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Last Reviewed
July 25, 2025
First Published:
January 31, 2023
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Multiple choice questions (MCQs) are among the most widely used formats in health sciences education due to their efficiency in assessing broad content areas, ease of scoring, and suitability for computer-based testing. When well-constructed, MCQs can assess not only factual recall, but also application, analysis, and clinical reasoning. However, poorly written items can mislead students, encourage cueing, or test irrelevant knowledge. Research in medical education consistently emphasizes that MCQs should align with learning objectives, reflect cognitive complexity, and avoid flaws that compromise validity or reliability. Developing high-quality MCQs requires attention to both content and structure, as well as strategies to reduce bias and ensure fairness across diverse learners.
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Use the comments section below to let us know your ideas about writing multiple-choice questions.
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- Improves Student Performance and Assessment Quality: MCQs that follow established item-writing guidelines lead to more accurate measurement of student knowledge and stronger overall performance. Research shows that students tend to perform better on exams when the questions are written using recommended best practices, while poorly written items can negatively affect scores and obscure what students know.
- Pate, A., & Caldwell, D. J. (2014). Effects of multiple-choice item-writing guideline utilization on item and student performance. Currents in Pharmacy Teaching and Learning, 6(1), 130–134. https://doi.org/10.1016/j.cptl.2013.09.003
- Promotes Clinical Reasoning and Decision-Making: Well-designed MCQs can go beyond rote memorization by prompting students to apply principles, interpret clinical data, or analyze patient scenarios.
- Tarrant, M., Ware, J., & Mohammed, A. M. (2009). An assessment of functioning and non-functioning distractors in multiple-choice questions: a descriptive analysis. BMC Med Educ, 9, 40. https://doi.org/10.1186/1472-6920-9-40
- Improves Validity and Reliability of Assessment: MCQs with clear stems, plausible distractors, and alignment to learning goals are more likely to accurately assess student competence and reduce construct-irrelevant variance.
- Haladyna, T. M., Downing, S. M., & Rodriguez, M. C. (2002). A review of multiple‐choice item‐writing guidelines for classroom assessment. Applied Measurement in Education, 15(3), 309–333. https://doi.org/10.1207/S15324818AME1503_5
- Align Questions with Learning Outcomes. Use Bloom’s Taxonomy or discipline-specific competencies to target desired cognitive or behavioral levels. Avoid questions that test only trivial facts unless foundational knowledge is the goal.
- Write Clear, Focused Questions (Stems). Ensure the stem presents a single, clearly defined problem. Avoid teaching or explaining unnecessary background information or ambiguous phrasing that could confuse rather than challenge.
- Use Plausible Answer Choices. All should be similar in length, detail, and complexity. Distractors should be common misconceptions, errors in clinical reasoning, or clinically relevant alternatives. Avoid “all of the above” or “none of the above” unless pedagogically justified.
- Avoid Item-Writing Flaws. Minimize cues through grammatical inconsistencies or patterned answers. Eliminate negatives unless necessary (and highlight them when used). Avoid using “always”, “never”, “sometimes”, and “occasionally”.
- Pilot Test and Analyze Items. Use item analysis (e.g., difficulty index, discrimination index) when possible, to evaluate question performance and make iterative improvements based on real student responses.
- Include Clinical Context When Appropriate. Use brief clinical vignettes to simulate decision-making, which promotes transfer of learning and diagnostic reasoning.
- Design for All Learners. Avoid idioms, cultural references, or language complexity that could affect answers beyond knowledge, skill, or understanding. Consider using universal design principles in your assessment strategy.
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