Writing five-star multiple choice questions (MCQ) for your medical courses

In this lesson, we will provide you with some tips and tricks for how to create five-star multiple choice questions that can be used for both retrieval practise and assessment.

Franz Wiesbauer, MD MPH
Franz Wiesbauer, MD MPH
9th Jun 2021 • 5m read

Multiple choice questions have a bad reputation as being the lazy form of testing, but research shows that if you write them properly, they can enhance learning for related information that was not actually included in the question. In this lesson, we will provide you with some tips and tricks for how to create five-star multiple choice questions that can be used for both retrieval practise and assessment.

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Video transcript

Multiple choice questions can be a convenient means of testing, whether for retrieval practice or assessment, especially in an online course. But multiple choice questions also have a bad reputation as being the lazy form of testing. And both teachers and students often view multiple choice questions as being less challenging than other types of questions.

However, research shows that multiple choice questions are just as effective as other types of questions, and that they can enhance learning for related information that was not actually included in the question. But, this is only if you write good questions. In this lesson, I will provide you with some tips and tricks for how to create five star multiple choice questions, that can be used for both retrieval practice and for assessment.

The key to writing any good question, multiple choice or otherwise, is to challenge the learner and make them retrieve the information you want them to learn. My number one tip for creating five star multiple choice questions is to ensure that you create competitive answer options. One common criticism of multiple choice questions is that because the answer options are provided, it is easier to narrow down or even guess the correct answer, without really learning the information.

With a poorly written question, this is certainly possible. Take this example. Where is the mitral valve located? Between the liver and gallbladder. Between the brain and spinal cord. Between the left atrium and left ventricle. Or, between the stomach and small intestine. These answer options are so far removed from each other, that the student only needs minimal knowledge, in this case, knowing that the mitral valve is in the heart in order to narrow down the answer.

So in order to force the student to retrieve the information we're looking for, namely the location of the mitral valve within the heart, we need to create competitive or plausible alternative answer options. A good way to choose the incorrect answers is to think about the common mistakes that students make, then make your other answer options reflect those common wrong answers.

If the student were to mix up one term with another, what answer might they give? If they forgot to perform a key step in a calculation? What would their answer be? Those should be your answer options. Let's revisit our mitral valve question. What are the most logical mistakes a student might make when answering this question?

In my mind, it's most likely that they would mistake the mitral valve for one of the other heart valves. So to me, the most logical alternative answer options would represent the locations of the other heart valves. You may be thinking that even in this case, if the student knows the locations of the other valves, then they could still narrow down the answer without actually knowing the location of the mitral valve, which is certainly true.

But in that scenario, at least you have forced the learner to recall the names and positions of the tricuspid, pulmonary and aortic valves in order to answer this question, which is likely just as valuable as retrieving information about the mitral valve itself. In fact, this is how multiple choice questions with competitive answer options are thought to enhance learning for related information that was not specifically part of the question. Another aspect of writing competitive answer options that teachers often overlook is homogeneity.

That is, ensuring that all answer options are similar in length and complexity. If one answer is much longer or shorter, or more complex than another, it could stand out, making it more obviously right or wrong. Take this example from Medmastery's dialysis essentials course. A haemodialysis alarm is ringing in your unit, the machine states that it is an electrical conductivity problem. What does this mean?

A. The carbon tank has failed. B. The proportioning system that dilutes the concentrate with water has malfunctioned creating either excessively dilute or concentrated dialysis solution. C. The venous air trap has failed. Or, D. The deaerator unit has failed. As you can see, answer B is much longer and contains much more detail than the other answer options, suggesting it could be the right answer, and it is.

To fix this problem, we added additional detail to the other answer options. But we could also have achieved the same effect by shortening the correct answer. We tend to think of multiple choice questions as being good for testing basic facts, but they can also be structured to require the learner to integrate several pieces of information, or understanding of mental models to arrive at the answer.

In medicine, this is commonly achieved using case based questions. By presenting a case, the student has to apply their learning to the specific scenario to come up with an appropriate answer. These are highly effective types of questions. But higher order questions don't always have to be cases. Take this example. How many DNA molecules would you expect to find in a diploid human cell during prophase of mitosis?

A. One. B. 23. C. 46. D. 92. Or E. Too many to count. This question requires the learner to know that a diploid human cell contains 46 chromosomes, and that in prophase of mitosis, the number of chromosomes is doubled, so there are 92 chromosomes at this stage. They also need to know that every chromosome is made up of one single DNA molecule. So, 92 chromosomes represents 92 molecules of DNA. If they integrate all of this information, they will come up with the correct answer, which is 92.

Well, we could have tested each of these pieces of basic knowledge using individual questions. By combining them into one, we required the learner to not only retrieve the individual facts, but to consider how they all fit together, which enhances learning and transfer of knowledge to different contexts.

To add additional challenge to your multiple choice questions, consider adding more than one correct answer. This is most challenging if the student doesn't know how many of the answer options will be correct. If any, or all possibilities could be correct, the learner can no longer discount any answer just because they know another to be true.

Instead, they will need to work through all of the answer options individually, determining whether each one is correct or incorrect. This takes more time, but is also generally more challenging and requires retrieval of more information, than a simple one correct answer question. Multiple choice questions are often the most efficient means of testing in an online environment. Taking the time to write five star questions will ensure that your students get the most out of this form of retrieval practice.