/fail point
was judged to be between 50 and 60% correct (see
vertical lines).
5. A line is drawn on the diagonal from upper left to
lower right. The point where this intersects the
curve is the standard (ie, just above 55% correct in
the figure).

A useful reference on compromise methods is:

de Gruijter D. Compromise models for establishing examination standards. Journal of Educational Measurement. 1985;22:263-269.

114

Chapter 10
Miscellaneous Thoughts on Topics Related to Testing

Comments on a hodge-podge of topics related to testing are provided below. In general, the points made are speculative and
based on anecdotal experience rather than evidence. That is, they reflect our biases rather than the results of research.

Multiple Station Exams (a.k.a. Practical Exams, Steeplechases, OSCEs)

Though logistically complex to set up and administer, these are very useful in the basic sciences, particularly to assess handson skills that cannot be measured with paper-and-pencil tests (eg, ability to use a microscope, to perform a laboratory procedure). In addition, reproduction of some kinds of material (eg, results of imaging studies, color pictorial material) is very
expensive; in such situations, the multiple-stations approach can be used to reduce test administration costs.

Take-Home Exams
Take-home exams can be a substantial learning experience for students by stimulating them to read broadly and deeply on
important topics. Unfortunately, students tend to produce tomes as answers, and it can be unclear if submitted answers represent the students own work. The same advantages can be gained by distributing (a superset of) test questions in advance,
and administering (a subset of) questions as a timed test.

Open-Book Tests
Open-book tests can be a very good idea because of the impact on the kinds of questions that faculty prepare. For open-book
tests, it is pointless to ask questions about isolated facts that can be looked up quickly on a single page of a text book, so test
material developed for these tests tends to focus more on understanding of key concepts and principles in problem situations.

Chapter 10. Miscellaneous Thoughts on Topics Related to Testing

115

Frequent Short Quizzes versus Infrequent Tests

Infrequent testing makes each exam a major event; students may even stop attending class to prepare, and this seems undesirable. In addition, with infrequent tests, students may be unable to determine if they are studying the right material or learning in enough depth. Though it may be more time consuming for faculty, frequent testing reduces the importance of each
individual exam and helps students to better gauge their progress. On the whole, frequent testing seems preferable, though
students are likely to complain regardless of the approach adopted.

Keeping Tests Secure versus Permitting Students to Retain Them

Because tests can have a substantial steering effect on student learning, permitting students to retain test material can aid
in focusing student attention on key topics, reinforcing curricular goals and course objectives (assuming test materials reflect
these). However, preparation of good exam questions is very time consuming, and, over time, the quality of test material
can deteriorate if faculty have to develop new test materials each time a course is taught. The best approach may be to make
sample good-quality test material available in order to influence student learning, but maintain a bank of secure questions
for repeated use, keeping in mind that security is likely to be poor, since students commonly memorize questions and reproduce them for each other.

Use of Cumulative Tests

Cumulative tests that hold students responsible for all material presented to date encourage attention to inter-relationships
among topics, particularly if test questions require understanding of both old and newly presented topics. Use of tests that
cover only material presented since the previous test encourages students to study topics in isolation; relationships among
topics from different units may be missed. Since students can do badly on a series of tests because they never master basic
material, this approach can also motivate students to remediate weaknesses.

Use of Integrative, Cross-Course Tests

Like the use of cumulative tests, integrative cross-course tests encourage students to see inter-relationships among disciplines
and topics; this should be very helpful for long-term retention and for application of basic science knowledge to clinical situations. Generally, faculty from both basic science and clinical departments are needed for preparation of such exams.
While time consuming, this joint effort may result in better test material as well as useful discussion among faculty of what
material should be included in the curriculum.

116

Appendix A
The Graveyard of NBME Item Formats

Appendix A
The Graveyard of NBME Item Formats

The first National Board examination was administered in 1916. It was a five-day examination consisting of written, oral,
laboratory, and clinical tests. Following World War I, the National Board appointed a commission to visit England, Scotland, and France to study methods of evaluation used for medical licensure. In 1922, the National Board administered a
new examination: Part I was a three-day essay exam in the basic sciences; Part II was a two-day essay exam in the major
clinical sciences; and Part III was a one-day oral exam conducted at the bedside. The examinations continued in those formats until the 1950s when multiple-choice testing became popular. In 1951, the National Board, with the cooperation of
the Educational Testing Services, began a three-year study comparing the essay test with the multiple-choice test, and Part
I and Part II were converted to a multiple-choice format in 1953; Part III was revised throughout the early 1960s as new
formats were introduced and discontinued. The first exam consisted of primarily A-type items involving recall of facts,
such as the following example:
In the 40 years since the first MCQ exam, the National Board
has broadened the scope of the A-type item to test reasoning
and problem-solving skills by including a clinical vignette in
most item stems. Today, the A-type remains the most commonly used item format on the Step examinations. Many
other item formats that were developed during this period
have been discontinued. These formats (named by a letter in
order of origination) are described on the following pages.

Of the following, the most effective prophylactic agent

for the prevention of recurrences of rheumatic fever is
A. acetylsalicylic acid
B. para-aminobenzoic acid
C. adrenocorticotrophic hormone
D. cortisone
E. sulfadiazine

The items shown in this section were obtained from:

Hubbard JP, Clemens WV. Multiple-Choice Examinations in Medicine. Philadelphia PA: Lea & Febiger;1961.

Critiques of these formats were obtained from:

Hubbard JP. Measuring Medical Education. Philadelphia PA: Lea & Febiger;1971.
Hubbard JP, Levit EJ. The National Board of Medical Examiners: The First Seventy Years. NBME;1985.

And also from various articles by Morton published in the Federation Bulletin in 1985 and 1986.

Appendix A

119

B-Type Items
B-type items were matching items that consisted of a list of lettered headings followed by a list of numbered words or phrases. The examinee was instructed to select the one heading that was most closely associated with each word or phrase.
Because each response could be used more than once or not at all, B-type items could not be solved by elimination. B-type
items were believed to widen the scope of an MCQ examination by allowing testing of a number of related subjects in a single series of items. Unlike the matching formats used today, the B-type items did not typically include a lead-in; as a result,
the question being asked was sometimes unclear. These items generally performed well, and were only discontinued recently as the extended-matching format became widely used.

Sample B-type Item

DIRECTIONS: Each set of matching questions in this section consists of a list of three to five lettered options (some of which may be in figures) followed by several numbered items. For each
numbered item, select the ONE lettered option that is most closely associated with it and fill in the
circle containing the corresponding letter on the answer sheet. Each lettered option may be selected once, more than once, or not at all.

120

A.
B.
C.
D.
E.

Coarctation of the aorta

Patent ductus arteriosus
Tetralogy of Fallot
Aortic vascular ring
Tricuspid atresia

1.
2.
3.
4.
5.

Benefited by systemic-pulmonary artery anastomosis

Most common type of congenital cyanotic heart disease
Surgically corrected by resection and end-to-end anastomosis
Possible cause of dysphagia in infants and children
Hypertension in the arms and hypotension in the legs

D-Type Items
D-type items were complex matching items in which each item consisted of three functional disturbances (designated by a
letter) and five situations (in a numbered list). The examinee was instructed to 1) select the functional disturbance or category that four of the five situations were related to and 2) indicate the one situation that did not belong in that category. It
was believed that these items required discriminatory understanding of a number of similar factors. However, D-type items
were difficult to write, and the directions were confusing. In addition, they did not discriminate between knowledgeable and
unknowledgeable examinees.

Sample D-type Item

DIRECTIONS: There are two responses to be made to each of the following questions. In the lefthand list are three lettered categories. Exactly four of the five numbered items in the right-hand
list are related in some way to ONE of these categories. (1) on the appropriate line in the answer
sheet blacken the space under the letter of the category in which these four items belong. (2) Then
blacken the space under the number of the item in the right-hand list that does NOT belong in the
same category with the other four.

A. Eosinophilia of diagnostic significance

B. Plasmacytosis of diagnostic significance
C. Lymphocytosis of diagnostic significance

Appendix A

1.
2.
3.
4.
5.

Trichinosis
Multiple myeloma
Loefflers syndrome
Hodgkins disease
Schistosomiasis

121

K-Type Items
K-type items were the most commonly used multiple true/false item format at the National Board. They consisted of a stem
followed by four options, one or more of which was correct. It was believed that K-type items tested in-depth knowledge or
understanding of several aspects of a disease, a process, or a procedure, and required an examinee to be familiar with several different facts about a given topic. However, K-type items were criticized as being too complicated, requiring the examinee to constantly keep the answer code in mind. In addition, the possible response combinations introduced a cueing effect
that reduced item discrimination and lowered test reliability. It was difficult to write good, unambiguous true/false items.
Because the items could include only absolutely true or false facts, K-type items could not be used to assess clinical judgement except in comparisons (eg, Drug X is better than Drug Y in treating disease K). K-type items were more difficult
and less discriminating than other item types. In addition, they were less efficient than other MCQ formats, and the relative
reliability per unit of test time was lower.

Sample K-type Item

Directions Summarized

1.

122

1, 2, 3 only

1, 3 only

2, 4 only

4 only

All are correct

A child suffering from an acute exacerbation of rheumatic fever usually has

(1)
an elevated sedimentation rate
(2)
a prolonged PR interval
(3)
an elevated antistreptolysin O titer
(4)
subcutaneous nodules

C-Type Items
C-type items were similar to B-type items in appearance but were multiple true/false in the task required of examinees. A
C-type item consisted of a list of lettered headings followed by a list of numbered words or phrases. For each numbered
item, the examinees were required to decide if A was true, B was true, both were true (option C), or neither was true (option
D). This item type was used to compare and contrast two diseases, signs and symptoms, laboratory findings, etc. C-type
items match K-types in level of difficulty. The primary problem with C-types was in deciding to what extent something had
to be true to be selected. If, for example, something was associated with both A and B, but was more strongly associated
with A, the examinee had to decide whether an appropriate response was A only or Both A and B. With relatively weak
associations, the examinee had to decide whether the association was strong enough to note, or whether neither was the
appropriate response. These judgements were not related to medical knowledge, but rather forced the examinee to think
about what the item writers intended.

Sample C-type Item

DIRECTIONS: Each set of matching questions in this section consists of a list of four lettered options followed
by several numbered items. For each numbered item, select the ONE lettered option that is most closely associated with it and fill in the circle containing the corresponding letter on the answer sheet. Each lettered option may
be selected once, more than once, or not at all.
A.
B.
C.
D.
1.
2.
3.
4.

Plasmodium vivax malaria

Plasmodium falciparum malaria
Both
Neither
A combination of primaquine and chloroquine is treatment of choice for acute attack.
Clinical attacks suppressed by ingestion of chloroquine once a week while in an endemic area.
Permanently cured by treatment with chloroquine.
Infection prevented by ingestion of chloroquine once a week.

Appendix A

123

E-Type Items
E-type items were multiple true/false items that are based on the analysis of relationships. Examinees who took E-type items
still refer to them as the True, True and Unrelated items. The E-type consisted of a sentence with two main parts: an assertion and a reason for that assertion. The examinee was directed to select A if both were true statements and the reason was
a correct explanation of the assertion; B if both were true statements but the reason was not a correct explanation of the assertion; C if the assertion was true but the reason was a false statement; D if the assertion was false but the reason was a true
statement; E if both assertion and reason were false statements. It was thought that good reasoning skills and an understanding of the basic principles were required to answer this item type correctly. However, E-type items were difficult to
construct, and examinees found them to be confusing.

Sample E-type Item

Directions Summarized
A
B
C
D
E

True
True
True
False
False

True
True
False
True
False

Reason is a correct explanation.

Reason is NOT a correct explanation.

Assertion

124

Reason

1. Herpes simplex is usually regarded

as an autogenous infection

BECAUSE

patients given fever therapy

frequently develop herpes.

2. Cows milk is preferable to breast

milk in infant feeding

BECAUSE

cows milk has a higher content

of calcium.

H-Type Items
H-type items were comparison items that consisted of paired statements describing two entities to be compared in a quantitative sense. The examinee was directed to select A if A was greater than B; B if B was greater than A; and C if the two
were approximately equal.
Although it was generally agreed that questions that depend on the memorization of absolute quantitative amounts should be
limited, the H-type item was believed to be useful for those instances where recall of quantitative information was believed to
be important. The problem for the examinees was in deciding how great the difference needed to be in order to be relevant.

Sample H-type Item

DIRECTIONS: The following paired statements describe two entities that are to be compared in a quantitative
sense. On the appropriate line of the answer sheet blacken the space under
A if (A) is greater than (B),
B if (B) is greater than (A),
C if the two are equal or very nearly equal.

1. (A)
(B)

The usual therapeutic dose of epinephrine

The usual therapeutic dose of ephedrine

2. (A)
(B)

Life expectancy with glioblastoma of the occipital lobe

Life expectancy with glioblastoma of the frontal lobe

Appendix A

125

I-Type Items
The I-type item was similar to the H-type. It consisted of pairs of phrases that describe conditions or quantities that might
vary in relation to each other. The examinee was directed to select A if the two phrases were related directly (ie, an increase
in the first was accompanied by an increase in the second or a decrease in the first was accompanied by a decrease in the second); B if the phrases were related inversely (ie, an increase in the first was accompanied by a decrease in the second or a
decrease in the first was accompanied by an increase in the second); or C if the changes were independent of one another.

Sample I-type Item

DIRECTIONS: Each of the following pairs of phrases describe conditions or quantities that may or may not be
related. On the appropriate line of the answer sheet blacken the space under
A if increase in the first is accompanied by increase in the second or if decrease in the first is accompanied
by decrease in the second
B if increase in the first is accompanied by decrease in the second or if decrease in the first is accompanied
by increase in the second
C if changes in the first are not necessarily accompanied by changes in the second.

1.

(A)
(B)

Urine volume
Urine specific gravity

2.

(A)
(B)

Plasma protein concentration

Colloid osmotic pressure of plasma

Neither the H- nor I-type formats were particularly popular. Because there were fewer options than in other item types, there
was an increased chance of guessing the correct answer. In addition, the items tended to focus on minor details rather than
scientific concepts.

126

In his series in the Federation Bulletin, Morton (1985-86) implied that different item types were included on medical licensure examinations simply to add variety to a lengthy examination. But, 25 years after the National Board converted from an
essay exam to MCQ exams, the NBME reviewed the research on the various types of MCQs used, and the variety of item
types was then reduced to include A-, B-, C-, G-, K-, X-, and M-type items. Staff again reviewed item types in the mid1980s. The general consensus, at that time, was that four basic item types provided sufficient variety to test the knowledge
specified as important for the awarding of a National Board certificate. These four basic types included A-, B-, C- and Ktype items. G-types (sets of A-type items), N-types (sets of K-type items), and M-type items were no longer considered as
separate formats.
More recently, the variety of item types has again been reviewed. The current Step examinations include A- and R-type items
only. Some of the steps taken to improve the examinations include: concentrating on item types that are psychometrically
sound, educating item writers on various item-writing techniques, focusing on clinical decision-making rather than recall
items, and pretesting newly written items.

Appendix A

127

Appendix B
Sample Item-Writing Templates, Items,
Lead-Ins, and Option Lists
For the Basic and Clinical Sciences

Appendix B
Sample Item-Writing Templates, Items, Lead-Ins, and Option Lists
for the Basic and Clinical Sciences

Gross Anatomy
Template for Gross Anatomy Items
Item Stem (Patient Vignette): (Describe a patient with a problem)
Lead-In: A defect is most likely to be present in which of the following structures/processes?
Options: (List of structures/processes)

A 65-year-old man has difficulty rising from a seated position and straightening his trunk, but he has no difficulty flexing
his leg. Which of the following is most likely to be injured?
A.* Gluteus maximus
D. Iliopsoas
B. Gluteus minimus
E. Obturator internus
C. Hamstrings

A 30-year-old man has loss of pain and temperature sensation on the left side of the face and on the right side of the body
from the neck down; partial paralysis of the soft palate, larynx, and pharynx on the left; and ataxia on the left. This syndrome
is most likely to result from thrombosis of which of the following arteries?
A. Basilar
D. Right superior cerebellar
B. *Right posterior inferior cerebellar
E. Left superior cerebellar
C. Left posterior inferior cerebellar

Appendix B

131

Insert patient vignette describing a patient with a problem.

A. Chondromalacia patellae
F.
B. Dislocation (tibiofemoral)
G.
C. Fracture of the patella
H.
D. Ganglion cyst
I.
E. Giant cell tumor of bone
J.

Which of the following is the most likely disorder of the knee?

Osteochondritis dissecans
Osteosarcoma
Prepatellar bursitis
Septic arthritis
Tear of the meniscus

Insert patient vignette describing a patient with a problem. Which of the following is the vessel into which contrast medium should be injected during fluoroscopy to visualize the site of the abnormality?
A Celiac artery
D. Superior mesenteric artery
B. Internal iliac artery
E. Renal artery
C. Inferior mesenteric artery
F. Portal vein

Insert patient vignette describing a patient with a problem. Which of the following gastrointestinal disorders is the most
likely cause of these findings?
A. Candidal esophagitis
F. Pyloric stenosis
B. Diverticulitis
G. Regional enteritis
C. Hiatal hernia
H. Subphrenic abscess
D. Peptic ulcer
I. Ulcerative colitis
E. Pseudomembranous enterocolitis

Isolated Fact Version:

Application of Knowledge Version:

Which of the following areas is supplied

with blood by the posterior inferior
cerebellar artery?

A 62-year-old man develops left-sided limb ataxia,

Horner's syndrome, nystagmus, and loss of pain
and temperature sensations on the face. Which
of the following arteries is most likely to be occluded?

132

Behavioral Sciences
Insert patient vignette describing a child's age and what he can do. Which of the following best describes the level of
development?
Cognitive
Gross Motor
Social
Language Skills
Skill
Skills
A. Normal
Normal
Normal
B. Normal
Normal
Delayed
C. Normal
Delayed
Normal
D. Normal
Delayed
Delayed
E. Delayed
Normal
Normal
F. Delayed
Normal
Delayed
G. Delayed
Delayed
Normal
H. Delayed
Delayed
Delayed

A 55-year-old man comes to the emergency department because of chest pain. He is in no apparent distress. His temperature is 98 5F, pulse is 68/min, respirations are 16/min, and blood pressure 130/74 mm Hg. Which of the following questions is most appropriate to ask first?
A. Do you have a history of heart disease or myocardial infarction?
B. Have you ever had chest pain before?
C. How long did your chest pain last?
D. Is the chest pain sharp or dull?
E. Tell me about your chest pain?
F. Where is your chest pain located?

Appendix B

133

A 35-year-old woman comes to the physician after finding a lump in her breast. She is crying and tells the physician that her
mother died of breast cancer. Which of the following responses by the physician is the most appropriate?
A. "I can see finding the lump was upsetting to you."
B. "I doubt that this lump is breast cancer."
C. "Tell me about how finding the lump made you feel."
D. "Tell me more about the lump."
E. "There is no reason to worry until we biopsy the lump."
F. "Treatment for breast cancer has improved a lot since your mother died of breast cancer."

Isolated Fact Version:

Application of Knowledge Version:

Which of the following characterizes

separation anxiety disorder?

An 8-year-old boy needs to be coaxed to go to school and, when at

school, he often complains of severe headaches or stomach pain.
Sometimes his mother has to take him home because of his symptoms.
At night, he tries to sleep with his parents. When they insist that he
sleep in his own room, he says that there are monsters in his closet.
Which of the following best explains this behavior?
A. Age-appropriate behavior
B. Childhood schizophrenia
C.* Separation anxiety disorder
D. Social phobia
E. Shared psychotic disorder

134

Biochemistry
Insert patient vignette describing a patient with a problem.
likely to be involved?
A. Amylase
F.
B. Chymotrypsin
G.
C. Colipase
H.
D. Enterokinase
I.
E. Lactase

Which of the following digestive enzymes or cofactors is most

Insert patient vignette describing a patient with a problem.

A. Hypercalcemia
E.
B. Hypocalcemia
F.
C. Hypermagnesemia
G.
D. Hypomagnesemia
H.

Which of the following laboratory findings is the most likely?

Hypernatremia
Hyponatremia
Hyperkalemia
Hypokalemia

Lipase
Pepsin
Sucrase
Trypsin

Isolated Fact Version:

Application of Knowledge Version:

Acute intermittent porphyria is the result

of a defect in the biosynthetic pathway for

An otherwise healthy 33-year-old man has a 6-month history of

episodes of mild weakness and steady, severe abdominal pain with
some cramping but no diarrhea. One aunt and a cousin have had
similar episodes. During an episode, his abdomen is distended,
similar episodes. During an episode, his abdomen is distended, and
bowel sounds are decreased. Neurologic examination shows mild
weakness in the upper arms. These findings suggest a defect in the
biosynthetic pathway for which of the following?

A.
B.
C.
D.
E.
F.

collagen
corticosteroid
fatty acid
glucose
heme
thyroxine

A. Collagen
B. Corticosteroid
C. Fatty acid
D. Glucose
E.* Heme
F. Thyroxine (T4)

Appendix B

135

Isolated Fact Version:

Application of Knowledge Version:

Which of the following characterizes

"-Fetoprotein?

A 45-year-old woman has rapid enlargement of the liver associated

with deterioration of hepatic function associated with cirrhosis resulting
from an episode of hepatitis . Serum concentration of which of the
following is most likely to be abnormal?
A. "1-Antitrypsin
B. Carcinoembryonic antigen
C. Chorionic gonadotropin
D.* "-Fetoprotein
E. Gastrin

Non-Vignette Version:

Vignette Version:

An inherited metabolic disorder of carbohydrate

metabolism is characterized by an abnormally
increased concentration of hepatic glycogen with
normal structure and no detectable increase in
serum glucose concentration after oral
administration of fructose. These two observations
suggest that the disease is the result of the absence
of which of the following enzymes?

A 6-month-old infant has an enlarged liver. Evaluation for

metabolic disease shows an abnormally increased concentration
of hepatic glycogen with normal structure and no detectable
increase in serum glucose concentration after oral
administration of fructose. These two observations suggest that
the disease is a result of the absence of which of the
following enzymes?

A. Fructokinase
B. Glucokinase
C.* Glucose 6-phosphatase
D. Phosphoglucomutase
E. UDPG-glycogen transglucosylase

136

A. Fructokinase
B. Glucokinase
C.* Glucose 6-phosphatase
D. Phosphoglucomutase
E. UDPG-glycogen transglucosylase

Recall of Isolated Fact: Which of the following

vitamins or minerals is involved in clotting
factor synthesis?

A. Vitamin A
B. Vitamin B1
C. Vitamin B2
D. Vitamin B6
E.* Vitamin C
F. Vitamin D
G. Vitamin E
H. Vitamin K

Application of Knowledge: A 70-year-old widower has

ecchymoses, perifollicular petechiae, and swelling of the
gingiva. His diet consists primarily of cola and hot dogs.
Which of the following vitamins or minerals is most
likely to be deficient?
I. Biotin
J. Copper
K.* Folate
L. Iodine
M. Iron
N. Magnesium
O. Niacin
P. Zinc
Alternate options (beriberi; kwashiorkor; pellagra; rickets;
scurvy) seem less appropriate.

In the branched metabolic pathway, a different single

enzyme catalyzes each of the individual steps. The enzyme
that would be expected to be most severely inhibited by
compound V is enzyme
A. A
B.* B
C. C
D. D
E. E

(A)
(A)

II
II

(E)
(E)

(B)
(B)

III
III

(C)
(C)

IV
IV

(D)
(D)

IV
IV

A 25-year-old woman is pregnant at 8 weeks' gestation. Her oral intake of calcium is inadequate. If she does not receive
supplements which of the following will be the primary source of calcium for the developing fetus
A.* cancellous bone
D. renal tubules
B. liver
E. small intestine
C. parathyroid glands

Appendix B

137

Genetics
A male neonate has severe hemolysis and circulatory failure. The 26-year-old mother is Rh negative and had two previous
second-trimester abortions. This condition could have been prevented by administration of which of the following to the
mother?
A. Anti-RhD IgG during the most recent pregnancy
B.* Anti-RhD IgG on termination of each of the first two pregnancies
C. Anti-RhD IgM during the most recent pregnancy
D. Anti-RhD IgM on termination of the first pregnancy

Genes on the bacterial chromosome have the following linkages in conjugal transfer: x and y, 25% of the time; y and z, 50%
of the time. If the gene order is x-y-z, approximately what percentage of the time will x and z be transferred together?
A. 1%
B. 5%
C. 13%
D. 20%
E.* 40%

Hereditary hyperammonemia, characterized by a grossly abnormal EEG and an increased blood ammonium concentration,
is most likely to be caused by a deficiency of which of the following enzymes?
A. Asparagine synthetase
B.* Carbamoyl phosphate synthetase I
C. Fumarase
D. Glutamate-oxaloacetate aminotransferase
E. Glutaminase

138

Histology/Cell Biology
Insert description of "action". Which of the following cellular organelles is most directly involved?
A. Golgi complex
E. Nuclear envelope
B. Lysosome
F. Secretory (zymogenic) granule
C. Peroxisome
G. Rough endoplasmic reticulum
D. Mitochondria
H. Smooth endoplasmic reticulum

Lab Vignette
Several contiguous cells are labeled with a fluorescent dye that cannot cross cell membranes. One cell is experimentally
bleached with a light that destroys the dye but soon recovers dye fluorescence. This recovery is best explained by the presence of which of the following structures between the bleached cell and its fluorescent neighbors?
A. Basal lamina
D. Glycosaminoglycans
B. Desmosomes (maculae adherentes)
E. Tight junctions (zonulae occludentes)
C.* Gap junctions

Appendix B

139

Microbiology
Template for Microbiology Items:
Item Stem (Patient Vignette): (Describe a patient with a problem)
Lead-In: Infection with which of the following organisms is most likely?
Options: (List of pathogens)

At a banquet, the menu included fried chicken, home fried potatoes, peas, chocolate eclairs, and coffee. Within 2 hours, most
of the diners became violently ill, with nausea, vomiting, and abdominal pain. Analysis of the contaminated food is most
likely to yield large numbers of which of the following organisms?
A. Escherichia coli
B. Proteus mirabilis
C. Salmonella typhimurium
D.* Staphylococcus aureus
E. Streptococcus faecalis
F. Enterococcus

Insert patient vignette describing a person with a problem.

pathogenesis?
A. Botulinum toxin
F.
B. Diphtheria toxin
G.
C. Pertussis toxin
H.
D. Shiga toxin
I.
E. Tetanus toxin

140

Which of the following toxins is most likely to be involved in

Cholera enterotoxin
Clostridium difficile enterotoxin
Escherichia coli heat-stable enterotoxin
Staphylococcus aureus enterotoxin

Insert patient vignette describing a patient with a problem. Which of the following is the most appropriate therapeutic agent?
A. Acyclovir
H. Pyrantel pamoate
B. Amphotericin B
I. Pyrazinamide
C. Erythromycin
J. Rifampin
D. Ganciclovir
K. Trimethoprim-sulfamethoxazole
E. Gentamicin
L. Vancomycin
F. Ketoconazole
M. Zidovudine (AZT)
G. Miconazole

Isolated Fact Item: Which of the following pathogens is an encapsulated gram-positive organism that usually grows in
pairs or short chains? (Same option list as below) Answer: T
Application of Knowledge Item: A 7-year-old girl has a high fever and a sore throat. There is pharyngeal redness, a
swollen right tonsil with a creamy exudate, and painful right submandibular lymphadenopathy. Throat culture on blood
agar yields numerous small $-hemolytic colonies that are inhibited by bacitracin. Which of the following pathogens is
most likely to have caused her illness? Answer: U
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Adenovirus
Aspergillus fumigatus
Bacillus anthracis
Candida albicans
Chlamydia psittaci
Coccidioides immitis
Coronavirus
Corynebacterium diphtheriae
Coxiella burnetii
Coxsackievirus
Epstein-Barr virus

Appendix B

L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.

Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium tuberculosis
Mycoplasma pneumoniae
Neisseria gonorrhoeae
Neisseria meningitidis
Pneumocystis carinii
Rhinovirus
Streptococcus pneumoniae
Streptococcus pyogenes (group A)

141

Sample Item Set

A 2-year-old boy has had recurrent infections since he was 6 months old. Serum complement concentrations,
phagocytic function, and bactericidal of neutrophils are normal. A skin test with Candida antigens results in
2 cm of induration by 48 hours. Which of the following provides the best explanation for the time of onset of the
disease at 6 months of age?
A.
B.
C.
D.
E.

Development of a viral infection

Exposure to rare bacteria
Loss of passive immunity from the mother
A maturation defect in the thymus
Transplacental transfer of IgM antibodies

Which of the following laboratory tests is most likely to be abnormal?

A.
B.
C.
D.
E.

142

Activity of myeloperoxidase
CD4/CD8 T lymphocyte ratio
Sweat chloride concentration
Fc receptors on macrophages
Serum IgG concentration

Neuroscience (Neuroanatomy and Neuropathology)

Template for Neuroanatomy Items
Item Stem (Patient Vignette): (Describe a patient with a problem)
Lead-In: An abnormality is most likely to be present at which of the following locations?
Options: (List of sites)

Insert patient vignette describing a patient with a problem.

the underlying lesion?
A. Olfactory nerve
G.
B. Optic nerve
H.
C. Oculomotor nerve
I.
D. Trochlear nerve
J.
E. Trigeminal nerve
K.
F. Abducens nerve
L.

Which of the following cranial nerves is the most likely site of

Facial nerve
Vestibulocochlear nerve
Glossopharyngeal nerve
Vagus nerve
Spinal accessory nerve
Hypoglossal nerve

Insert patient vignette describing a patient with a neurologic abnormality. Which of the following branches of the brachial
plexus is most likely to be affected?
A. Axillary
G. Musculocutaneous
B. Dorsal scapular
H. Radial
C. Suprascapular
I. Long thoracic
D. Upper subscapular
J. Thoracodorsal
E. Lower subscapular
K. Ulnar
F. Median

Appendix B

143

Insert patient vignette describing a patient with a problem. Which of the following components of the motor system is most
likely to be involved?
A. Basal ganglia
F. Sensory motor cortex
B. Cerebellar hemisphere
G. Superior colliculus/pretectal area
C. Cerebellar vermis
H. Supplementary motor area
D. Motor relay of the thalamus
I. Ventral horn
E. Premotor area

Insert patient vignette describing a patient with a problem. The most likely cause is occlusion of which of the following
arteries?
A. Left anterior cerebral
E. Left posterior cerebral
B. Right anterior cerebral
F. Right posterior cerebral
C. Left middle cerebral
G. Left lenticulostriate
D. Right middle cerebral
H. Right lenticulostriate

Insert patient vignette describing a patient with a problem.

A. Amyotrophic lateral sclerosis
E.
B. Huntington's disease
F.
C. Multiple sclerosis
G.
D. Parkinson's disease

144

Which of the following is the most likely diagnosis?

Poliomyelitis
Polyneuropathy
Retinitis pigmentosa

Sample Item Set

An unresponsive 58-year-old woman is brought to the emergency department after collapsing at a local shopping mall.
Her family reports that she felt well that morning but developed a progressively severe headache. She has had hypertension and atrial fibrillation and is taking an antihypertensive medication and an oral anticoagulant. Her blood pressure
is 220/130 mm Hg and she has apnea alternating with hyperpnea. She responds only to noxious stimuli with extensor
posturing involving the right arm and leg. Funduscopic examination shows papilledema involving the left optic disc.
Pupils are 3.0/7.0 (R/L) with no reaction to light on the left. There is a left gaze preference. There is diffuse hyperreflexia, R > L, and bilateral Babinski signs are present.
1. The dilated, unreactive left pupil is most consistent with injury to which of the following structures on the left?
A. Optic nerve
D. Lateral geniculate nucleus
B. Optic tract
E. Superior colliculus
C.* Oculomotor nerve
2. The extensor posturing on the right is most consistent with injury to which of the following areas of the brain
on the left?
A. Telencephalon
D. Pons
B. Diencephalon
E. Medulla
C.* Midbrain
3. Which of the following best describes her respiratory pattern?
A.* Cheyne-Stokes
B. Central neurogenic hyperventilation
C. Apneustic
D. Ataxic
4. Which of the following herniation syndromes is most consistent with her clinical presentation?
A. Cingulate gyrus beneath the falx
B.* Temporal lobe uncus across the tentorium
C. Diencephalon through the tentorial notch
D. Brain stem through the tentorial notch
E. Cerebellar tonsils through the foramen magnum

Appendix B

145

Pathology
Insert description of "action". Which of the following cellular organelles are most directly involved?
A. Golgi complex
E. Nuclear envelope
B. Lysosomes
F. Secretory (zymogenic) granules
C. Peroxisomes
G. Rough endoplasmic reticulum
D. Mitochondria
H. Smooth endoplasmic reticulum

Insert patient vignette describing a patient with a problem.

tion of tissue obtained on renal biopsy?
A. Acute necrotizing vasculitis
F.
B. Amyloid deposits
G.
C. Cortical necrosis
H.
D. Glomerular mesangial IgA
I.
E. Glomerular peripheral IgG
J.

Which of the following is the most likely finding on examina-

Insert patient vignette describing a patient with a problem.

to be present?
A. Adrenal cortical adenoma
F.
B. Adrenal cortical carcinoma
G.
C. Adrenal hyperplasia
H.
D. Adrenal necrosis
I.
E. Adrenal neuroblastoma
J.

Which of the following endocrine abnormalities is most likely

Granulomas
Interstitial neutrophils
Nodular glomerulosclerosis
Regenerating tubules
Tubular uric acid crystals

Adrenal pheochromocytoma
Pancreatic islet cell adenoma
Parathyroid adenoma
Parathyroid carcinoma
Parathyroid hyperplasia

A 32-year-old man dies 4 days after fracturing his femur in an automobile collision. Examination of his brain at autopsy
shows widespread petechiae in the cerebral white matter. Which additional autopsy finding is most likely?
A. Adult respiratory distress syndrome
B. Contrecoup injury
C.* Fat embolization
D. Septicemia
E. Subdural hematoma

146

Autopsy of a 24-year-old woman shows pleuritis, membranous thickening of glomerular capillary walls, concentric rings of
collagen around splenic arterioles, and excrescences on the underside of the mitral valve. Which of the following findings
is most likely on evaluation of blood from this woman?
A.* Antinuclear antibody
B. Increased C3 concentration
C. Lymphocytosis
D. Monoclonal gammopathy
E. Positive bacterial culture

A patient with hepatitis B dies 9 days after the onset of symptoms. Which of the following findings is most likely on microscopic examination of his liver?
A. Diffuse fatty vacuolization with minimal necrosis
B. Diffuse fibrosis with nodularity
C. Limited peripheral zonal necrosis
D.* Widespread hepatocellular necrosis
E. Widespread neutrophilic infiltration in lobules

Appendix B

147

Pathology Mechanisms
Template for Mechanisms Items
Item Stem (Patient Vignette): (Describe a patient with a problem)
Lead-In: Which of the following mechanisms is the most likely cause of the patient's findings?
Options: (List of mechanisms)

Insert patient vignette which describes a patient with a problem. Which of the following is the most likely cause of the
myocardial disease?
A. Alcohol toxicity
B. Cardiac amyloidosis
C. Endomyocardial fibrosis
D. Hemochromatosis
E. Hypertrophic cardiomyopathy
F. Lffler's endocarditis
G. Postviral myocarditis
H. Sarcoidosis
I. South American trypanosomiasis (Chagas' disease)
J. Vitamin B1 (thiamine) deficiency
Insert patient vignette describing a patient with jaundice. Which of the following is the most likely cause of the jaundice?
A. Alcoholic hepatic disease
F. Intrahepatic ductal atresia
B. Drug reaction
G. Obstructive jaundice
C. Dubin-Johnson syndrome
H. Primary biliary cirrhosis
D. Gilbert's syndrome
I. Viral hepatitis
E. Hemolytic jaundice

148

Insert patient vignette describing a patient with a hemostatic abnormality. Which of the following is the most likely cause
of the hemostatic abnormality?
A. Acute disseminated intravascular
E. Hemophilia B
coagulation
F. Idiopathic thrombocytopenia purpura
B. Factor V (proaccelerin) deficiency
G. Pulmonary thromboembolism
C. Factor VII (proconvertin) deficiency
H. von Willebrand's disease
D. Hemophilia A
Insert patient vignette describing a patient with a problem. Which of the following is the most likely gastrointestinal lesion?
A. Candidal esophagitis
F. Pyloric stenosis
B. Diverticulitis
G. Regional enteritis
C. Hiatal hernia
H. Subphrenic abscess
D. Peptic ulcer
I. Ulcerative colitis
E. Pseudomembranous enterocolitis

Appendix B

149

Pathology Diagnosis
Template for Diagnosis Items
Item Stem (Patient Vignette): (Describe a patient with a problem)
Lead-In: Which of the following is the most likely diagnosis?
Options: (List of diagnoses)

Insert patient vignette to describe a patient with a histologic abnormality. Which of the following is the most likely thyroid
disorder?
A. Chronic autoimmune (Hashimoto's) thyroiditis
B. Graves' disease
C. Myxedema after 131I therapy
D. Subacute thyroiditis
E. Well-differentiated thyroid carcinoma

Insert patient vignette describing a patient with a problem. Which of the following is the most likely diagnosis?
A. Acute lymphoblastic leukemia
B. Acute myelogenous leukemia
C. AIDS
D. Chronic lymphocytic leukemia
E. Ewing's sarcoma
F. Follicular lymphoma
G. Hodgkin's disease
H. Idiopathic thrombocytopenic purpura
I. Multiple myeloma
J. Polycythemia vera
K. Histiocytosis X
L. T-cell lymphoma

150

Insert patient vignette describing a patient with heart disease. Which of the following is the most likely diagnosis?
A. Acute viral myocarditis
F. Hypertensive cardiomyopathy
B. Chagas' disease
G. Hypertrophic cardiomyopathy
C. Dilated cardiomyopathy
H. Ischemic cardiomyopathy
D. Giant cell myocarditis
I. Pompe's disease
E. Hemochromatosis
J. Restrictive cardiomyopathy

Insert patient vignette to describe a patient with a problem. Which of the following cell types is the most likely to be
involved in the lesion?
A. Basophil
E. Mesothelial cell
B. Endothelial cell
F. Monocyte
C. Eosinophil
G. Neutrophil
D. Lymphocyte
H. Plasma cell

Insert patient vignette describing a patient with renal disease. Which of the following is the most likely diagnosis?
A. Acute poststreptococcal
E. Lupus nephritis
glomerulonephritis
F. Membranoproliferative
B. Focal segmental sclerosis
glomerulonephritis
C. Goodpasture's syndrome
G. Membranous glomerulonephritis
D. IgA nephropathy
H. Minimal change nephropathy

A 21-year-old man has weight loss and severe intermittent bloody diarrhea. Barium enema and colonoscopy show multiple
ulcers and inflammatory changes extending from the rectum to the mid-transverse colon. Biopsy specimens taken from
multiple sites show acute and chronic inflammation restricted to the mucosa. Which of the following is the most likely
diagnosis?
A. AIDS-associated gastroenteritis
E. Escherichia coli-associated colitis
B. Amebiasis
F. Ischemic colitis
C.* Crohn's disease
G. Salmonella gastroenteritis
D. Clostridium difficile-associated colitis
H. Ulcerative colitis

Appendix B

151

A 38-year-old woman has congestive heart failure, premature ventricular contractions, and repeated episodes of ventricular
tachycardia. Her blood pressure is normal. Her heart is markedly enlarged. There are no murmurs; coronary angiography is
normal. Which of the following is the most likely diagnosis?
A. Acute rheumatic fever
B. Congenital fibroelastosis
C. Constrictive pericarditis
D.* Myocardial infarction
E. Primary cardiomyopathy

A 74-year-old man has colicky abdominal pain in the left lower quadrant, leukocytosis, and fever. He has not had diarrhea
or constipation. Which of the following is the most likely diagnosis?
A. Carcinoma of the sigmoid colon
B.* Diverticulitis
C. Familial adenomatous polyposis
D. Ulcerative colitis
E. Villous adenoma of the upper rectum

152

Pathophysiology
Template for Pathophysiology Items - Additional Findings
Item Stem (Patient Vignette): (Describe a patient with a problem)
Lead-In: Which of the following additional findings is most likely to be present?
Options: (List of findings)

Laboratory tests on an edematous 35-year-old man show a normal serum concentration of complement and an increased
serum concentration of cholesterol. Urinalysis show proteinuria (4+), 0-5 erythrocytes/hpf, and several hyaline casts. Which
of the following findings is most likely on renal biopsy?
A. Acute poststreptococcal(proliferative) glomerulonephritis
B. Membranoproliferative glomerulonephritis
C.* Membranous glomerulonephritis
D. Minimal change disease
E. Rapidly progressive glomerulonephritis

A 16-year-old boy is undergoing evaluation for jaundice. Laboratory studies show normal hepatic enzyme activities, a negative direct antiglobulin test, increased mean corpuscular hemoglobin concentration, and increased osmotic fragility of erythrocytes. Which of the following types of erythrocyte is most likely to be seen on a peripheral blood smear?
A. Ovalocyte
D. Target cell
B. Schistocyte
E. Teardrop cell
C.* Spherocyte

Appendix B

153

An asymptomatic 50-year-old woman has hypertension. Urinary excretion of catecholamines is increased. A CT scan shows
a suprarenal mass. Which of the following findings is most likely on microscopic examination of the resected mass?
A. Benign neoplasm of the adrenal cortex
D. Malignant neoplasm of the adrenal medulla
B.* Benign neoplasm of the adrenal medulla
E. Diffuse hyperplasia of the adrenal cortex
C. Malignant neoplasm of the adrenal
F. Diffuse hypoplasia of the adrenal medulla
cortex

Insert patient vignette describing a patient with a problem. Which of the following is the most likely pulmonary finding at
autopsy?
A. Soft with fluffy consistency, multiple blebs over the surface
B. Very heavy; frothy and bloody fluid exudes freely from the cut surface
C. Diffuse fibrotic nodules; whorled appearance replacing normal lung parenchyma
D. Liver-like consistency in left lower lobe; microscopically contains fibrin and neutrophils in the alveoli
E. Normal-appearing; large Y-shaped, coiled, laminated clot almost filling both pulmonary arteries

Insert patient vignette describing a patient with a problem. Which of the following sets of findings is most likely?
Effective circulating volume
Extracellular fluid volume
Plasma volume
Urine Na+ excretion
A. Decreased
decreased
decreased
decreased
B. Decreased
increased
decreased
decreased
C. Decreased
increased
increased
decreased
D. Increased
increased
increased
increased

Insert patient vignette describing a patient with a problem.

likely to be involved?
A. Amylase
F.
B. Chymotrypsin
G.
C. Colipase
H.
D. Enterokinase
I.
E. Lactase

154

Which of the following digestive enzymes or cofactors is most

Lipase
Pepsin
Sucrase
Trypsin

Insert patient vignette describing a patient with a problem.

A. Hypercalcemia
E.
B. Hypocalcemia
F.
C. Hypermagnesemia
G.
D. Hypomagnesemia
H.

Which of the following laboratory findings is the most likely?

Hypernatremia
Hyponatremia
Hyperkalemia
Hypokalemia

Insert patient vignette describing a patient with a problem. Which of the following is the most likely thyroid function
profile?
Thyroxine (T4)
Triiodothyronine (T3)Resin Uptake
Thyroid-stimulating Hormone
T3
A.

B.

normal

C.

normal

normal
D.

normal
normal
E.

F.

normal

G.
normal
normal
normal
normal

Insert patient vignette describing a patient with electrocardiographic findings. Which of the following cardiac arrhythmias
is most likely to be present?
A. Atrial fibrillation
F. Premature atrial contractions
B. Atrial paroxysmal tachycardia
G. Premature ventricular contractions
C. First-degree incomplete heart block
H. Sinus arrhythmia
D. Second-degree incomplete heart block
I. Ventricular fibrillation
E. Third-degree complete heart block
J. Ventricular paroxysmal tachycardia

Appendix B

155

Insert patient vignette describing a patient with cardiac abnormalities (A 4-week-old infant has a loud systolic murmur with
a systolic thrill; otherwise, the infant appears healthy. There is no cyanosis). Which of following congential heart diseases
is most likely to be present?
A. Atrial septal defect
E. Patent ductus arteriosus
B. Coarctation of the aorta
F. Pulmonic valve stenosis
C. Complete transposition of the great arteries
G. Tetralogy of Fallot
D. Endocardial cushion defect
H. Ventricular septal defect

156

Pharmacology
Template for Adverse Effects Pharmacology "Guess My Drug"
Item Stem (Patient Vignette): (Describe a patient with adverse drug effect)
Lead-In: Which of the following drugs has the patient most likely been taking?
Options: (List of drugs)

A patient in the emergency department cannot remember which "heart drug" he is taking. He says he has "ringing in his ears."
His heart rate is greater than 80/min. The ECG shows prolonged PR and QRS intervals. Which of the following drugs has
the patient most likely been taking?
A. Digoxin
B. Lidocaine
C. Phenytoin
D. Propranolol
E.* Quinidine

Insert patient vignette describing a patient with an adverse drug effect. Which of the following is the most likely to have
caused the adverse effect?
A. Acetaminophen
J. Nalidixic acid
B. Amiodarone
K. Nitrofurantoin
C. ACE inhibitors
L. Penicillin
D. Aspirin
M. Prednisone
E. Atenolol
N. Procainamide
F. Bleomycin
O. Propranolol
G. Cytosine arabinoside
P. Sulfasalazine
H. Furosemide
Q. Tetracycline
I. Metronidazole
R. Verapamil

Appendix B

157

Drug Y has a volume of distribution (Vd) of 75 L in both younger and older adult men. In younger adults, it has a clearance
rate of 15L/h, 50% of which is via the liver and 50% via the kidneys. For younger men, the maintenance regimen is 100 mg
every 6 hours. Which of the following regimens will produce essentially the same steady-state concentration in an older man,
whose creatinine clearance is half that of younger men, but whose hepatic function is unimpaired?
A. 75 mg every 3 hours
B.* 75 mg every 6 hours
C. 75 mg every 9 hours
D. 100 mg every 3 hours
E. 100 mg every 6 hours
F. 100 mg every 12 hours

A 24-year-old sexually active woman reports increased vaginal discharge. Pelvic examination shows a green frothy
discharge. Microscopic examination of a wet mount of the discharge shows motile unicellular organisms 10-30 in length.
Which of the following features of this disorder best explains why the infection can be effectively treated with metronidazole?
A. Facultatively aerobic
B. Microaerophilic
C. Strictly aerobic
D.* Strictly anaerobic

Template for Site/Mechanism of Action Items Pharmacology

Item Stem (Patient Vignette): (Describe a patient who requires pharmacotherapy)
Lead-In: A drug with which of the following sites/mechanisms of action is most likely to be effective?
Options: (List of mechanisms of action) OR (List of sites of action)

158

Pharmacotherapy
Template for Pharmacotherapy Items
Item Stem (Patient Vignette): (Describe a patient who requires pharmacotherapy)
Lead-In: Administration of which of the following is most appropriate?
Options: (List of drugs)

A 40-year-old black man has the sudden onset of severe headache, dizziness, and vomiting. His blood pressure is 260/130
mm Hg; he has encephalopathy and grade IV retinopathy. Administration of which of the following is most appropriate?
A. Alpha agonists
G. Central sympatholytics
B. Alpha blockers
H. Direct vasodilators
C. ACE inhibitors
I. Negative inotropic agents
D. Beta agonists
J. Thiazide diuretics
E. Beta blockers
K. Vasoconstrictors
F. Cardiac glycosides

Insert patient vignette describing a patient who requires pharmacotherapy. Which of the following is the most appropriate
initial drug therapy?
A. Adenosine
G. Naloxone
B. Aspirin
H. Prednisone
C. Caffeine
I. Propranolol
D. Epinephrine
J. Quinidine
E. Insulin
K. Streptokinase
F. Lidocaine

Appendix B

159

Insert patient vignette describing a patient who requires pharmacotherapy. Which of the following is the most appropriate
therapeutic agent?
A. Carbamazepine
F. Lithium carbonate
B. Dextroamphetamine
G. Phenobarbital
C. Ethosuximide
H. Primidone
D. Haloperidol
I. Propranolol
E. L-dopa/carbidopa
J. Pyridostigmine

Insert patient vignette describing a patient who requires pharmacotherapy. Which of the following is the most appropriate
therapeutic agent?
A. Atropine
F. Milk of magnesia
B. Bismuth subsalicylate
G. Misoprostol
C. Cimetidine
H. Omeprazole
D. Diphenoxylate
I. Ranitidine
E. Kaolin
J. Sucralfate

Insert patient vignette describing a patient who requires pharmacotherapy. Which of the following is the most appropriate
diuretic?
A. Carbonic anhydrase inhibitor
B. High-ceiling or loop
C. Nonsteroidal potassium-sparing
D. Osmotic
E. Steroidal potassium-sparing
F. Thiazide
G. Xanthine

160

Physiology
An anesthetized patient is being mechanically ventilated. Initial arterial blood gas values are normal. If the ventilation is
decreased, which of the following best describes arterial PCO2 and pH.
Arterial PCO2
A. Decrease
B. Decrease
C.* Decrease
D. Increase
E. Increase
F. Increase

pH
decrease
increase
no change
decrease
increase
no change

Insert patient vignette describing a patient with a problem.

A. ADH (vasopressin)
E.
B. Aldosterone
F.
C. Angiotensin
G.
D. Atrial natriuretic peptide
H.

Which of the following substances is most likely involved?

Bradykinin
Calcitonin
Parathyroid hormone
Renin

A 22-year-old man with a 3-week history of polyuria and polydipsia has had nausea, vomiting, and decreased responsiveness for the past 12 hours. Urinalysis shows 4+ glucose and 4+ ketones. Which of the following sets of arterial blood gas
findings is most likely?
pH
PO2 (mm Hg)
PCO2 (mmHg)
HCO3 (mEq/L)
A.
7.15
98
33
11
B.*
7.15
98
24
8
C.
7.30
56
80
38
D.
7.40
100
40
25
E.
7.50
100
33
25
F.
7.50
100
24
18
G.
7.50
56
33
25

Appendix B

161

Insert patient vignette describing a patient with a problem. Which of the following humoral substances is most likely
involved?
A. Acetylcholine
G. Prostacyclin (PGI2)
B. Adenosine
H. Prostaglandin E2
C. Aldosterone
I. Prostaglandin F2"
D. Bradykinin
J. Serotonin
E. Epinephrine
K. Thromboxane A2
F. Norepinephrine

162

Integrative Item Sets

Template for Integrative Indications Items: Microbiology/Pharmacology
Item Stem (Patient Vignette) (Describe a patient with a problem)
Lead-In: Infection with which of the following pathogens is most likely?
Options: (List of pathogens)
Lead-In: Administration of which of the following drugs is most appropriate?
Options: (List of drugs)

Appendix B

163

A 40-year-old man with AIDS has a 1-week history of low-grade fever and lethargy. Temperature is 38 C (100.4 F), pulse
is 90/min, and blood pressure is 110/70 mm Hg. There is slight resistance to passive flexion of the neck. Laboratory studies of cerebrospinal fluid show:
Opening pressure
210 mm Hg
Appearance
straw-colored
Leukocyte count
400/mm3 (100% lymphocytes)
Erythrocyte count
50/mm3
Glucose
30 mg/dL
Protein
100 mg/dL
India ink preparation
encapsulated yeast
1. Infection with which of the following pathogens is most likely?
A. Blastomyces
B. Cryptococcus
C. Histoplasma
D. Toxoplasma gondii
E. Treponema pallidum
2. Administration of which of the following drugs is most appropriate?
A. Amphotericin
B. Ketoconazole
C. Miconazole
D. Nystatin
E. Trimethoprim-sulfamethoxazole

164

Sample Item Set

A 34-year-old woman has had severe watery diarrhea for the past 4 days. Two months ago, she had infectious mononucleosis. She abuses drugs intravenously and is seropositive for HIV. Physical examination shows dehydration and
marked muscle weakness.
1. Which of the following laboratory abnormalities is most likely?
D.* Increased serum Na+ concentration
A. Decreased serum K+ concentration
B. Decreased serum Ca2+ concentration
E. Increased serum pH
C. Increased serum HCO3 concentration
2. In evaluating the cause of the diarrhea, which of the following studies is most appropriate?
A. Colonic biopsy to identify Giardia lamblia
B. Culture of the oral mucosa for Candida albicans
C. Duodenal biopsy to identify Entamoeba histolytica
D. Gastric aspirate to identify Mycobacterium avium-intracellulare
E.* Stool specimen to identify Cryptosporidium
3. Further studies to evaluate her HIV infection show a helper to suppressor T lymphocyte ratio of 0.3.
Which of the following actions of HIV best explains this ratio?
A. Induction of helper T lymphocyte proliferation
B. Induction of suppressor T lymphocyte proliferation
C.* Infection of cells with CD4 receptor
D. Infection of macrophages
E. Stimulation of leukotriene synthesis

Appendix B

165

Template for Pathology/Pharmacology Items

Item Stem (Patient Vignette): (Describe a patient with a problem)
Lead-In: Which of the following is the most likely diagnosis?
Options: (List of diagnoses)
Next Lead-In: Administration of which of the following drugs is most appropriate?
Next List of Options: (List of drugs)

Sample Item Set

1. A 62-year-old man with alcohol dependence is admitted to the hospital for transurethral resection of the prostate.
The following morning, while being transported to the operating room, he has two generalized seizures within
5 minutes. Neurologic examination shows no focal abnormalities. Which of the following is the most likely
diagnosis?
A.* Alcohol withdrawal
C. Partial complex seizure
B. Korsakoff's syndrome
D. Wernicke's encephalopathy
2. The most appropriate management is intravenous administration of which of the following drugs?
A. Diazepam
D. Phenytoin
B. Haloperidol
E. Valproate
C. Phenobarbital

166

Sample Item Set

A 2-year-old boy has had recurrent infections since he was 6 months old. Serum complement concentrations, phagocytic
function, and bactericidal activity of neutrophils are normal. A skin test with Candida antigens results in 2 cm of induration
by 48 hours. Which of the following provides the best explanation for the time of onset of the disease at 6 months of age?
A. Development of a viral infection
B. Exposure to rare bacteria
C. Loss of passive immunity from the mother
D. A maturation defect in the thymus
E. Transplacental transfer of IgM antibodies

Which of the following laboratory tests is most likely to be abnormal?

A. Activity of myeloperoxidase
B. CD4/CD8 T lymphocyte ratio
C. Sweat chloride concentration
D. Fc receptors on macrophages
E. Serum IgG concentration

Template for Integrative Physiology/Pharmacology Items

Item Stem (Patient Vignette): (Describe a patient with a problem)
Lead-In: Administration of a drug aimed at achieving which of the following effects is most appropriate? OR
Administration of {specific drug} is most likely to have which of the following effects?
Options: (List of physiological effects)

Appendix B

167

Sample Item-Writing Option Lists For the Clinical Sciences

Components of a Patient Vignette
Age, Gender (eg, A 45-year-old man)
Site of Care (eg, comes to the emergency department)
Presenting Complaint (eg, because of headache)
Duration (eg, that has continued for 2 days).
Patient History (with Family History?)
Physical Findings
+/- Results of Diagnostic Studies
+/- Initial Treatment, Subsequent Findings, Etc.

Abdominal Mass
A.
B.
C.
D.
E.
F.
G.
H.
I.

Abdominal abscess
Acute lymphocytic leukemia
Carcinoma of the colon
Carcinoma of the ovary
Choledochal cyst
Constipation
Desmoid tumor
Distended bladder
Hepatoma

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Hernia
Hydatid cyst
Inflammatory bowel disease
Neuroblastoma
Pancreatic pseudocyst
Polycystic kidney
Uterine fibroids
Volvulus
Wilms' tumor

For each patient with an abdominal mass, select the most likely diagnosis.

168

Abdominal Pain
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

Abdominal aneurysm
Appendicitis
Bowel obstruction
Cholecystitis
Colon cancer
Constipation
Diverticulitis
Ectopic pregnancy ruptured
Endometriosis
Hernia

K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.

Kidney stone
Mesenteric adenitis
Mesenteric artery thrombosis
Ovarian cyst ruptured
Pancreatitis
Pelvic inflammatory disease
Peptic ulcer disease
Perforated peptic ulcer
Pyelonephritis
Torsion

For each patient with abdominal pain, select the most likely diagnosis.

Altered Mental Status

A. Brain abscess
B. Cerebrovascular occlusion/
transient ischemic episode
C. Dehydration
D. Drug overdose/drug toxicity
E. Hepatic encephalopathy
F. Hypercalcemia
G. Hyperglycemia
H. Hyperkalemia
I. Hypertensive encephalopathy

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Hypoglycemia
Hyponatremia
Hypothyroidism
Multi-infarct dementia
Primary degenerative dementia, Alzheimer type
Seizure
Sepsis
Uremia
Wernicke's encephalopathy

For each patient with altered mental status, select the most likely diagnosis.

Appendix B

169

Anemia
A.
B.
C.
D.
E.
F.
G.
H.

Acute myeloblastic leukemia

Aplastic anemia
Chronic lymphocytic leukemia
Drug-induced immune hemolytic anemia
Falciparum malaria
Folate deficiency
Glucose 6-phosphate dehydrogenase deficiency
Hereditary spherocytosis

I.
J.
K.
L.
M.
N.
O.
P.

Iron deficiency anemia

Malignancy metastatic to bone marrow
Microangiopathic hemolytic anemia
Multiple myeloma
Myelofibrosis
Sickle cell disease
Thalassemia minor
Vitamin B12 (cyanocobalamin) deficiency

For each patient with anemia, select the most likely diagnosis.

Back Pain
A.
B.
C.
D.

Ankylosing spondylitis
Intervertebral disc infection
Multiple myeloma
Myofascial pain

E.
F.
G.
H.

Osteoporosis
Spinal stenosis
Spondylolysis
Tuberculosis of the spine

For each patient with back pain, select the most likely diagnosis.

170

Bizarre Behavior
A.
B.
C.
D.
E.
F.
G.
H.
I.

Acidosis
Acute psychosis
Acute subdural hematoma
Alcohol intoxication
Cocaine ingestion/overdose
Delirium tremens
Depression
Hypoglycemia
Hypoxia

J.
K.
L.
M.
N.
O.
P.
Q.

LSD ingestion
Malingering
Meningitis
Reye's syndrome
Steroid psychosis
Subarachnoid hemorrhage
Temporal lobe seizure
Tricyclic antidepressant overdose

For each patient with bizarre behavior, select the most likely diagnosis.

Breast Lump / Complaint

A.
B.
C.
D.
E.
F.
G.

Breast cyst
Fat necrosis of the breast
Fibroadenoma of the breast
Galactocele
Gynecomastia
Inflammatory carcinoma of the breast
Intraductal papilloma

H.
I.
J.
K.
L.
M.

Lipoma of the breast

Mastodynia
Metastatic carcinoma of the breast
Paget's disease of the breast
Puerperal mastitis
Tietze's syndrome

For each patient with a breast-related problem, select the most likely diagnosis.

Appendix B

171

Chest Pain
A.
B.
C.
D.
E.
F.
G.

Angina pectoris
Compression fracture of the spine
Dissecting aortic aneurysm
Esophageal spasm
Esophagitis
Herpes zoster
Hyperventilation

H.
I.
J.
K.
L.
M.

Myocardial infarction
Pectoral muscle pain
Pericarditis
Pneumonia
Pneumothorax
Pulmonary embolism

For each patient with chest pain, select the most likely diagnosis.

Diarrhea
A.
B.
C.
D.
E.
F.
G.
H.
I.

Amebiasis
Bacterial gastroenteritis
Carcinoid syndrome
Carcinoma of the colon
Chronic pancreatitis
Crohn's disease
Cryptosporidium infection
Diverticulitis
Dumping syndrome

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Gastric lymphoma
Ischemic colitis
Laxative abuse
Pseudomembranous colitis
Short gut syndrome
Sprue
Villous adenoma
Viral gastroenteritis
Zollinger-Ellison syndrome

For each patient with diarrhea, select the most likely diagnosis.

172

Fatigue
A.
B.
C.
D.
E.
F.
G.

Acute leukemia
Anemia: chronic disease
Congestive heart failure
Depression
E-B virus infection
Folate deficiency
Glucose 6-phosphate dehydrogenase deficiency

H.
I.
J.
K.
L.
M.

Hereditary spherocytosis
Hypothyroidism
Iron deficiency
Lyme disease
Miliary tuberculosis
Vitamin B12 deficiency

For each patient with fatigue, select the most likely diagnosis.

Fever/Adults
A.
B.
C.
D.
E.
F.
G.
H.
I.

Appendicitis
Aspirin intoxication
Cellulitis
Crohn's disease
Gastritis
Hodgkin's disease
Infectious mononucleosis
Meningitis
Narcotic overdose

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Pancreatitis
Pneumonia
Prostatitis
Pulmonary embolism
Pyelonephritis
Sinusitis
Tuberculosis
Urinary tract infection
Viral respiratory infection

For each patient with fever, select the most likely diagnosis.

Appendix B

173

Fever in Children
A.
B.
C.
D.
E.
F.
G.
H.
I.

Acute lymphocytic leukemia

Bacterial meningitis
Chickenpox
Drug fever
Gastroenteritis
Juvenile rheumatoid arthritis
Kawasaki disease
Mastoiditis
Measles

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Osteomyelitis
Otitis media
Pneumococcal pneumonia
Pyelonephritis
Rheumatic fever
Roseola
Rubella
Sinusitis
Streptococcal infection

For each patient with fever, select the most likely diagnosis.

Gastrointestinal Bleeding
A.
B.
C.
D.
E.
F.
G.
H.
I.

Amebiasis
Angiodysplasia of the colon
Clostridium difficile colitis
Carcinoma of the colon
Carcinoma of the esophagus
Carcinoma of the stomach
Coagulopathy
Diverticulitis
Epistaxis

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Esophageal varices
Hemorrhoids
Inflammatory bowel disease
Ischemic colitis
Mallory-Weiss tear
Peptic ulcer disease
Reflux esophagitis
Salmonella infection
Shigella infection

For each patient with gastrointestinal bleeding, select the most likely diagnosis.

174

Headache
A.
B.
C.
D.
E.
F.
G.
H.
I.

Aseptic meningitis
Bacterial meningitis
Brain abscess
Brain metastases
Cerebrovascular occlusion
Cluster headache
Drug-induced headache
Dysfunction of temporomandibular joint
Hypertensive crisis

J.
K.
L.
M.
N.
O.
P.
Q.

Migraine
Primary brain tumor
Pseudotumor cerebri
Subacute bacterial endocarditis
Subarachnoid hemorrhage
Temporal arteritis
Tension headache
Trigeminal neuralgia

For each patient with headache, select the most likely diagnosis.

Leg Pain
A.
B.
C.
D.
E.
F.
G.
H.
I.

Acute arterial insufficiency

Buerger's disease
Causalgia
Cellulitis
Chronic arterial insufficiency
Chronic venous stasis
Dermatomyositis
Diabetic neuropathy
Frostbite

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Leriche's syndrome
Lymphedema
Obstruction of the inferior vena cava
Osteomyelitis
Pressure ulcer
Raynaud's disease
Thrombophlebitis
Varicose veins
Venous insufficiency

For each patient with leg pain, select the most likely diagnosis.

Appendix B

175

Limb Weakness
A.
B.
C.
D.
E.
F.
G.
H.
I.

Brachial plexopathy
C1-2 subluxation
C7-T1 subluxation
Encephalopathy
Epidural abscess
Fracture of the cervical spine
Guillain-Barr syndrome
Lead neuropathy
Migraine

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Multiple sclerosis
Myasthenia gravis
Osteoarthritis
Poliomyelitis
Postictal state
Ruptured cervical disc ischemia
Stroke/transient cerebrovascular
Subdural hematoma
Vertebral metastases

For each patient with weakness of a limb, select the most likely diagnosis.

Nausea/Vomiting
A.
B.
C.
D.
E.
F.
G.
H.
I.

Bulimia nervosa
Digoxin toxicity
Gastric outlet obstruction
Gastroenteritis
Gastroparesis
Hepatitis
Inflammatory bowel disease
Intracranial hemorrhage
Labyrinthitis

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Meningitis
Migraine
Myocardial infarction
Pancreatic carcinoma
Pancreatitis
Pregnancy
Sigmoid volvulus
Small bowel obstruction
Vasovagal attack

For each patient with nausea and vomiting, select the most likely diagnosis.

176

Respiratory Problems
A.
B.
C.
D.
E.
F.
G.
H.
I.

Allergic reaction
Aspiration pneumonia
Bronchiectasis
Carcinoma of the lung
Chronic obstructive pulmonary disease
Congestive heart failure
Cystic fibrosis
Drug side effects
Exercise-induced asthma

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Foreign body
Gastroesophageal reflux
Mitral stenosis
Occupational asthma
Pleurisy
Pulmonary embolism
Respiratory syncytial virus
Sarcoidosis
Tuberculosis

For each patient with respiratory symptoms, select the most likely diagnosis.

Shock
A.
B.
C.
D.
E.
F.
G.
H.
I.

Addisonian crisis
Anaphylaxis
Atrial fibrillation
Atrioventricular block
Bleeding peptic ulcer
Carcinoid syndrome
Cardiac tamponade
Cardiomyopathy
Dehydration

J.
K.
L.
M.
N.
O.
P.
Q.

Fracture of the pelvis

Myocardial infarction
Pulmonary embolus
Ruptured abdominal aortic aneurysm
Ruptured abscess of the appendix
Ruptured ectopic pregnancy
Ruptured ovarian cyst
Small bowel obstruction

For each patient with shock, select the most likely diagnosis.

Appendix B

177

Shortness of Breath
A.
B.
C.
D.
E.
F.
G.
H.
I.

Abscess of the lung

Adult respiratory distress syndrome
Anemia
Asthma
Chronic obstructive pulmonary disease
Congestive heart failure
Diaphragmatic rupture
Foreign body
Hyperventilation

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Laryngeal spasm
Mesothelioma
Myasthenia gravis
Pancoast's tumor
Pleural effusion
Pneumothorax
Primary pulmonary hypertension
Pulmonary embolism
Pulmonary fibrosis

For each patient with shortness of breath, select the most likely diagnosis.

Urinary Problems
A.
B.
C.
D.
E.
F.
G.
H.

Acute cystitis
Acute urinary retention
Carcinoma of the bladder
Carcinoma of the prostate
Diabetes insipidus
Diabetes mellitus
Hypercalcemia
Interstitial cystitis

I.
J.
K.
L.
M.
N.
O.

Neurogenic bladder
Psychogenic polydipsia
Prostatic hyperplasia
Prostatitis
Pyelonephritis
Renal cell carcinoma
Urethral stricture

For each patient with a urinary problem, select the most likely diagnosis.

178

Urinary Symptoms
A.
B.
C.
D.
E.
F.
G.
H.
I.

Acute urinary retention

Bladder fistula
Carcinoma of the bladder
Cystitis
Drug effect
Endometriosis
Gonorrhea
March hemoglobinuria
Menstruation

J.
K.
L.
M.
N.
O.
P.
Q.

Myoglobinuria
Nephrolithiasis
Pneumaturia
Prostatism
Renal carcinoma
Stress incontinence
Syphilis
Trauma

For each patient with urinary symptoms, select the most likely diagnosis.

Vaginal Bleeding/Pain
A.
B.
C.
D.
E.
F.
G.
H.
I.

Abruptio placentae
Bacterial vaginitis
Breakthrough bleeding
Candidal vaginitis
Cervical carcinoma
Condyloma acuminatum
Ectopic pregnancy
Endometrial cancer
Foreign body

J.
K.
L.
M.
N.
O.
P.
Q.

Gonococcal cervicitis
Molar pregnancy
Normal menses
Placenta previa
Threatened abortion
Trichomoniasis
Vesicovaginal fistula
Vulvar carcinoma

For each patient with vaginal bleeding or pain, select the most likely diagnosis.

Appendix B

179

Vaginal Discharge/Pruritus
A.
B.
C.
D.
E.
F.
G.
H.

Allergic vaginitis
Atrophic vaginitis
Bacterial vaginitis
Breakthrough bleeding
Candidal vaginitis
Cervical carcinoma
Condyloma acuminatum
Endometrial cancer

I.
J.
K.
L.
M.
N.
O.
P.

Foreign body
Gonococcal cervicitis
Normal menses
Placenta previa
Threatened abortion
Trichomoniasis
Vesicovaginal fistula
Vulvar carcinoma

For each patient with vaginal discharge or pruritus, select the most likely diagnosis.

Wheezing
A.
B.
C.
D.
E.
F.
G.
H.
I.

Angioedema
Asthma
Bronchiectasis
Carcinoid syndrome
Chronic obstructive pulmonary disease
Congestive heart failure
Cystic fibrosis
Endobronchial polyp
Epiglottitis

J.
K.
L.
M.
N.
O.
P.
Q.
R.

Esophageal reflux
Foreign body
Goiter
Laryngeal dyskinesia
Pneumonia
Pulmonary edema
Pulmonary embolism
Respiratory syncytial virus infection
Viral croup

For each patient with wheezing, select the most likely diagnosis.

180