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J Thorac Cardiovasc Surg 2001;122:637
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

A few words about multiple choice tests: An open letter to the American Board of Thoracic Surgery

Francis Robicsek, MD, PhD

Department of Thoracic and Cardiovascular Surgery, Carolinas Medical Center,
Charlotte, NC 28232

To the Editor:

I hate multiple choice tests more than I hate cheap Scotch.—Stephen Madden

Everybody's taking multiple choice tests. We use them to prove our professional readiness, to attest our education, to flaunt our intellectual prowess, whatever.

Why do we use multiple choice tests? Some malicious contenders may state that they are used because some of our examinees might be able to make a checkmark but are unable to give an intelligent answer in their own words. Probably there is some truth to that. On the other hand, multiple choice tests do allow us to provide a uniform and unbiased grading, as well as anonymity. They also let us rely on a computerized evaluation to establish a uniform passing-failing rate. Multiple choice tests are simple and easy to handle, and they do reflect knowledge or lack of the same.

So what is the problem? The truth is that multiple choice questions as they are administered at our specialty board examinations are basically unfair. More often than not, multiple questions presented to our applicants are either "too close" or "too far." If they are too close, they are unfair because for a reasonable examinee more than one of the answers could be either valid or "very close to being valid."

For example: What is the first step to be taken to treat an acute occlusion of the femoral artery?

  1. Perform an angiogram
  2. Perform Doppler studies
  3. Take the patient to the operating room and explore the femoral artery without further ado
  4. All of the above

If we designate one of the above as the proper answer, the person examined is put in a highly unfair position because all the answers may be reasonably chosen as the right one.

On the other hand, if the answers are too far, then the examination is greatly slanted toward the examinee.

For example: What is the first step to treat acute occlusion of the femoral artery?

  1. Perform an arteriogram
  2. Determine the patient's blood cholesterol level
  3. Do a computed tomographic scan
  4. Do a nuclear magnetic resonance scan

Only a moron would not choose answer "a."

The examination using multiple choice questions may also be unfair because of the so-called "know too much" factor. This problem has become especially prevalent now that experienced physicians require recertification. It may easily happen that the examinee knows as much on the subject as the examiner who assembled the multiple choice questions and simply has a personally biased but still valid disagreement.

For example: The appropriate way to treat chronic femoral artery occlusion is:

  1. To bypass it with a reversed saphenous vein graft
  2. To apply an in situ vein graft
  3. To use a polytetrafluoroethylene graft
  4. To treat the patient conservatively if he can walk more than a block without pain

A less experienced physician may easily come up with a "right" answer; an old clinical hand may have difficulty because he or she may view several of the above answers as acceptable depending on personal experience and preference. It may also be that without additional information (eg, anatomic details), the examinee cannot give an answer that he or she believes to be right and must adopt the state of mind of a novice to figure out the proper response and survive the examination.

Evidently the multiple choice question system as applied today is less than ideal. It would be advisable, while maintaining its simplicity and other of its advantages, for us to adapt it to more realistic expectations. One way we could improve the system is to not label the answers simply "right" or "wrong" but rather to adopt a point system. If the examinee gives the answer that the examiner judges to be the most proper one, the examinee should receive, let's say, 100 points. If the answer to the question is not the "best" (so thought by the examiner) but a "second best but still acceptable," the examinee should receive 50 points. If the answer is improper but still within reason, the examinee should get no points. And if the answer is "way out wrong," the examinee should receive punitive points, such as –100 to –500. To pass the examination, the examinee must accumulate (depending on the number of questions) a specific number of points.

Example: A 52-year-old former smoker otherwise in good health presents himself with a 2 x 2 cm coin lesion in the left upper lung field, which was not present a year before. What is your line of action?

  1. Do an appropriate workup and if there is no evidence of any active process anywhere else, do a wedge resection. If during surgery the lesion turns out to be malignant, perform a lobectomy.—For this answer, the examinee would receive 100 points.
  2. The same answer, but remove the lesion by wedge resection "in the clean" and do not do a more extensive resection.—For this answer, the examinee would receive 50 points.
  3. Discharge the patient home without surgery, reexamine him 6 months later, and proceed with additional intervention only if the lesion further increases in size.—For this answer the examinee would get no points.
  4. Reassure the patient that the lesion is nonmalignant because it does not contain calcium and take no further action.—For this answer the examinee would be assessed –100 points.

The system described above would not only maintain all the advantages of the presently applied multiple choice system but also would eliminate most if not all of its unfair aspects. It could be further sensitized by assigning a various number of punitive points to different degrees of wrong answers.

Why don't we give it a try?

12/8/118042

doi:10.1067/mtc.2001.118042





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