USMLE, Pediatrics, Internal Medicine boards - How are the questions created?

Most medical board examinations in the United States are in the form of multiple-choice questions (MCQs). In order to answer these questions well and get high scores, it is important that residency and fellowship program physicians understand how a multiple-choice question is created. This article will take you through this process and suggest strategies to answer them correctly. The features highlighted here are similar to the general guidelines given by various boards (USMLE, NBME, ECFMG, ABIM Internal medicine boards, ABP Pediatric boards etc.) to question writers and medical residency programs. If you understand the following information, you will be able to recognize what the board question is testing you about and answer appropriately.   

USMLE, Pediatrics, Internal medicine board questions consist of three main parts… 

• The Stem – this is the long story about the patient’s medical condition. This usually contains information on the patient’s age, sex and his present location.

• The Lead line- the actual question itself. This is usually the last line of the long medical question.

• The choices – this is a list of options given as possible answers to the test question. 

USMLE, Internal medicine boards - Different types of MCQs tested.  

• Recall questions – these USMLE questions require you to recall some simple medical facts.

• Synthesis questions – these require you to interpret medical facts, lab values and solve simple problems. You have to “connect the dots”, making use of the clues given in the USMLE question.

• Clinical decision-making questions – these are usually tested by USMLE, Internal medicine, Family practice, Pediatrics & other boards. These questions require advanced clinical skills. They test a combination of medical knowledge, synthesis of information, interpretation of medical facts and making clinical decisions (Judgment) on the best course of appropriate medical action.  

The “two step” question: In these types of questions, the stem gives a medical story and the lead line (question) is not “what is the medical diagnosis”. Instead, the question is “what is the next appropriate action to take”. Here you first have to make a medical diagnosis (for your own benefit), and then make a clinical decision on the next best course of action (for answering the question). 

Patient-encounter locations for USMLE, Internal medicine boards. 

Most multiple-choice questions are written to represent a clinical scenario that you are likely to encounter in real life. They describe a patient with several medical problems who presents to you for diagnosis and medical management. Most USMLE / Medical board questions are written to represent three common medical situations or patient encounter locations.  

• Emergency Room (ER)

• Hospital (Inpatient setting)

• Clinic or medical Office (Out patient setting)  

Once this clinical scenario is set, and the long medical story is given, you will be asked a question (lead line) at the very end. There will be 4 or 5 choices given as possible answers and you will be asked to select one correct answer. You will then be required to enter the correct answer on the computer screen (answer sheet for paper based exams). USMLE Step 1, Step 2, and Step 3 are given as computer based tests. The American Board of Internal Medicine (ABIM) is currently giving only paper and pencil-based exams. ABIM plans to switch to computerized exams over the next 3 years. Most other medical boards are looking into computerized test administration. 

Multiple choice questions are written is such a way that, most USMLE examinees and physicians from residency and fellowship programs can easily eliminate 2 or 3 choices right away. Once the choices are narrowed down to 2 or 3, only a well-read physician will be able to select the correct answer.