Multiple-choice questions

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Chapter 2 Multiple-choice questions

Every problem has a gift for you in its hands.

Richard Bach

The multiple-choice question (MCQ) section of the written component causes a great deal of anxiety for many candidates. As with most MCQ examinations, it is possible to leave the exam room feeling that you know nothing but actually still have passed.

The MCQ section is therefore very difficult to study for, other than reading the recommended fellowship textbooks and high-impact journals closely, since all pos sible answers in an MCQ ‘should be referenced to at least one (and ideally multiple) texts from the College’s recommended text list’ (ACEM, Training and Examination Handbook, 2008). Aft er you have consolidated your knowledge base, practising critical time management and MCQ technique on a lot of sample questions is the key to improving your performance in the actual exam.

Candidates are oft en told that some MCQs are re-used to assess inter-examination correlation and to enable diff erentiation between candidates performing at various levels. We caution against overreliance on previous questions, because banking on pattern recognition is supremely unreliable.

Although this section of the exam correlates well with overall performance, most people, with the exception of the outstanding candidates, leave the MCQ session feeling dispirited, unsure whether they have correctly answered enough questions to pass. Many will not have encountered any questions similar to or even vaguely resembling those used in their practice sessions. Although you may feel discouraged, it is crucial that this does not impair your performance in the other sections of the written component. As for all components of the exam, we recommend that you do not discuss your answers with other candidates during any rest periods, as this can lead to a false sense of reassurance or, worse, a conviction that you have performed badly when you have not.

Purpose

The MCQ section aims to test a broad range of factual knowledge in the fellowship curriculum. Paradoxically, each question generally targets a narrow area of the syllabus (see Table 2.1). Topics that are difficult to cover in other sections of the exam are often included here.

TABLE 2.1 Typical mix of MCQs

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Format

This section comprises 60 questions to be answered over a period of 90 minutes, giving you approximately one and a half minutes per question. In addition, you have 10 minutes of reading time prior to commence ment. The questions are all type ‘A’ MCQs. This type of question contains a ‘stem’ — an introductory statement or paragraph — followed by a choice of five possible responses labelled (a) to (e).

• Approximately 80% of questions seek a single correct response from five possible responses, with ‘TRUE’ being clearly displayed in the stem. For these questions, there is only one correct ‘best’ answer, although frequently two or more responses may potentially be correct at face value. One of the hardest aspects of the MCQ exam is deciding which single response is more correct than the others, when none of the possibilities are clearly wrong.
• The remaining questions seek the only incorrect answer from five possible responses, with the word ‘FALSE’ being clearly displayed in the stem.

Th ere is no negative marking in the MCQ section, so ensure that you answer every question. Th e pass mark is 55% (or 33 correct answers out of 60). Th is allows for the possibility that candidates may simply guess a percentage of answers correctly.

According to the ACEM Training and Examination Handbook (2008), one-third of the section will cover medicine, one-third will cover surgery/obstetrics and gynaecology, and the final third will cover the remainder of the curriculum, as outlined in Table 2.1 (this matrix is in the latest edition of the ACEM Training and Examination Handbook).

Preparation

Since the MCQ section tests candidates’ theoretical knowledge, general preparation in the form of specific learning based on the fellowship curriculum is essential. The breadth and depth of emergency medi cine theory and practice covered in this component can be extremely daunting. If you are time pressured, you could focus in greater depth on the first two curriculum areas covered by the MCQs (medicine, and surgery/obstetrics and gynaecology).

An equally important aspect of preparation for this section is practice. Th e more sample MCQs you answer, the more likely your chances of success. Practise using type ‘A’ questions, as this will prepare you for the format used in the exam.

You can find practice MCQs in a number of places, including the College website and a number of other websites (see Table 2.2). Alternatively, you can purchase MCQ books that cover specific areas of the curriculum (see Table 2.2), or your DEMT and colleagues should have some ‘old’ questions (either ones that have been written by previous candidates or ones that have been ‘passed down’). However, don’t rely on the exact wording of what people have recalled from past examinations. Very few candidates score 100% and memory is notoriously unreliable for the sort of detail that makes the diff erence between a correct answer and an incorrect answer. Use these questions simply as guides to topics.

TABLE 2.2 Useful sources of MCQs

Websites Books
• Emergency Medicine Multiple Choice Questions (EM.MCQ) at www.applecoresoftware.com
• Surgical Tutor MCQ at www.surgical-tutor.org.uk
• Herlihy A. Get Through Accident and Emergency Medicine: MCQs. Royal Society of Medicine Press Ltd, London, 2006.
• Galvani DW et al. MCQs for the MRCP Part 1: Infectious Disease, Haematology and Chemical Pathology. Baillière Tindall, 1999.
• Johnston DI and Hull D. Essential Paediatric MCQs. Churchill Livingstone, 1995.
• Parks RW and Diamond T. Surgery MCQs and EMQs. Greenwich Medical Media, London, 2005.

Finally, writing your own MCQs to quiz your colleagues and having them do the same for you is one of the best ways of preparing yourself for this type of question. Th e FACEMs setting the exam do this. If you do it as well, you are likely to come up with similar questions, but they have to be based on the best or latest evidence from the College’s recommended text or high-impact journals list.

MCQ creation process

The MCQ Exam Committee creates questions utilising and referencing existing and evolving information. The committee then workshops these questions and reviews them following each exam. Some examples of questions developed utilising this process are shown below.

Sample MCQs

MCQ 1

In the management of croup in children, which one of the following is TRUE?

a. Use of single-dose oral dexamethasone is effective in mild croup.
b. Recommending use of steamed warm air generated in an enclosed bathroom at home has been shown to be effective in alleviating croup symptoms.
c. Recommended corticosteroid in the treatment of croup is either single-dose oral dexamethasone 1 mg/kg or oral prednisolone 0.1 mg/kg.
d. Helium–oxygen mixtures have been shown to be of unequivocal benefit in infants with severe croup.
e. Oral prednisolone has been the most frequently studied corticosteroid in croup.

Correct answer:a.

Source material

• Bjornson CL, Klassen TP, Williamson J et al. A randomized trial of a single dose of oral dexa methasone for mild croup. NEJM 2004; 351:1306–1313. ‘Conclusions: For children with mild croup, dexamethasone is an effective treatment that results in consistent and small but important clinical and economic benefits. Although the long-term effects of this treatment are not known, our data support the use of dexamethasone in most, if not all, children with croup.’
• Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD002870. DOI: 10.1002/14651858.CD002870.pub2. ‘The croup score of children managed in an emergency setting with mild to moderate croup probably does not improve greatly with inhalation of humidi fied air. Further research is needed in primary care settings, using a wider range of more sensitive outcome measures.’
• Geelhoed G. Chapter 6.7 Croup. In Cameron P, Jelinek G, Everitt I, Browne G, Raftos J. Text book of Paediatric Emergency Medicine. 1st edn. Elsevier, Sydney, 2006. ‘The recommended dose of corticosteroids for croup in Australasia is either single dose oral dexamethasone 0.15 mg/kg or oral prednisolone 0.75 mg/kg.’
• Vorwerk C, Coats T. Heliox for croup in children (protocol). Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006822. DOI: 10.1002/14651858. CD006822. ‘It remains un clear whether there is any evidence to support the imple mentation of heliox for croup in clinical practice.’
• Russell K, Wiebe N, Saenz A, Ausejo Segura M, Johnson D, Hartling L, Klassen TP. Gluco corticoids for croup. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD001955. DOI: 10.1002/14651858.CD001955.pub2. ‘Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased in inpatients. Dexamethasone is also effective in mild croup populations.’ (There are few studies using prednisolone.)

MCQ 2

With regard to thrombolysis or aspirin in acute is chaem ic stroke, which one of the following is FALSE?

a. ECASS III suggests lytic therapy is still able to achieve a better neurological outcome when administered six hours after the onset of stroke symptoms.
b. One hundred and eighty minutes after stroke symptom onset remains widely advocated as the therapeutic time window in which a benefit may still be derived with lytic therapy.
c. Oral aspirin confers a benefit if used within 48 hours of the onset of ischaemic stroke.
d. Unfractionated heparin may be beneficial in acute ischaemic stroke due to a cardioembolic source.
e. In ECASS III, treatment benefit from lytic therapy outweighed the risk of symptomatic intracranial haemorrhage attributable to lytic therapy.

Correct answer:a.

Source material

• Hacke W, Kaste M, Bluhmki E et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. NEJM 2008; 359:1317–1329. ‘Conclusions: As compared with placebo, intravenous alteplase administered between three and four and a half hours after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke.’ Risk difference of favourable outcome with alteplase = 7.2%. Risk difference of symptomatic intracranial haemorrhage with alteplase = 2.2%.
• Wardlaw JM, del Zoppo GJ, Yamaguchi T, Berge E. Thrombolysis for acute ischaemic stroke. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD000213. DOI: 10.1002/14651858.CD000213.
• Aplin P. Chapter 7.2 Stroke & TIA. In Textbook of Adult Emergency Medicine. 2nd edn. Elsevier, Sydney, 2004.

On the day

Reading time

You have 10 minutes of reading time before com menc ing the exam during which no writing is allowed. You can maximise your use of this time in a number of different ways. One approach is to use this time as part of the exam time. Start answering the questions in the usual time frame, but since you cannot write anything, you need to remember the answers until you can. Another approach is to spend the time scanning as many of the questions as possible in order to start thinking about the content.

Answering the questions

Remember these important points:

• You have plenty of time to answer all the questions, so there is no need to race through the exam. If you take the time to calmly consider each question, you are less likely to make silly errors.
• Ensure that you answer the question that is asked. If the most correct answer is required, the word ‘TRUE’ will be displayed prominently in the stem. Conversely, if the most incorrect answer is being sought, the word ‘FALSE’ will be displayed prominently in the stem.

Th is section is marked by a computer and candidates input their answers onto a paper answer sheet. For the computer to be able to mark accurately, for each question only one answer circle can contain a mark. For this reason, the answer sheet needs to be filled in using ‘lead’ pencil. Note the instructions on completely filling the circles. Do not use ticks, crosses or other marks. If you make a mistake, ensure that you completely erase any extra marks. Sample answer sheets can be found on the College website (www.acem.org.au).

Th ere are two approaches to completing the answer sheet:

• You can enter the answer as you read each question, the advantages being that you are less likely to enter answers in the incorrect spot and it can save a small amount of time.
• You can write your answers to all the questions on the question sheet first, then transcribe them to the answer sheet, the advantage being that you can check all your answers prior to entering them on the answer sheet. However, the disadvantages to this method are that, unless you are careful, it is possible to run out of time before you complete the answer sheet, and if you accidentally miss transcribing an answer, you can put all your answers on the wrong line. To avoid this, keep a constant check that question and answer numbers match.

Whichever approach you take, it is worthwhile putting your answers on the question sheet, as this can assist with your later checking.

If your answer sheet is damaged or you consider that it will not be able to be interpreted by the com puter, you can ask for a replacement — in which case, it is very useful to have written your answers on the question sheet!

Your confidence and therefore thought processes may be improved by answering those questions that you are sure of first and going back to the more difficult questions on your second and subsequent run through the paper. Improve your chances of answering correctly by excluding any obviously incorrect answers first. Finally, be cautious in changing answers once you have committed to a response, as it is commonly believed that initial judgements are more likely to be correct — your practice questions should help determine whether this is true for you.

Key points

• Write your own MCQs and share them with your study group.
• Decide on your MCQ answering strategy ahead of time, practise it and stick to it in the exam.
• Aim to answer all questions, since there is no negative marking.
• Remember the correct answer is the most correct answer. Be aware that other options may be correct, but not as emphatically!
• Maintain your focus and positive attitude during the exam. It may seem an impossible task, but your accumulated knowledge will shine through.

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