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Teaching/Learning Development - Faculty Development - Faculty Resources - Guidelines for Writing Multiple Choice Questions

Guidelines for writing multiple-choice questions

Multiple-choice questions (MCQs) are one of the most common student assessment tools in Memorial University’s Faculty of Medicine, and they are the method by which some qualifying exams are delivered. The National Board of Medical Examiners (NBME) provides the following guidelines for writing effective MCQs and we have adopted them as our standards. If a question is determined to not meet these standards, the faculty member who wrote a question may be asked to revise it.


Students should not be given cues to the correct answer by virtue of a poorly written question. To avoid this, the NBME suggest:
  • Ensuring compatibility between the question and all answer options when it comes to grammar, tense, pluralization, a/an (consonant/vowel), etc.
  • Ensuring that all options are plausible
  • Ensuring that all options are of similar length

Irrelevant Difficulty

An irrelevant level of difficulty should not be introduced by complex or vague question wording. Clinical scenarios may be complex and in-depth, but the phrasing of questions should not be the most difficult part of an MCQ. To avoid irrelevant difficulty, they suggest:
  • Avoiding questions phrased in the form “All of these EXCEPT” or “Which of these is NOT”
  • Avoiding options such as “all of the above”, “none of the above” or combination options e.g. “A; B; C; A&B; A, B & C”
  • Avoiding using absolutes in options e.g. “Always, Never”
  • Avoiding vague frequency terms in options e.g. “Usually, Often, Rarely”
  • Avoiding long and/or complicated options
  • Avoiding numerical range questions where the option ranges overlap one another e.g. “10-1000, 100-10000, 500-50000”

General Guidelines

The best questions follow these general guidelines
  • Make sure that the question can be answered without looking at the options.
  • If background or clinical information is necessary, put most of the information in the question and lead-in to the question. Leave the options short.
  • Focus on testing important concepts
  • All MCQs must have 5 options
For more information and examples, consult “Constructing Written Test Questions for the Basic and Clinical Sciences”, Third Edition, Case and Swanson 2002 NBME ( or contact the MESC office. (
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