Hands-On Workshop on Writing Patient Vignettes and Clinical Problem-Solving Questions Lecia Apantaku, MD Michael Fennewald, PhD Sept. 16, 2015

Session Objective: to be able to construct patient vignette and problem-solving questions Outline: 1. Brief intro to writing test questions in general. 2. Intro to writing clinical vignette questions 3. Writing the questions in small groups 4. Reviewing the questions

The Basic Rules for One-Best-Answer Items Each item should focus on an important concept, typically a common or potentially catastrophic clinical problem. Each item should assess application of knowledge, not recall of an isolated fact. The stem of the item must pose a clear question, and it should be possible to arrive at an answer with the options covered. To determine if the question is focused, cover up the options and see if the question is clear and if the examinees can pose an answer based only on the stem. Rewrite the stem and/or options if they could not.

All distractors (ie, incorrect options) should be homogeneous. Avoid technical item flaws that provide special benefit to testwise examinees or that pose irrelevant difficulty. Do NOT write any questions of the form “Which of the following statements is correct?” or “Each of the following statements is correct EXCEPT.” These questions are unfocused and have heterogeneous options.

Guidelines for Item Content Test application of knowledge using experimental and clinical vignettes Focus items on key concepts and principles that are essential information (without access to references) for all examinees to understand Test material that is relevant to learning in clinical clerkships, postgraduate medical education, and beyond Avoid items that only require recall of isolated facts Avoid esoteric or interesting topics that are not essential

The patient vignettes may include some or all of the following components: Age, Gender (eg, A 45-year-old man) Site of Care (eg, comes to the emergency department) Presenting Complaint (eg, because of a headache) Duration (eg, that has continued for 2 days). Patient History (with Family History ?) Physical Findings +/- Results of Diagnostic Studies +/- Initial Treatment, Subsequent Findings, etc.

Additional Templates A (patient description) has a (type of injury and location). Which of the following structures is most likely to be affected? A (patient description) has (history findings) and is taking (medications). Which of the following medications is the most likely cause of his ( history, PE or lab finding)? A (patient description) has (abnormal findings). Which [additional] finding would suggest/suggests a diagnosis of (disease 1) rather than (disease 2)? A (patient description) has (symptoms and signs). These observations suggest that the disease is a result of the (absence or presence) of which of the following (enzymes, mechanisms)?

Let us look at some examples of converting recall questions into clinical vignette style questions.

So, how can we convert a old-fashioned recall question into a modern board style board question? Let us consider a couple of examples and then I have some forms to help that are from the NBME(via the Santa Fe meeting, where NBME presented) Old: Which of the following cells is infected by EBV? A.B lymphocytes B.Kupffer cells C.Macrophages D.Neutrophils E.T Lymphocytes. New: A 19 year old female presents with low grade fever, sore throat, swollen cervical nodes, and fatigue. She is positive for the monospot test. Which of the following cells are primarily infected in this patient? Choices are the same.

Now, let us break into small groups to try a and rewrite or create clinical vignette questions. Old q. Believing that change will enhance my well being defines: A conviction B Confidence C optimism D skepticism E. Frustration A 62 year old woman who weighs 300 lbs. with Type 2 diabetes believes that regular exercise and weight loss will improve her quality of life. This is an example of: