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Properly constructed MCQs can assess higher cognitive processing of bloom's taxonomy in a large group of examinees in a short period of time. Other advantages associated with the MCQs are high reliability, more content coverage, and capacity to discriminate between high and low achievers.[6,7,8] Constructing good MCQ item is a complex, challenging, and time consuming process particularly for finding plausible distracters.[8,9] MCQs offer another disadvantage that chances of guessing increases with the decrease in number of options.[8] There are various types of MCQs used in the assessment in education-single best option type/multiple option, extended matching items, patient vignettes, etc., Single best response MCQs can also be divided further based on number of options such as three responses, four responses, and five responses.[4]

For scoring pattern, there was progressive reduction of scores from three options to five options groups. Such type of scoring pattern may reflect more chances of guessing with fewer distracters, so issue of guessing may be raised if MCQs with less number of options are used.[15] For blind guessing in MCQ test, quality of options would be responsible rather than number of options.[10] Meta-anyalysis by Rodriguez suggested that examines might be engaged in the educated guessing rather than blind guessing when elimination of least plausible distracter would be done.[16] Because of our study design, we eliminated distracters in random manner, so this significant difference might be due to the method of elimination of distracters and quality of distracters.

This study showed that mean time taken by examinees in three option group was less than mean time taken by examinees in four and five option groups. Hence, mean time per item decreased with decrease in number of alternatives per item. Overall saving time per item in three option groups was 6 s as compared to four option and five option groups. This time difference would allow completion of more questions in time limited three option MCQs exams which will increase the validity.[11,12,15] Fewer options also have distinct advantages for test takers that they need less time for item development and item administration.[1,11]

Mean item facility values in all three different option groups had an acceptable level, but there was significant difference in facility index values between three option and five option groups.[14] Rodriguez suggested that a small increase in facility index was observed when reducing the options from four to three, while there was a large increase in the facility index (items were easier) if the options were reduced to two.[10] In this study, small increase in facility value was observed when reducing from five options to four options, but there was a large increase in facility value if the options were reduced from five to three. Previous studies concluded that there was no significant difference in item facility after reduction of number of options, but reducing the number of options may increase the probability of random guessing to choose correct answer.[15,17,18,20] The reason for such findings in previous researches may be because of use of nonfunctional distracter elimination method to minimize the effects on difficulty level. Motivated examinees rarely resort to random guessing when they have sufficient time and appropriate difficulty level.[11] In this study, significant difference between three and five options facility values might be due to option deletion method. In this study, all the test groups had mean discrimination index values and point biserial values within acceptable range and there were no significant difference in discrimination index and point biserial values and also consistence with previous studies.[17,18]

Test anxiety is a situation-specific form of anxiety in response to taking tests.4 It is an unpleasant emotional state or condition with perceived feelings of tension, apprehension, nervousness, and worry. The physiological manifestations of any situation-specific anxiety generally include increased blood pressure, rapid heart rate with palpitations and tachycardia, sweating, dryness of the mouth, nausea, dizziness, hyperventilation, restlessness, tremors, and feelings of weakness.5 In general, the more difficult an examination and the more important the consequences that are attendant upon successful performance, the more likely the test will be perceived as threatening by students and the greater the effects of situation specific anxiety.4,6

Although there is conflicting evidence in the test anxiety literature, there is broad agreement that test anxiety is associated with lower academic performance and that a linear relationship exists between anxiety and examination performance.8,10 Frierson and Hoban11 reported that first-year medical students with low levels of anxiety during an MCQ examination achieved better scores than students with high levels of anxiety. There is little research, however, on anxiety levels of third-year clerkship students and test performance.

A majority of students believe that MCQ examinations give rise to less anxiety than other types of examinations.15 Standardized patient (SP) examinations are being used in medical schools, residency programs, and for licensing purposes. There is now an SP clinical skills (CS) licensure requirement called the United States Medical Licensing Examination (USMLE) Step 2 CS whereby students are videotaped interviewing, examining, and counseling trained actors pretending to be patients. The unique qualities of the standardized patient examination make it, understandably, a stressful experience. In less than 15 minutes, a student must interview and examine a patient and accurately formulate a differential diagnosis and plan. With each patient, the student must demonstrate excellent communication skills and composure. The examination was developed to provide more information about the bedside skills of future physicians. Medical students must pass this examination before graduation or starting a residency-training program. Some medical schools are beginning to add SP examinations into the curriculum, not only to test students, but also to help them gain confidence and experience before the USMLE Step 2 CS examination.

By the time our third-year students start the medicine clerkship, they have taken at least 25 medical school MCQ and as few as 5 SP examinations. We hypothesized that the lack of student experience in taking SP examinations might evoke greater anxiety for the SP test. Additionally, our SP examination is 40 minutes longer and precedes the MCQ exam by 1 week, additional factors that could contribute to higher anxiety levels. Although most medical students are experienced at taking MCQ examinations, the SP examinations are relatively new for some students. There are little data on clerkship student levels of anxiety during a SP examination.

The MCQ examination consisted of 100 questions and lasted 2 hours and 10 minutes. The departmental SP examination was developed using the United States Licensing Examination (USMLE) Step 2CS (Clinical Skills) blueprint and resembles the new licensing examination requirement. The test lasted 3 hours and consisted of 6 simulated patient encounters (the USMLE has 11 to 12 cases) specifically designed to reflect a balance of acute, subacute, and chronic medical problems. Each student was expected to gather a pertinent history and perform a relevant physical examination based on the complaint of the patient (i.e., cough, weight loss, chest pain). Each patient encounter was 10 minutes long (USMLE has 15-minute encounters) and was graded by the SP based on a predefined performance checklist of 20 to 25 essential skills and behaviors needed to be adequately performed by the student. Standardized patients had been trained to perform reliable assessments in all components of the examination and students were videotaped as they interacted with SPs to assure quality control (interrater reliability >0.90). Similar to the USMLE, SP encounters were followed by postencounter stations where students were required to answer questions regarding the history, physical examination, differential diagnosis, and diagnostic plan of the previous SP encounter. Postencounters were graded by the clerkship director using predefined performance standards.

In responding to the 20-item Likert-type TAI questionnaire, students self-reported the intensity of their feelings at a particular time (i.e., at the time of the examinations). Scores were obtained by summing up the scores for the 20 items that comprise the scale. The TAI consists of 2 subscales for measuring emotionality and worry which appear to be the major components of test anxiety.15 Eight questionnaire items make up an emotionality subscale (the autonomic nervous system reactions evoked by the stress of being evaluated). Eight items make up a worry subscale (cognitive concerns about the consequences of failure that interfere with attention). Subscale scores range from 8 to 32 points. The remaining 4 TAI items are used to derive the total score. Given the scale of 1 to 4 for each of the 20 items, the range of possible scores for the questionnaire could vary from a minimum of 20 to a maximum of 80. Although norms are not available for medical students, the questionnaire is reported to have excellent psychometric properties in college and high school students.4,16 041b061a72


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