Mistakes That Question Writers Make That You Should Capitalize On
First, what is the anatomy of a multiple-choice question?
Stem - this is the clinical vignette
For example: A 34-year-old man presents to the ED with complaints of fatigue. The patient states that over the previous week he was camping at a near-by National Park. On exam you note motor weakness in his lower extremities.
Lead-in - this is the question
For example: Which of the following conditions is associated with ascending weakness?
Options - your answer choices
- A. Botulism
- B. Ciguatera poisoning
- C. Miller-Fisher Variant Guillian Barre Syndrome
- D. Tick paralysis
Well-written questions have one answer choice that is correct, but it is surrounded by distractors. Think about the answer choices on a continuum that looks something like this:
Are there tricks to help tip you off to which of the answer choices are incorrect?
Or even better, which of the answer choices is most likely the correct one...without even reading the question.
While preparing for the board exam, you should utilize these simple techniques to guarantee the best chance of passing the exam.
Grammatical cues - one or more answer choices (distractors) don’t follow grammatically from the stem
Q: A 60-year-old man is brought to the ED by the police who found him lying unconscious on the sidewalk. On exam, he is breathing spontaneously and has clear, bilateral breath sounds. He is diaphoretic. The first step in management should be intravenous administration of?
- A. Examination of CSF
- B. Glucose with thiamine
- C. CT scan of the head
- D. Phenytoin
- E. Diazepam
Question writers tend to pay more attention to the correct answer than to the distractors, grammatical errors are more likely to occur in the distractors. In the example above, It is clear that answer choices A and C can be ruled out because they do not grammatically fit with the question stem.
Logical cues - a subset of the options are collectively exhaustive
Q: Which of the following is true regarding febrile seizures?
- A. Most occur between the ages of 3 months and 5 years
- B. Most occur in infants younger than 6-months-old
- C. Most occur in children older than 5-years-old
- D. Administration of acetaminophen reduces the likelihood of an occurrence
- E. There is an 5-fold increase in the risk of developing epilepsy
Options A, B, and C include all possibilities. Therefore, one of these options has to be the correct answer. Choices D and E, therefore, can be eliminated.
Absolute terms - such as “always”, “never”, or “all”
Q: An 88-year-old man is found lying on the floor of his apartment. He states that he fell 3 days ago and was not able to stand up. Lab results reveal a CPK of 15,000. Which of the following is true regarding his condition?
- A. Hypocalcemia frequently develops
- B. Mannitol should always be administered to maintain urine output
- C. Renal failure always occurs unless hydration is immediately started
- D. Hypokalemia frequently develops
Options A and D contain terms that are less absolute (frequently) than options B and C (always). Therefore, options B and C can be eliminated because they are less likely to be true than something stated less absolutely (choices A and D).
Longer option is the correct answer - often the answer choice that is longest, more specific, or more complete than the other options is the correct choice
Q: Which of the following is correct regarding aortic dissection?
- A. A normal blood pressure rules it out
- B. Asymmetric pulses in the radial arteries will occur if the subclavian artery is involved
- C. The most common symptom is dyspnea
- D. Type A dissections should be medically managed
Option B is longer and more specific than the other answer choices. Question writers tend to pay greater attention to the correct answer rather than the distractors and write longer correct answers that are more in-depth.
Word repeats - a word or phrase is included in the stem and in the correct answer
Q: A 49-year-old man with a history of schizophrenia and bipolar disorder presents to the ED confused and agitated. He states that he is hearing voices and that the world he is living in is not real. Which of the following best describes his condition?
- A. Derealization
- B. Depersonalization
- C. Dissociative amnesia
- D. Somatoform disorder
The question contains the word “not real” and the correct answer is option A, derealization.
Opposites - two answer choices that are opposites of each other, one of them is usually the correct answer
Q: A 45-year-old man presents to the ED after a syncopal event. On exam, you note a loud crecendo-decrecendo systolic murmur at the left lower sternal boarder. Which of the following maneuvers will accentuate the murmur?
- A. Leg elevation
- B. Squatting
- C. Standing
- D. Trendelenburg
Options B and C are opposites and the correct answer is likely one of them...in this case option C is correct
Similar answer choices - when two choices are very similar in detail it is likely that one of them is correct. Question writers rarely create two similar distractors.
Q: A 42-year-old woman with HIV presents with dyspnea, cough, and fever. Her CD4 count is unknown. You note oral thrush on exam. The chest x-ray reveals bilateral hilar infiltrates. Her pulse ox reads 98% on room air. Which of the following best describes the next step in management?
- A. Start her on antibiotics for community acquired pneumonia and discharge home
- B. Order a STAT echocardiogram to determine her ejection fraction
- C. Place the patient in isolation, send off basic labs, and initiate treatment with trimethoprim-sulfamethoxazole
- D. Place the patient in isolation, send off basic labs, and initiate treatment with ceftriaxone and azithromycin
Options C and D are similar in detail and only differ by which antibiotic is recommended. One of these similar options is likely to be the correct answer...in this case option C is correct.
- Focus on the STEM of the question - think of the correct answer before looking at the possible options
- Every piece of information is important either by its INCLUSION or EXCLUSION - age, gender, race, nationality, occupation, activity
- The are no “red herrings” and nothing is meant to trick you
- There is no pattern to correct answers. Do not change your choice because it is the fourth “option A” in a row.
- Expect classic presentations
- elderly men with hypotension and abdominal pain that radiates to the back has a AAA
- young women with lower abdominal pain and hypotension have an ectopic pregnancy
- patients with pleuritic chest pain after a long airplane flight have a pulmonary embolism
- overweight adolescents with hip pain have slipped capital femoral epiphysis (SCFE)
- Identify key historical information
- patients who partake in home canning have botulism
- patients using rust remover have hydrofluoric acid burns
- newborns born at home have vitamin K deficiency
- young marathon runners with feculent vomiting have a cecal volvulus
- Recognize confirmatory physical findings
- shooting pain when tapping the volar wrist = Tinel sign = median neuropathy or carpel tunnel syndrome
- spasm of the hand and forearm upon application of an inflated blood pressure cuff = Trousseau sign = hypocalcemia
- crunching sound heard when listening to the heart = Hamman’s crunch = mediastinal emphysema/pneumomediastinum
- When in doubt about management options, always fall back on the fundamentals: Airway, Breathing, Circulation.
- Consider the life-threatening conditions before choosing the more benign conditions
- think myocardial infarction before GERD in the patient with epigastric burning
- think spinal epidural abscess rather than musculoskeletal strain in the IV drug user with back pain
- Abnormal vital signs are abnormal for a reason...pay attention to them
- Answers with percentages...mid-range is usually the correct choice
- Always choose the “gold-standard” answer, not the answer with information published in last month’s journal as cutting-edge
- The correct answer will be the “National” standard of care, not what your institutional surgical service wants
- There are no cowboys...practice the standard of care (atrial fibrillation with rapid ventricular response still gets rate control and not rhythm control...unless unstable)
- Any answer option that has the potential to harm the patient is incorrect
- No consultant is lying or withholding information
- Any unethical or abusive physician behavior is incorrect
- Avoid paralysis by analysis...don’t over think, go with your educated instinct
And Check with the Source...
When preparing for any exam, you need to know the specifics of the exam. Exam specifications, procedures, times, and additional testing tips are usually always provided online by the board, academy, or specialty society issuing a respective exam. A quick web search of the organization issuing the exam or certification will likely provide you the specific preparation tips you need.