MCQ Writing
How to write flaw-free multiple-choice questions — common item-writing flaws, distractor counts, stem wording, and evidence-based MCQ rules.
Multiple-choice questions carry most of the assessment load in medical education, yet the evidence shows that a large share of locally written items are flawed. Tarrant, Knierim, Hayes and Ware (2006) found that roughly 46% of items on nursing examinations contained at least one item-writing flaw, and similar problems appear wherever faculty write questions without formal training. Flawed items matter because they change what a test measures: cues such as the longest option or grammatical mismatches let testwise students guess correctly, while negatively worded or convoluted stems penalize students who know the content. Both effects add noise to scores and can shift pass-fail decisions for borderline examinees, a point Downing (2005) documented in medical school examinations.
The good news is that item-writing quality is teachable. A small set of evidence-based rules — synthesized by Haladyna, Downing and Rodriguez (2002) and codified in Case and Swanson's NBME item-writing guide — eliminates most common flaws. This topic covers those rules: the flaws to look for, how many options an item really needs, why negative stems cause trouble, and simple quality checks like the cover-the-options test.
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