The impact of cueing on written examinations of clinical decision making: a case study

CONTEXT: Selected-response (SR) formats (e.g. multiple-choice questions) and constructed-response (CR) formats (e.g. short-answer questions) are commonly used to test the knowledge of examinees. Scores on SR formats are typically higher than scores on CR formats. This difference is often attributed to examinees being cued by options within an SR question, but there could be alternative explanations. The purpose of this study was to expand on previous work with regards to the cueing effect of SR formats by directly contrasting conditions that support cueing versus memory of previously seen questions. METHODS: During an objective structured clinical examination, students (n = 144) completed two consecutive stations in which they were presented with the same written cases but in different formats. Group 1 students were presented with CR questions followed by SR questions. Group 2 students were presented with questions in reverse order. Participants were asked to describe their testing experience. RESULTS: Selected-response scores (M = 4.21/10) were statistically higher than the CR scores (M = 3.82/10). However, there was no significant interaction between sequence and format (F(1,142) = 1.59, p = 0.21, ηp2 = 0.01) with scores increasing from 3.49/10 to 4.06/10 in the group that started with CR and decreasing (4.38/10-4.15/10) in the group that started with SR first. Correlations between SR scores and CR scores were high (CR first = 0.78, SR first = 0.89). Questionnaire results indicated that students felt the SR format was easier and led to cueing. CONCLUSION: To better understand test performance, it is important to know how different response formats could influence results. Because SR scores were higher than CR scores, irrespective of the format seen first, the pattern is consistent with what would be expected if cueing rather than memory for prior questions led to higher SR scores. This could have implications for test designers, especially when selecting question formats.