Writing the Ideal Multiple-Choice Question (and 3 Common Mistakes Test Writers Make)

October 6, 2023
Have you ever wondered how the writers of standardized exams come up with test questions? What makes a good test question? 
Writing effective test questions is at the heart of our work at Rosh Review by Blueprint Test Prep. We hold ourselves to a high standard when it comes to creating high-yield content, ensuring that every question in a Qbank effectively prepares our learners for their exams.
Though a question may take less than a minute to answer, our team dedicates dozens of hours to writing, editing, and reviewing the content before it ever reaches our learners. In this post, we’ll break down the ideal way to write a multiple-choice question (MCQ) with a focus on clarity, validity, and reliability that you can apply within your own program.

Understanding the Principles of Writing Effective MCQs

MCQs are a ubiquitous assessment tool used in education, from elementary school to professional licensure exams. They serve as a valuable means of evaluating a person’s knowledge, critical thinking, and problem-solving abilities. Crafting well-structured MCQs that effectively measure a student’s knowledge and understanding of a subject is a skill that requires careful consideration and adherence to best practices.

At Rosh Review, we are constantly improving our Qbanks, both in refreshing content and enhancing our processes. Here are a few of our main takeaways that may help you when writing questions for your own medical education program.

1. Start with Clear Goals and Learning Objectives

Valid MCQs are those that accurately assess the intended learning outcomes. To achieve this, alignment with the curriculum and clear objectives is essential. Before beginning to craft MCQs, educators must define what they want to measure and select content that reflects those objectives. 

The first step in writing an effective MCQ is to clearly define the learning objective. This learning objective should reflect the knowledge, skills, and competencies that the question is meant to assess. Understanding the purpose of the question is essential in ensuring alignment between the question and the desired learning outcomes.

2. Write a Focused Stem

The stem is the main part of the MCQ that presents the problem or question to the test taker. In medical test taking, a clinical vignette is now considered as standard for the question stem. It should be clear, concise, and focused on a single concept or issue. Stems should avoid vague or ambiguous language and should not introduce new information. Test takers should be able to understand the essence of the question from the stem alone.

3. Construct Plausible Distractor Response Options

It is crucial to have well-constructed response options (distractors) that are plausible and relevant to the stem. Distractors should be free from grammatical errors and should not be overly obvious or misleading. They should also be similar in length and format to the correct answer to ensure that the question tests the intended knowledge rather than test-taking skills.

4. Avoid Clues and Triggers

One common pitfall in MCQ writing is the unintentional inclusion of clues or triggers that give away the correct answer or a wrong answer choice as wrong.  Questions should be carefully reviewed to eliminate any hints that may inadvertently guide test takers to the right choice. These hints may include grammar inconsistencies, repetition of words from the stem, or repeated words in the answer choices that alert the test taker to the likely right answer.

5. Use One-Best-Answer Question Format

One best answer questions are preferred by many medical exams because they assess a candidate’s ability to make precise clinical judgments, mirroring real-world medical scenarios where selecting the most appropriate course of action is crucial. This format also aligns with standardized testing principles, ensuring consistent and reliable evaluation across diverse candidates. Moreover, one-best-answer questions reduce the potential for guessing and encourage deeper understanding, as there is only one completely correct choice. The focus on critical thinking and clinical reasoning makes one best answer questions an effective tool in assessing a candidate’s medical knowledge and decision-making skills.

6. Maintain Consistency in Terminology and Format

Consistency in the use of terminology, formatting, and structure is crucial to creating fair and unbiased MCQs. Test takers should not be required to decipher different styles or formats within the same assessment. Writers should adhere to consistent language and structure throughout the test.

7. Pilot Testing and Revision

Before using MCQs in high-stakes assessments, it is essential to pilot test them on a diverse group of individuals. Pilot testing helps identify potential flaws, ambiguities, or biases in the questions. Based on the feedback and statistical analysis, revisions should be made to improve the clarity and quality of the questions.

Putting It All Together

The art of crafting effective multiple-choice questions is a skill that requires practice and adherence to established guidelines. By following the principles above, educators, test developers, and professionals can construct questions that accurately assess knowledge, promote critical thinking, and maintain fairness and validity in assessments. In doing so, they contribute to the enhancement of educational and evaluative practices in various fields.

3 Common Mistakes Test Writers Make
1. Validity and Content Coverage

When writing a medical test question, clinical scenarios should be used to promote content validity. These scenarios mirror real-world situations and require students to apply their knowledge to solve problems, mimicking the demands of their future careers. When constructing MCQs, ensure that the stem and answer choices are clinically relevant and directly related to the content being assessed.

To assess higher-order thinking skills, consider incorporating questions that require analysis, synthesis, or application of knowledge rather than mere recall. These questions challenge students to think critically and demonstrate a deeper understanding of the material.

2. Reliability and Avoiding Bias

Reliability is a crucial aspect of assessment. Reliable MCQs yield consistent results when administered repeatedly to the same group of students.

One essential recommendation is to avoid using negatively-worded questions, as they can lead to confusion and misinterpretation. Instead, formulate questions in a positive and straightforward manner.

Another potential source of bias is the use of “all of the above” or “none of the above” options. While these can be useful in some cases, they should be used sparingly and judiciously, as they may introduce ambiguity and reduce the clarity of the question.

3. Clarity of Learning Dimension Being Tested

Moreover, a well-written MCQ will have distractors that are homogeneous, meaning they all answer the question in the same manner and can be ordered along a single dimension in terms of being more right (less wrong) or less right (more wrong). When options can be listed on multiple dimensions and deal with miscellaneous facts, they are considered heterogeneous, which can introduce vagueness and unnecessary difficulty to the question. 

To determine the most correct answer, the test taker must decide whether option A is more or less true than option 1. Although an MCQ written this way appears to assess knowledge in several different points, its inherent flaws negate this, resulting in suboptimal testing of all points of knowledge.

We at Blueprint / Rosh Review always use an exam’s specific content blueprint to craft our Qbanks. Not only are our questions written in the same format as the questions on the actual exam, but we also follow best practices for MCQ writing as outlined above.

This means that we don’t use any negatively phrased questions, or “all of the following except,” or “A and B” answer choices. We don’t use the “which of the following is true” format in our Qbanks. Most importantly, all questions include selective distractors (incorrect answer choices), which will help test takers think critically.


Crafting effective multiple-choice questions that adhere to the above principles is a fundamental skill for educators and test developers. By prioritizing clarity, validity, and reliability, educators can create assessments that accurately measure students’ knowledge and understanding of the subject matter.

Clear and concise questions, aligned with curriculum objectives, and free from bias, will enhance the educational experience and contribute to the development of knowledgeable and competent learners. In following these principles, educators can ensure that MCQs serve as valuable tools for assessing student progress and promoting effective learning outcomes.

Rosh Review is a board review company providing Qbanks that boost your confidence for your boards and beyond. 

If you’re a program leader looking to take the work of writing your own test questions off your plate, contact us using this form to get free institutional access to the Rosh Review Qbank in your program’s specialty.

By Jennifer Conroy, MD

Comments (0)