Complex Board Exam Review Questions in Materials Matter

David BeardPersonal Education

Why We Use Complex Board Exam Review Questions in Materials for Medical Education

“I just want boards-style questions!” is a discussion we hear a lot. But when your exam preparation materials are just boards style, single-answer multiple choice questions, you are missing a lot of the key components that drive retention.

And whether you are reviewing material for recertification or a Maintenance of Certification exam, or studying for initial certification or shelf exams, the issue you face is retention. How long will you keep the information in your head?

“Board style” questions are typical on exams, sure, but a mix of assessment and complex board exam review questions is actually better for overall retention.

Programmed Learning

The technique of using question and answer based interactive material for teaching is an old one, called programmed learning. Programmed learning follows a pattern of questions, answers, and remediation – explanations of why you got the answer right, or wrong. In medical education, these are usually referenced back to medical journal articles or textbooks. There have been a variety of names for this technique over the decades, but the value is in interacting with the material being reviewed or studied – do you have to consciously think about it, and as a result of that, how long do you retain the information.

complex board exam review questions programmed learning
Programmed learning progression: Practice > Review > Assess.

Types of Questions in Programmed Learning

There are two types of questions used in the common forms of programmed learning, assessment questions, which test knowledge, and complex, which force conscious thought, and drive retention.

Assessment questions are commonly referred to as “boards style” in medical education.

Assessment vs. Complex Questions

An assessment question usually presents a short scenario or factual statement, and asks for single answer:

A 13-year-old girl presents complaining of short stature. She has a sexual maturity rating (SMR) of 5, and she achieved menarche at 9 years, 6 months of age. Her mother states that she has always been on the “heavy side” but was also always tall for her age. She continues to gain weight but has not grown in height in the past 1 to 2 years.

Of the following, which is the most likely explanation for the patient’s failure to grow in height?

Turner syndrome
hypothyroidism
growth hormone deficiency
physiologic attainment of adult height
inflammatory bowel disease

This patient has reached her physiologic adult height. Her growth chart shows that she has had above-average height and has been overweight throughout her childhood. Obesity can increase linear growth through a variety of mechanisms, including increased production of insulin-like growth factor. Obesity may also contribute to early-onset puberty, advanced bone age, and earlier closure of epiphyseal growth plates. Most girls continue to grow in height for approximately 2 years after attaining menarche, similar to this patient.

Patients with Turner syndrome or hypothyroidism are most likely to be obese and have short stature as well as low height velocity, which is measured by the slope of the curve on the growth chart. Before this patient completed puberty, her height velocity was normal. Prepubertal children who are obese will be tall for their age, although they will still have an abnormally high body mass index. Thus, an obese prepubertal child presenting with short stature warrants further endocrinologic evaluation. In addition, patients with Turner syndrome will have delayed puberty, not early puberty.

Patients with growth hormone deficiency will not have above-average height and normal growth velocity–unlike this patient–prior to completing puberty.

Patients with inflammatory bowel disease may present with short stature, but they will have poor weight gain rather than excessive weight gain, and they are more likely to have delayed–not advanced–puberty.

Simple assessment style questions are designed to present the key finding quickly in the question stem, provide short answers that are easily read, and extensive remediation explaining the answers if needed.

Complex board exam review questions are designed to force conscious thought about the question. This can be done a couple of ways. One method is longer case presentation with distractors in the question stem, or complex answers. Another method is to reverse the structure – the infamous “which does NOT apply” answer sets.

Mostly, medical educators prefer to provide the longer stems and answers. But interspersing the occasional “all except” breaks up the flow and forces retention.

Complex Board Exam Review Questions

This is a short-stem complex board exam review question:

Regarding risk assessment for violence in the medical setting, which of the following statements is true?

Searching and disarming of all patients results in an increased feeling of safety for both patients and staff.
Patients who are obviously violent and verbally abusive should not be triaged until their behavior is appropriate to be in proximity to the staff and other patients.
Reliable predictors of violence include male gender, drug use, ethnicity, and education.
The uncooperative, nonverbal patient is likely less physically violent than an angry, verbose patient.
When a patient invokes a feeling of fear or trepidation in the provider, the provider should inwardly remember that it is the practitioner who needs to be in control of the situation.

There are few reliable predictors of medical setting violence; neither ethnicity nor education was associated with violence in one recent study. If the emergency physician experiences fear in exposure to a potentially violent patient, that visceral response should key the provider that indeed this circumstance may be dangerous and a safe distance should be established. A particularly dangerous patient is one who does not verbalize or emote, yet remains uncooperative and brooding. It has been shown that increased waiting times correlate positively with violent behavior and these patients should circumvent typical triage protocols and be seen as soon as possible. Finally, studies have shown patients and staff agree with searching all patients for weapons.

This question requires that you read each of the answers to determine validity. That, in turn, drives retention of a tricky question – a tricky question that will appear on the certification exam.

The goal of any medical education products for physician boards, question banks for study or review, or maintenance of certification is to provide high retention after the study session. While rapid progress through a bank of simple questions can make you feel like you are accomplishing something, you may be missing a key component of programmed learning. The inclusion of both assessment and complex board exam review questions in materials is not an error – it’s a benefit.

Fast assessments of knowledge level, on the other hand, lend themselves to simple boards style question with rapid progress through the material, and a prescriptive presentation on your topic scores after the fact.

In short, one style of question may act as a template for exams, but varying the question style, tone, and structure forces your brain to adapt to different presentations of related information. When this occurs, retention tends to improve.

The best questions banks – the ones that provide the greatest effect – utilize more than a single style.