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How to write exam questions for written examinations

General points

When writing questions always think about:

  • Clarity: “Nothing in the content or structure of a test item should prevent an informed student from responding correctly” (Gronlund,1998)
  • Reliability: “Does the question test what I want it to?”
  • Validity: “Does the question test the learning outcome?”
  • Authenticity: “Is the question realistic?”
  • Fairness: “Is the question relevant, important and with no ambiguity?” “Am I asking the right question to the right candidates?”

Question writing Do's:

  • Try to match the question setting to real practice (authenticity)
  • Try to assess the application of knowledge and not simply recall of facts
  • Clear instructions are essential

Question writing Don'ts:

  • Don't assess knowledge of trivial facts
  • Avoid ambiguity & confusing terminology
  • Avoid overly complicated vocabulary
  • Avoid unnecessary and distracting detail
  • Avoid providing the answer in the question
  • Avoid leading questions

Single Best Answers

The stem

The stem should be a brief (40-50 words) summary of a problem or clinical scenario, which is realistic to clinical practice and written in such a way that the answer is not too obvious.

  • Clinical scenario / vignette
  • Realistic problem (something you have encountered)
  • Approximately 40-50 words
  • Present tense
  • Don't give the correct answer away
  • Should be possible to formulate the correct answer without looking at options

The lead in

The lead in should provide clear instructions, avoiding negative or confusing phrasing.

  • Clear question / instructions
  • Avoid negative or confusing phrasing
  • Avoid “always” / “never” / “rarely”

The distractors

These are the answer options and should be plausible so as to provide a challenge and test candidate's knowledge, whilst still being incorrect.

  • 5 answers
  • Should all be plausible
  • Only 1 correct answer
  • Should be homogeneous e.g. all drugs, all conditions
  • Should be of roughly equal length (the longest is usually the correct one)
  • Should be alphabetised

Clinical Scenario Papers (CSP)

  • A case study / vignette is required with all relevant clinical details, photographs, radiographs (high quality only)
  • No question should be dependent on getting another correct
  • Answers should not be cued by subsequent questions
  • Make it clear how many points you want or what length of answer is expected, e.g. name the 3 most likely diagnoses.
  • Clear instruction - "list" or "explain"
  • Aim for around 120-150 marks in total