Using Multiple Choice Questions to Evaluate the Difficulty and Long-Term Retention of Factual Versus Conceptual Knowledge

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Using Multiple Choice Questions to Evaluate the Difficulty and Long-Term Retention of Factual Versus Conceptual Knowledge

https://doi.org/10.21203/rs.3.rs-1965172/v1

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Multiple choice questions (MCQs) are the mainstay of examinations for medical education, physician licensing, and board certification. MCQs are traditionally a preferred way to test rote recall of memorized facts. Their utility in assessing higher cognitive functions has been more problematic to determine. We classified a series of 43 MCQs into two groups to test recall/verbatim thinking and conceptual/inferential thinking, respectively. The MCQs were used to test two related hypotheses 1) scores for recall/verbatim questions would be significantly higher than scores for inferential questions and 2) memory loss would be more rapid for factual minutiae compared to loss in the ability to critically reason about concepts. The MCQs were first used on a summative exam in 2020, which served as a retrospective benchmark of their performance characteristics. The same questions were readministered to volunteers (n = 56) from the same cohort of students in 2022. Retrospective analysis showed the recall/verbatim questions were indeed answered correctly more often than the concept/inference questions (82.0% vs. 60.9%, P = 0.002). Per quartile, only the concept/inference questions showed a significant decline in performance. Two years later, the performance decline was significant for recall/verbatim questions (P < 0.001) but not concept/inference questions (P = 0.050). Analysis of subgroups showed a general convergence of performance on both question types, indicating regression to a baseline mean that may be influenced by the clinical applicability of the material. These findings suggest that conceptual/inferential thinking is more difficult than rote memorization, but the knowledge acquired is more durable, especially if it is reinforced in clinical settings.

multiple choice questions

concept

inference

fact

recall

verbatim

retention

Multiple choice questions (MCQs) are ubiquitous in the medical profession. The Medical College Admissions Test (MCAT), United States Medical Licensing Examination (USMLE) exams, specialty-specific board certification exams, and innumerable other exams related to the basic and clinical sciences are built using MCQs. We may take them for granted in the present day, but in previous decades the utility of MCQs in medical education was disputed (Dudley, 1973; Joorabchi and Chawhan, 1975; Joorabchi, 1981). Data emerged that MCQs can be reliable, valid, and efficient (Norcini et al., 1984, 1985), but questions persisted about the ability of MCQs to evaluate cognitive levels above rote recall (Ferland et al., 1987). Over the years, a number of studies have attempted to classify MCQs and link them to the cognitive levels described in Bloom’s Taxonomy, although the effectiveness of this strategy has not been demonstrated (Huxham and Naeraa, 1980; Ferland et al., 1987; Zaidi et al., 2018).

Given the widespread use of MCQs, the question of whether they can assess different levels of cognitive function has broad implications. The systematic design of instruction typically begins with objectives and ends with an assessment that can determine if the objectives (learning outcomes) have been achieved. The promotion of higher order thinking is desirable given the complexity of clinical medicine. An ideal MCQ-based exam would therefore use questions that provide a meaningful assessment of higher cognitive functions, testing understanding and application of knowledge beyond rote memorization.

This idea also has possible implications for education research. For example, the posttest-only control group design is a true experimental design commonly found in such research (Tuckman and Harper, 2012). Briefly, an intervention is administered to an experimental group but not a control group, and a subsequent comparative assessment of the two groups (which may take the form of MCQs) tests the effect of the intervention. Since MCQs can be written to different levels of difficulty, and potentially assess different levels of cognitive function, they introduce an additional variable to the experimental design, as well as a potential source of measurement bias. It is possible that the selection of MCQs for comparative assessments may itself influence whether an effect is observed, how large it is, and how it evolves over time.

In fact, Karpicke and Blunt report such a finding (Karpicke and Blunt, 2011), where in certain experimental groups the posttest questions classified as “inference” showed greater recall than those classified as “verbatim.” While not the focus of that particular study, the observation is nonetheless intriguing. A related observation was shown by Zaidi et al. (2016), who used a dichotomized Bloom’s taxonomy to classify MCQs as “lower order” and “higher order” based on cognitive level. They found a modest but statistically significant difference in performance on the two question types, with lower order questions answered correctly more often than higher order questions. Both of these studies suggest it is possible to differentiate MCQs based on function: those that are designed to test memorization, and others that are designed to test deeper conceptual understanding.

The present study used Karpicke and Blunt’s work as a starting point to develop a classification scheme for medically-related MCQs, categorizing them as recall/verbatim or concept/inference. The hallmark of recall/verbatim questions is that they are based primarily on facts, and therefore assess whether a learner has absorbed relevant factual information. In contrast, concept/inference questions are based primarily on relationships, and therefore assess whether a learner knows how facts are connected, which in turn provides greater context and enables the ability to make predictions. A third category, mixed/ambiguous, was added for MCQs that could potentially be answered by recall or inference.

We formed two related hypotheses using this classification system. First, that after preparing for an exam, medical students will answer recall/verbatim questions correctly more often than concept/inference questions. This hypothesis presumes that concept/inference questions will be generally more challenging based on the relatively more sophisticated processes needed to answer them. Second, that erosion of conceptual knowledge, as assessed by concept/inference questions, will be slower than the erosion of straight factual knowledge, as assessed by recall/verbatim questions. This hypothesis presumes that conceptual knowledge is relatively difficult to acquire, but once encoded it is durable.

Ethical approval was obtained from the UNLV Biomedical IRB on April 3, 2017 (Protocol 1030906-1).

Forty-five questions were extracted from a faculty-authored summative examination on the pulmonary and renal systems. One of the authors (NH) developed a system to categorize each question as (1) recall/verbatim or (2) concept/inference (Table 1). A third category, mixed/ambiguous, was for questions that could be answered using recall or inference. Seven faculty members, representing a mixture of MDs and PhDs with variable levels of content expertise, reviewed the questions independently and as a group, and reached consensus on the best category for each question.

Table 1

Basic framework for categorizing multiple choice questions
Processing	Information	Category
Simple	Familiar	Recall/Verbatim (easier)
Simple	Esoteric	Recall/Verbatim (more difficult)
Complex	Familiar	Concept/Inference
Complex	Esoteric	Recall/Verbatim (more difficult)

[Insert Table 1 here]

The categorization system is discussed in greater detail below. Briefly, recall/verbatim questions require relatively simple cognitive processes to answer them. These include straightforward recall, solving arithmetic equations, recognizing basic patterns, and deductive reasoning that requires little or no content mastery. Verbatim/inquiry questions involving information that is more esoteric and less familiar will have relatively high difficulty indices. A question may be also classified as recall/verbatim if answering it requires recall of a specific, non-intuitive piece of information, regardless of what other cognitive processes are involved. Concept/inference questions require fairly complex cognitive processes to answer them, which commonly involve deductive reasoning to discern or predict relationships, recognizing subtle patterns, and solving problems that require substantial practice and content mastery. Mixed/ambiguous questions are answerable through more than one pathway. For example, the diagnosis of an acid-base disorder based on laboratory values can be done through logical inference or straight pattern recognition.

The categorization system described above was first applied retrospectively. Performance data on each question were collected from their first use in a summative basic science exam administered in April 2020. The same questions were then re-administered to volunteer students from the same cohort in January-February 2022, after they had progressed through most of the clerkship year. To reduce testing burden, the questions were broken into four separate quizzes (acid-base physiology, anatomy, renal physiology, pulmonary physiology). To be included in the analysis, a student must have taken the 2020 exam and completed at least one 2022 quiz. The included students (n = 56) were organized into various subgroups (top/bottom half, quartiles) based on their overall basic science exam scores relative to the class median of 84.1%. Statistical analyses were performed using Excel. A P-value of 0.050 was used as a threshold for statistical significance.

Consensus of the seven faculty members categorized 10 questions (22%) as concept/inference, 33 questions (73%) as recall/verbatim, and 2 (4%) as mixed/ambiguous. The mixed/ambiguous questions were excluded from further analysis.

Tables 2 and 3 summarize the major performance characteristics of recall/verbatim versus concept/inference questions. Retrospective analysis of question performance on the 2020 exam showed the recall/verbatim questions were answered correctly more often than the concept/inference questions (82.0% vs. 60.9%, P = 0.002). When the top and bottom halves of the class were compared, they answered recall/verbatim questions correctly at the same frequency (84.0% vs. 80.2%, P = 0.433). The top half answered concept/inference questions correctly more often than the bottom half (68.6% vs. 53.2%, P = 0.027). Further delineation showed a progressive decline in performance on concept/inference questions by quartile while performance on recall/verbatim questions was relatively stable (Fig. 1).

Table 2

Comparative performance by question type and year
	Percent correct
	Recall/Verbatim	Concept/Inference	P-Value
2020 Exam
All Participants (n = 56)	82.0	60.9	P = 0.002
Top Half (n = 28)	84.0	68.6	P = 0.020
Bottom half (n = 28)	80.2	53.2	P = 0.001
First Quartile (n = 14)	84.4	70.7	P = 0.060 (NS)
Second Quartile (n = 14)	83.5	66.4	P = 0.009
Third Quartile (n = 14)	80.7	57.9	P = 0.003
Fourth Quartile (n = 14)	79.4	48.6	P = 0.001
2022 Quizzes
All Participants (n = 56)	59.8	42.9	P = 0.079 (NS)
Top Half (n = 28)	62.5	44.2	P = 0.078 (NS)
Bottom half (n = 28)	57.1	41.7	P = 0.110 (NS)
First Quartile (n = 14)	64.1	49.7	P = 0.161 (NS)
Second Quartile (n = 14)	61.2	38.8	P = 0.044
Third Quartile (n = 14)	54.3	39.5	P = 0.135 (NS)
Fourth Quartile (n = 14)	59.8	43.5	P = 0.118 (NS)
Abbreviation: NS = not significant

Table 3

Statistical comparisons (P-values) of top/bottom half subgroups by question type and year
			2020				2022
			Recall/Verbatim		Concept/Inference		Recall/Verbatim		Concept/Inference
			Top Half	Bottom Half	Top Half	Bottom Half	Top Half	Bottom Half	Top Half	Bottom Half
2020	Recall/ Verbatim	Top Half	-	0.433	0.020	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001
	Recall/ Verbatim	Bottom Half	0.433	-	0.001	0.107	0.005	< 0.001	< 0.001	< 0.001
	Concept/ Inference	Top Half	0.020	0.001	-	0.027	0.502	0.205	0.024	0.003
	Concept/ Inference	Bottom Half	< 0.001	0.107	0.027	-	0.323	0.670	0.408	0.204
2022	Recall/ Verbatim	Top Half	< 0.001	0.005	0.502	0.323	-	0.432	0.078	0.036
	Recall/ Verbatim	Bottom Half	< 0.001	< 0.001	0.205	0.670	0.432	-	0.204	0.110
	Concept/ Inference	Top Half	< 0.001	< 0.001	0.024	0.408	0.078	0.204	-	0.827
	Concept/ Inference	Bottom Half	< 0.001	< 0.001	0.003	0.204	0.036	0.110	0.827	-
Values > 0.050 are in bold

[Insert Table 2 here]

[Insert Table 3 here]

[Insert Fig. 1 here]

Analysis of question performance on the 2022 quizzes showed no statistically significant difference between performance on recall/verbatim questions versus concept/inference questions (59.8% vs. 42.9%, P = 0.079). There was likewise no observed difference between the top and bottom halves of the class on recall/verbatim questions (62.5% vs. 57.1%, P = 0.432) or concept/inference questions (44.2% vs. 41.7%, P = 0.827).

Comparison of question performance between 2020 and 2022 showed a statistically significant decrease in performance on recall/verbatim questions (82.0% vs. 59.8%, P < 0.001) and a borderline significant decrease in performance on concept/inference questions (P = 0.050) (Fig. 2a). The decrease on recall/verbatim questions was similar for both the top half (84.0% vs. 62.5%, P < 0.001) and bottom half (80.1% vs 57.1%, P < 0.001) of participants. A statistically significant decrease was observed on concept/inference questions for only the top half (68.6% vs. 44.2%, P = 0.024). No significant difference was found on concept/inference questions for the bottom half (53.2% vs. 41.7%, P = 0.204) (Fig. 2b).

[Insert Fig. 2 here]

Defining question types

The notion that MCQs can be categorized based on the level cognitive function they assess is not a new one. In the 1970’s and 1980’s a number of studies attempted to classify MCQs according to Bloom’s taxonomy. This approach is both tempting and problematic. Learning and memory are complicated phenomena, and their complexity is not necessarily reflected in the six clean layers that comprise Bloom’s hierarchy. Zaidi et al. (2018) proposed that Bloom’s taxonomy may have no meaningful utility in categorizing MCQs, and instead developed a dichotomized scheme of “higher order” and “lower order” questions.

The classification scheme developed for this study started with the very basic idea that answering a given MCQ involves (1) information and (2) cognitive processing. Information was divided into familiar and esoteric forms. Familiar information is integral to the learning of a given subject. An example from pulmonary physiology is compliance, a core concept that underpins any accurate understanding of how the lungs function. By contrast, examples of esoteric information (also from the lung) are the locations and nomenclature for the twenty individual lung segments. While this information is important to a subset of practitioners, it would be a time-consuming and low-yield endeavor for the average medical student to commit the segments to memory.

Cognitive processing was likewise subdivided into simple and complex forms. Simple processing encompasses functions that all medical students should be able carry out with minimal cognitive load. Complex processing essentially involves all cognitive functions that go beyond the simple.

The classification of a given MCQ depends on the interplay between information and processing. Most will be classified based on processing type, with simple processing indicating a verbatim/recall question, and complex processing indicating a concept/inference question. Table 4 gives example questions from this study, each with a categorization and rationale.

Table 4. Example recall/verbatim and concept/inference questions

A 45-year-old man with a history of depression and substance abuse attempts suicide by sitting in his idling car while enclosed in a garage. His teenage daughter finds him and summons an ambulance. Which of the following most accurately describes the effect of the car exhaust on his hemoglobin? A. Decreases affinity for oxygen, no change to oxygen saturation B. Increases affinity for oxygen, no change to oxygen saturation C. No change to affinity for oxygen, decreases oxygen saturation D. Decreases affinity for oxygen, decreases oxygen saturation E. Increases affinity for oxygen, decreases oxygen saturation	A healthy 23-year-old man takes part of a research study. He is injected with an experimental drug X that has no known hepatic metabolism. A 24-hour urine collection amounts to 1.72 L with a urine [X] of 500 mg/L. His plasma [X] is 30 mg/L. Calculate the renal clearance of drug X. A. 10 mL/min B. 20 mL/min C. 30 mL/min D. 40 mL/min E. 50 mL/min	In which of the following conditions will supplemental oxygen be least helpful in raising the PO2 of systemic arterial blood? A. Ventral septal defect (VSD) B. Respiratory depression from drug overdose C. Pulmonary fibrosis D. Pulmonary embolism E. High altitude	A 32-year-old man goes for a hike in Death Valley National Park in July. By the time he finishes the hike he is fatigued, dizzy, and extremely thirsty. The osmolarity of his urine will be most similar to the osmolarity of his: A. Distal convoluted tubules B. Outer medullary collecting ducts C. Plasma D. Proximal convoluted tubules E. Renal papillae
Category: Recall/Verbatim	Category: Recall/Verbatim	Category: Concept/Inference	Category: Concept/Inference
Rationale: Question is primarily organized around factual recall: major toxic component of car exhaust (carbon monoxide) and properties of carboxyhemoglobin.	Rationale: Question requires recall of equation for calculating renal clearance. Remaining arithmetic operations require simple processing.	Rationale: Question requires conceptualization of different physiologic and pathophysiologic states, judging how they will be affected by changing one variable (alveolar oxygen concentration).	Rationale: Question requires conceptual understanding of how and why the kidney modifies urine osmolality, i.e., the purpose of the countercurrent multiplication mechanism, which informs its anatomic organization.

[Insert Table 4 here]

An exception to this rule exists where recall of specific esoteric information is necessary to correctly answer a question, regardless of the processing involved (Table 1). For example, consider a question where one must determine if a patient with an acid-base disorder has the expected compensatory response. Interpreting this question involves (among other things) understanding the relationship between PaCO₂, and HCO₃⁻, but to answer it confidently one must know the precise quantitative aspect of this relationship. A “cognitive bottleneck” such as this one, which requires recall of information that is not intuitive and cannot be deduced, classifies such a question as recall/verbatim.

It should be recognized that the lines that divide simple from complex and familiar from esoteric are not necessarily easily drawn, nor are they static. Complex processing may become simple with practice and acquisition of expertise, and esoteric information may become familiar to the point of being implicit.

Question performance

Our first hypothesis was that recall/verbatim and concept/inference questions would have significantly different performance characteristics. The data from the 2020 exam support this hypothesis, with concept/inference questions having a substantially higher difficulty index than recall/verbatim questions. Moreover, performance on the recall/verbatim questions was similar for all students, whereas it varied considerably for the concept/inference questions, which were the primary determinant of final exam score. All participants therefore demonstrated a similar ability to memorize and perform simple cognitive tasks, and were differentiated based on a subset of more challenging questions.

Our second hypothesis was that retention of more fact-oriented knowledge, as evidenced by performance on recall/verbatim questions, would degrade more rapidly than the knowledge tested by concept/inference questions. Both question types showed similar proportional declines in performance from 2022–2022, but the decline in recall/verbatim performance was statistically significant (P < 0.001) while the decline in concept/inference was of borderline significance (P = 0.050). These findings with respect to our second hypothesis are therefore inconclusive.

Interestingly, decline on performance was not the same for all analyzed subgroups. Decline on recall/verbatim questions was similar between the top and bottom halves of the class. However, this was not seen for concept/inference questions, with the top half averaging a statistically significant 24.3-point decrease (P = 0.024) and the bottom half averaging a statistically insignificant 11.5-point decrease (P = 0.204). The gap between these two groups averaged 15.4 points in 2020, and this difference narrowed to a statistically insignificant 2.5 points in 2022 (P = 0.827). In fact, by 2022 the performance of both groups on both question types had become statistically indistinguishable in all but one comparison (top half, recall/verbatim questions vs. bottom half, concept/inference questions, P = 0.036).

The reasons for this general convergence of performance are unclear. It is noteworthy that the participants in this study were near the end of their clerkship year, and therefore had spent significant time participating in patient care and studying for clinical subject exams. The “floor” observed for each question type in 2022 (~ 60% for recall verbatim, ~ 43% for concept/inference) may in part represent knowledge that was relevant and reinforced during the clerkships. Conversely, the questions that showed a substantial decline in performance may reflect knowledge that is obscure or of low clinical importance and was consequently not revisited. In other words, while the 2020 exam was able to stratify students based largely on their performance on concept/inference questions, performance over the long-term regresses to a mean of core knowledge necessary for clinical application.

If borne out by additional studies, this work has implications for exam design. The high performance seen on recall/verbatim questions, and their lack of ability to discriminate between different examinees, calls into question the utility of even including such questions on summative exams. It is well recognized that assessment drives learning (Wormald et al., 2009) and testing relatively basic information with recall/verbatim questions could appropriately incentivize students to learn foundational knowledge. Overreliance on them, however, could hypothetically disincentivize more significant mastery of the content by allowing those with superficial knowledge to pass.

Rather than designing a summative exam with a high proportion of relatively easy recall/verbatim questions, it may be more logical to compose a shorter exam with a higher proportion of more difficult concept/inference questions and a commensurately lower passing threshold. In theory, such an approach could incentivize students to focus on higher-level cognitive processes that would presumably be of greater value than transient memorization.

These findings also underscore the importance of MCQ selection for educational research experiments that utilize them. For example, if the MCQs from this study were used to form a question bank for a prospective experiment, their known performance characteristics would show a wide range of initial posttest difficulty indices (P values from 0.30-1.00) and a similarly wide range of performance variation between 2020 and 2022 (from − 64 points to + 17 points).

In designing assessments for educational research, it would be ideal to mitigate such potential distortions. MCQs should be chosen based on pre-defined learning objectives, categorized by cognitive level, and their respective performance characteristics determined in a variety of testing environments. Such deliberation would ensure that the assessments used in educational research experiments are optimal in terms of validity and difficulty.

Limitations

This study used questions from a single exam of limited scope that were administered to a single cohort of participants. The number of included concept/inference questions was modest, thus limiting the power of the analysis. Interpretation of the findings is confounded by the fact that participants had completed a substantial portion of the clerkship year by the time of the 2022 assessments. Whereas the 2020 assessment was a summative examination, participation in the 2022 assessments was voluntary and no-stakes, which may have impacted the amount of effort expended on the questions.

We found that short-term performance on recall/verbatim questions was significantly higher than concept/inference questions. Performance on concept/inference questions decreased by quartile whereas performance on recall/verbatim questions was uniform. After a prolonged interval of almost two years, performance on both question types declined, although only the decrease on recall/verbatim questions was statistically significant. The top and bottom halves both showed similar declines in performance on recall/verbatim questions. This was not observed for concept/inference questions, where only the top half showed a statistically significant decline. The overall findings suggest that factual information is both readily acquired and readily lost, whereas conceptual knowledge is more difficult to acquire but is relatively durable. They also indicate that MCQs can be used to assess different levels of cognition. If confirmed by additional studies, this has implications both for exam construction and the design of educational research experiments. Instructors should be cognizant of how assessment can influence learning, and investigators should consider how measurement tools can themselves influence results.

ACKNOWLEDGEMENTS

None.

Funding

No sources of funding to report.

Competing interest

No competing interests.

Ethics approval

Ethical approval was obtained from the UNLV Biomedical IRB on April 3, 2017 (Protocol 1030906-1). The approval permits the use of aggregated, deidentified data obtained from quality improvement activities to be used for research.

Informed consent

Not applicable.

Availability of data and materials

The data was obtained through internal quality improvement and is not publicly available.

Code availability

Not applicable.

Authors’ contribution

Neil G. Haycocks, Jessica Hernandez-Moreno, Johan C. Bester, and Thomas A. Vida wrote the main manuscript. Neil G. Haycocks prepared all figures and tables. All authors reviewed the manuscript.

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No competing interests reported.

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Using Multiple Choice Questions to Evaluate the Difficulty and Long-Term Retention of Factual Versus Conceptual Knowledge

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Abstract

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Introduction

Materials And Methods

Results

Discussion

Defining question types

Question performance

Limitations

Conclusion

Declarations

References

Additional Declarations

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