Q&A Writer Specifications

UPDATED: January 27, 2016

Congratulations! 

You have been selected to write original board-style questions and answers for MedStudy. As you may know, users of MedStudy’s products expect a very high level of scholarship and writing quality. We are grateful and appreciative of your commitment to teaching and for helping us meet and exceed our users’ expectations.

To make the process of writing new Q&As as easy as possible for you, we are providing the following tools to you:

• Detailed writer specifications on how to write a high-quality Q&A (see below)
• Examples of currently accepted Q&As
• A schematic of 'The Perfect Q&A'

Criteria the reviewer of your Q&A will look for can be found in:

• A short YouTube video tutorial on how to review Q&As
• A Q&A review checklist

Q&A Writer Specifications

Step 1: Identify a Concept

Concepts need to answer affirmatively to the following 5 questions (in order of importance):

1. Is knowledge of this concept important to direct patient care or public health?
2. Is the concept a standard of care and a concept that experts in your field plainly agree upon? No controversial concepts here!
3. Is the concept true? The concept should be evidence based and scientifically sound. Alternatively, it can also be based on nonevidence-based guidelines, consensus statements, and well-established standards of care.
4. Is the concept not too difficult or obscure? The concept needs to be appropriate for generalists preparing for the general internal medicine or pediatrics boards.
5. Is the concept not overly easy?
   The concept needs to be known by the average generalist at the beginning of their specialty training.

Step 2: Write a Clinical Scenario (Stem)

The clinical scenario needs to feature or lead up to a question that tests the concept. A scenario should be a clear, complete, and realistic (but fictitious!) clinical encounter. It should have the following features:

• Patient demographic identity
  Include facts that the examinee needs to know in order to properly understand or frame the clinical scenario such as age, gender, past medical history, social history. Mention race, ethnicity, and occupation only when relevant to the understanding of the clinical scenario!
  Example: A 39-year-old male smoker... 
• Location of the encounter
  Generally, the location should be assumed to be in the United States. Be specific about the exact location within the United States only if it is relevant to the patient's illness.
Example: A 39-year-old male smoker presents to the emergency department...
• Reason for the encounter
Example: A 39-year-old male smoker presents to the emergency department complaining of worsening cough, shortness of breath, and sputum production... 
• Duration of the symptoms
  Example: A 39-year-old male smoker presents to the emergency department because of a 5-day history of worsening cough, shortness of breath, and sputum production... 
• Focused physical examination
  The physical examination should emphasize the organ system involved. Describe the pertinent positive and negative physical findings. Transition to the physical examination with the words, "On physical examination..." 
• Pertinent diagnostic studies
  Include images (photos, x-rays, ECGs, micrographs, etc.) if they are necessary for proper presentation of the clinical scenario. All images MUST be free of copyright issues! If you cannot find a relevant image, let us know, and we will try to find one.

Things to avoid in clinical scenarios:

• Identifying the reader
  Example: You are a doctor moonlighting in a busy hospital. 
  Assume that the reader is a doctor and that hospitals are busy.
• Irrelevant or extraneous facts, including naming the patient
  Example: Mr. Smith, a 70-year-old Caucasian man presents in November with a fever and a cough. 
  The fact that the patient presents in November should only be mentioned if you want to draw attention to a seasonal condition such as influenza.
• Findings that are glossed over as “normal” or “unremarkable”
  Examples: The physical examination was normal. Potassium level was normal.
  Instead, say what was found exactly.
  Example: Potassium level was 3.9 mEq/dL.
• Identification of clinical signs by eponym
  Example: Kernig and Brudzinski signs were negative. Instead, describe what was performed and what the results were.
  Example: There was no resistance or pain on attempted extension of the leg at the knee with the thigh flexed at the hip.
• Humor
  Humor will typically irritate or distract, at least a subset of readers.

Step 3: Come up with a Question

The question should require a clearly identified clinical task:

• Diagnosis
  Examples: Which of the following is the most likely diagnosis? Which of the following best explains this patient’s current symptoms? 
• Diagnostic testing
  Examples: Which of the following tests should you order next? Which of the following is the most useful next step in the evaluation of the patient? 
• Treatment
  Example: Which of the following (drugs, procedure, counseling) should be ordered next? Which of the following is most likely to correct this patient’s problem?
• Management
  Examples: Which of the following is the best next step in management? Which of the following is the best course of action at this time?

Questions that may be used to probe for a “basic science” understanding:

• Clinical features
  Examples: Which of the following is characteristic of this patient’s illness? The clinical manifestations of this patient’s medical condition include which of the following? 
• Natural history/Epidemiology
  Examples: This patient is at increased risk for the development of which of the following? What is the most likely cause of this patient’s condition? 
• Pathophysiology/Basic science
  Examples: What is the most likely mechanism of this patient’s disease? The patient’s complaint is most likely a result of a defect in which of the following genes?
• Interpretation of literature/Statistical methods
  Example: Which of the following statements best describes the findings of these researchers?

Question types to avoid:

• Nonaction or historical questions
  Examples: Which of the following drugs should you consider prescribing in this patient? Which of the following drugs have been used in the treatment of X?
• Pseudo–vignette-based questions, i.e., a question that could be answered without reading the clinical scenario
  Example: Which of the following drugs should be used in the treatment of heart failure?
• Negatively phrased questions, i.e., questions that use the words “not,” “least,” “except,” “contraindication,” “contraindicated.” This type of question tends to be confusing and is no longer seen on the Boards.
  Examples: Which of the following is not correct? Which of the following is least likely?
• Question about doses or duration of therapy
  If the examinee knows both the drug and route of administration, that is good enough for Board purposes! 

Step 4: Define the Correct Answer

The correct answer must be scientifically sound and either evidence based or a choice that experts in your field plainly agree upon. In addition, it needs to be clearly better than the wrong answer choices.

Step 5: Develop the Distractors (Wrong Answer Choices) 

Each question must have 1 correct answer and 4 distractors (5 total answer choices). Good distractors must seem plausible to readers who don’t understand the concept rather well and must be plainly inferior compared to the correct answer choice.

Good distractors should contain some of the following features:

• Classic pitfalls, therapies, or interventions that are dangerous or ineffective but are sometimes, even if rarely, seen in clinical practice. 
  Example: "A patient who is hemodynamically unstable because of a tension pneumothorax requires immediate needle decompression" is the "correct" answer. In contrast, a downright dangerous or plainly wrong course of action would be to send the patient for a CT scan because the patient might "crash" in the radiology department. 
• Similar diseases
  Example: When writing about myasthenia gravis, think about diseases that are mechanistically similar to that disease (e.g., Guillain-Barré syndrome, hypothyroidism, botulism, or stroke). The "correct" answer for that wrong disease (e.g., lumbar puncture, TSH level) makes a terrific distractor! 
• Similar language or features
  Example: Mixed cryoglobulinemia and cold agglutinin disease have almost nothing to do with each other but both involve cold, hence are excellent decoy answers for one another! 
• Overly aggressive answer choices 
  Example: MRI for a straightforward case of mechanical back pain. 
• Overly conservative answer choices
  Examples: reassurance only, expectant management, follow-up in 6 months. 
• Special clinical features that make an otherwise right answer become wrong
  Examples: pregnancy, renal failure, and allergies. 
• Wrong route of administration
  Example: vancomycin IV for a patient with C. difficile diarrhea.
• Wrong treatment location
  A correct answer can be turned into a wrong answer by changing the location to an inappropriate one.
  Example: sending home a patient with PID with persistent nausea and vomiting and oral intolerance.

Avoid the following types of distractors:

• Obviously inappropriate answers. 
• Impossible or unrealistic answer choices.
  Example: Do not offer as answer choices experimental drugs that are only available "in Europe." 
• Answer choices that are not plainly inferior to the correct answer choices. 
• Answer choices that reference or subsume within them other answer choices.
  Examples: “All of the above” or “None of the above” or “Both A & B are correct”. 
• Answer choices that combine disparate ideas.
  Example: Advise the patient to quit smoking and then administer hepatitis B vaccination. 
• Answer choices that are physiologically the opposite of the correct answer choice.
  A physiologically “opposite” answer allows a test taker to narrow down the answer choices—without actually knowing much.
  Example: Give insulin vs. give glucose.  
• Morphologically dissimilar answers. Avoid answers that are too long, too short, or otherwise morphologically very different from the correct answer choice. 
• Answers with “explanations” in them.
  Example: Prescribe steroids [to a patient with pneumonia], because steroids will inhibit the inflammatory response.

Step 6: Write the Explanation

Tailor the explanation of the correct answer to the board testing point; separate the paragraphs as follows:

Paragraph 1: Write why the correct answer is right (may be 1 sentence).

Paragraph 2+ (optional): Supplemental information to support paragraph 1.

Paragraphs 3–6: Explain why each distractor is not correct (1 sentence per distractor in separate paragraphs).

After reading the explanation, the reader should have a clear and logical understanding why the correct answer is right and why the distractors are wrong (and in what clinical context they are right). 

Important Notes:

• Never say "choice B," etc. All answer options are randomized every time they are presented in the online products.
• At the beginning of the Explanation, the correct answer choice will automatically be quoted (e.g., Answer: D. Urgent bedside transesophageal echocardiogram"). Start writing your Explanation with this in mind.

Step 7: Compose the Board Testing Point

Use brief, clear, direct, and active language to express the board testing point.
Example: Know that vancomycin plus ceftriaxone is the empiric treatment of choice in adults with suspected acute bacterial meningitis.
Other “active” words include understand, perform, diagnose, manage, recognize, recall, etc.

Note that the Board Testing Point needs to precisely reflect the concept chosen for the Q&A!

Summary—Reviewing Q&As

• Step 1: Is the concept true, important to direct patient care or public health, not too hard, and not too easy?
• Step 2: Is the clinical scenario clear, concise, complete, and realistic? 
• Step 3: Does the question focus the reader’s mind on choosing the correct diagnosis or on selecting the best or most important next step or idea? 
• Step 4: Is the correct answer scientifically sound and either evidence-based or a choice that experts in your field plainly agree upon? 
• Step 5: Are the wrong answer choices plausible but plainly inferior and morphologically similar to the correct answer choice? 
• Step 6: Does the Explanation clearly explain why the correct answer is right and why the distractors are wrong? 
• Step 7: Does the Board Testing Point clearly articulate the testing objective that you previously identified?