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Open Access Highly Accessed Research article

The impact of two multiple-choice question formats on the problem-solving strategies used by novices and experts

Sylvain P Coderre1*, Peter Harasym2, Henry Mandin3 and Gordon Fick2

Author Affiliations

1 Department of Medicine, University of Calgary, Health Sciences Centre, 3330 Hospital Drive NW, T2N 4N1. Calgary, Alberta, Canada

2 Department of Community Health Sciences, University of Calgary, 2500 University Drive NW, T2N 1N4. Calgary, Alberta, Canada

3 Division of Nephrology, Foothills Hospital. 1403 29th St. NW, T2N 2T9. Calgary, Alberta, Canada

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BMC Medical Education 2004, 4:23  doi:10.1186/1472-6920-4-23

Published: 5 November 2004



Pencil-and-paper examination formats, and specifically the standard, five-option multiple-choice question, have often been questioned as a means for assessing higher-order clinical reasoning or problem solving. This study firstly investigated whether two paper formats with differing number of alternatives (standard five-option and extended-matching questions) can test problem-solving abilities. Secondly, the impact of the alternatives number on psychometrics and problem-solving strategies was examined.


Think-aloud protocols were collected to determine the problem-solving strategy used by experts and non-experts in answering Gastroenterology questions, across the two pencil-and-paper formats.


The two formats demonstrated equal ability in testing problem-solving abilities, while the number of alternatives did not significantly impact psychometrics or problem-solving strategies utilized.


These results support the notion that well-constructed multiple-choice questions can in fact test higher order clinical reasoning. Furthermore, it can be concluded that in testing clinical reasoning, the question stem, or content, remains more important than the number of alternatives.