Faiz Tuma, MD, MME, MDE, EdS, FACS, FRCSC, Department of General Surgery, Central Michigan University College of Medicine.
Writing is considered one of the effective tools of thinking and learning.1,2 Writing questions is an exercise of addressing a problem that incorporates mental learning activities such as evaluating and constructing knowledge. The process involves retrieval information, comprehension, application, and using critical thinking skills. The educational benefits of writing questions have been well recognized.3, 4 Writing multiple-choice question (MCQ) style was found to be positively correlated with improved test grades.5 Cognitive strategies used in writing questions improves knowledge comprehension and test results.6 The advantages of teaching and learning by writing questions are well discussed in the literature.7 Teaching to write formal questions with providing evidence-based explanations takes the learning educational experience steps further.8 MCQs are a commonly used assessment tool in medical education for formative and summative assessment.9 Yet, the learning benefits of writing MCQs with evidence-based answers is not well explored or explained. Hence, the aim of this article is to discuss and describe the educational value of writing MCQs as an effective learning tool.
Engaging in Learning
There are various ways of starting a learning activity; however, only a few approaches provide engagement in an adult active learning style. Pure reviewing of information from a book/article or listening to a lecture will likely turn to a passive and boring process with limited engagement and durability. While learning through active structuring of questions with specific learning points in a mini-project style that is built on examining information, selecting valuable details, and presenting conclusions provides a high quality active and engaging learning activity. Question generation promotes active engagement in learning and deeper thinking. 10
Learning New Knowledge
To write formal MCQs, a wide knowledge base is required and acquired during the process. The process involves reviewing and acquiring broader and deeper knowledge. Various topics and educational points have to be tackled in the questions and the provided explanation. Clear understanding and comprehensive knowledge about these points are essential requirements to write effective questions. This learning process usually accompanies the writing process and results in significant increase in the fund of knowledge.
Writing questions consolidate knowledge by verifying and evaluating the content.11,12 Learning takes place actively by examining information to clarify or modify and eventually consolidate learner’s knowledge. The exercise enhances functioning at higher cognitive learning levels that include analyzing and evaluating knowledge.8 Both basic and clinical sciences can apply the same learning activity. The topics of the questions have to be selected based on the desired learning objectives.
Problem and case-based scenarios involve applying medical knowledge in addressing these clinical scenarios. Writing clinical scenario-based MCQs can be used to stimulate clinical problem-solving learning.13 Learners will exercise critical appraisal and evaluate various management options for the particular scenarios of the questions.8 The exercise also increases learning curiosity to identify potential clinical applications that can be used to construct more questions.
Building Teaching and Evaluating Skills
Teaching is a well know method of learning. It requires a deep and comprehensive understanding of the taught topic. It promotes achieving mastery level of cognitive and psychomotor performance. Writing questions can be used as a powerful tool to develop teaching skills. Writing MCQs with the aim of sharing knowledge and providing teaching will inspire writers to develop their teaching skills.8 It can connect between learning and assessment as well as learning from different perspectives.11 Combining learning and assessment promotes active and investigative learning and maximizes learning quality.8
In addition to its learning and teaching benefits, writing questions evaluate learner’s knowledge in various aspects.14 It assesses several competencies and consumes minimal time and effort from the evaluator.15 Writing scenario-based MCQs measure higher cognitive learning skills such as applying, analyzing, and creating synthesizing compared to writing simple factual information-based MCQs that measure memorization and understanding.8 MCQS of scenarios derived from the clinical training experiences enable evaluating clinical knowledge and skills that may not be possible to evaluate otherwise.
Using Evidence-based Knowledge and Search
Preparing materials and clinical themes for MCQs makes the bulk of the educational effort and time of writing questions. Writing educational MCQs requires a thorough review of the literature to provide sound evidence and clarify misconceptions.16 A literature review develops searching skills, critical appraisal, and building sound conclusions.8 Choosing hot topics with abundant studies maximize the research experience of writing MCQs.
Establishing Scholarly Writing Style
Regular writing requires dealing with elements that enhance clarity, precision, and scientific tone of writing. Deliberate practice enhances scholarly writing style and format.17 While writing, learners refine, self-regulate, and enhance learning skills and critical thinking.18 Learning writing skills will be enhanced by producing and revising the writing product with additional feedback and academic support.
Other benefits of writing MCQs include enhancing learning skills, improving confidence, sharing knowledge, and learning concepts and principles more than factual information.8 Medical students were found to feel more confident after practiced question generation.19 Generating MCQs in group learning activities provides additional group learning benefits.7
It is imperative to realize that the value of writing MCQs depends on the quality of the produced questions and the cognitive efforts put into the activity.8 Factual information-based questions are of limited educational value while problem-solving-based questions are of higher cognitive learning level. Thus, scenario-based, problem-analysing, and solving questions using upper-level cognitive skills should be the ultimate goal.
Writing MCQs provides multiple educational advantages. The educational value ranges from learning new knowledge actively and deeply to improving scholar and searching skills and acquiring teaching skills. Utilizing this educational activity at a program or institution level might be demanding and require extra effort to implement in a practical way. However, it is much easier and practical at the individual learner level, and it is available everywhere and anytime.
1- Cowen VS, Kaufman D, Schoenherr L. A review of creative and expressive writing as a pedagogical tool in medical education. Med Educ. 2016;50(3):311-319. doi:10.1111/medu.12878
2- Arnold KM, Umanath S, Thio K, Reilly WB, McDaniel MA, Marsh EJ. Understanding the cognitive processes involved in writing to learn. J Exp Psychol Appl. 2017;23(2):115-127. doi:10.1037/xap0000119
3- Aflalo E. Students generating questions as a way of learning. Active Learning in Higher Education. April 2018. doi:10.1177/1469787418769120
4- Franzen D, Cuddy MM, Ilgen JS. Trusting Your Test Results: Building and Revising Multiple-Choice Examinations. J Grad Med Educ. 2018;10(3):337-338. doi:10.4300/JGME-D-18-00265.1
5- Hardy, J, Bates, SP, Casey, MM. (2014) Student-generated content: Enhancing learning through sharing multiple-choice questions. International Journal of Science Education 36(13): 2180–94.
6- Rosenshine B, Meister C, Chapman S. Teaching Students to Generate Questions: A Review of the Intervention Studies. Review of Educational Research. 1996;66(2):181-221. doi:10.3102/00346543066002181
7- Gooi AC, Sommerfeld CS. Medical school 2.0: How we developed a student-generated question bank using small group learning. Med Teach. 2015;37(10):892-896. doi:10.3109/0142159X.2014.970624
8- Tuma F. Educational benefits of writing multiple-choice questions (MCQs) with evidence-based explanation [published online ahead of print, 2021 Mar 9]. Postgrad Med J. 2021;postgradmedj-2021-139876. doi:10.1136/postgradmedj-2021-139876
9- Walsh JL, Harris BH, Smith PE. Single best answer question-writing tips for clinicians. Postgrad Med J. 2017;93(1096):76-81. doi:10.1136/postgradmedj-2015-133893
10- Terada Y. Using Students-Generated Questions to Promote Deeper Thinking. Edutopia. 2020. Retrieved from: https://www.edutopia.org/article/using-student-generated-questions-promote-deeper-thinking. Last viewed: April 04,2021.
11- Papinczak, TR, Peterson, AS, Babri, K. (2012) Using student-generated questions for student-centred assessment. Assessment & Evaluation in Higher Education 37(4): 439–52.
12- Schimmelfing LC, Persky AM. Activating prior knowledge using multiple-choice question distractors. Med Educ. 2020;54(10):925-931. doi:10.1111/medu.14162
13- Palmer E, Devitt P: Constructing multiple choice questions as a method for learning. Ann Acad Med Singapore. 2006, 35 (9): 604-608.
14- Chin C, Osborne J. Students’ questions: A potential resource for teaching and learning science. Studies in Science Education. 2008; 44(1): 1–39.
15- Tuma F, Kamel MK, Shebrain S, Ghanem M, Blebea J. Options of Surgical Curriculum Structure and Objects During COVID-19 Pandemic [published online ahead of print, 2020 Dec 18]. Surg Innov. 2020;1553350620979825. doi:10.1177/1553350620979825
16- Jobs, A., Twesten, C., Göbel, A. et al. Question-writing as a learning tool for students – outcomes from curricular exams. BMC Med Educ 13, 89 (2013). https://doi.org/10.1186/1472-6920-13-89
17- Moss F. Writing is an essential communication skill: let's start teaching it. Postgrad Med J. 2015;91(1076):301-302. doi:10.1136/postgradmedj-2015-133556
18- Nguyen LP, Ikeda M. The effects of ePortfolio-based learning model on student self-regulated learning. Active Learning in Higher Education. 2015;16(3): 197–209.
19- Baerheim A, Meland E. Medical students proposing questions for their own written final examination: Evaluation of an educational project. Medical Education. 2003;37(8): 734–8.