Collaborative Teaching: One Way to Improve Teaching and Learning

by Giang Le, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-Golden Triangle

I came across this interesting article the other day entitled “Teacher collaboration in curriculum design teams: effects, mechanisms, and conditions.”¹ This article got me thinking about my years in school. I recall only a few class sessions that had two or more teachers providing instruction together. For many courses, students are essentially learning from one teacher’s perspective — which is to say, one person’s perspective. Students might assume that what that teacher says is accurate and that piece of information must be the best answer.  I’m not sure that’s always true.  From the teacher’s perspective, I wonder if they get bored teaching the same materials every year? Do teachers ever get so used to their way of teaching that they become reluctant to change? Or unaware of the need to update their content or instructional methods? Maybe teachers need a partner. Maybe instruction is better when taught by a team. Indeed, there is evidence that collaborative teaching can help teachers update their knowledge, improve their practice, and enhance learners’ outcomes.^1,2

What are collaborative teaching design teams? These teams involve educators working together to design all classroom activities, including developing a curriculum, selecting the most effective teaching methods, creating test questions, and developing tools to assess performance. An essential part of being an educator is to continue to learn – not only about the content but also ways of teaching. However, it can be hard to keep up with all the newly available information, especially when there are thousands and thousands of scientific articles published every day. In the process of balancing work life and personal life, teachers can find themselves in situations where they quickly skim an abstract or a summary. Teachers often rely on their existing knowledge and beliefs to develop learning materials. This is when collaborative teaching can be of benefit. Having people with different knowledge, skills, and perspectives on a team creates more opportunities to share knowledge.¹ If a conflict arises (a conflict of ideas, not philosophies or personalities), teachers will have to provide evidence to support their reasoning and convince their peers. In this process of solving “constructive” conflicts, teachers begin to self-reflect on their existing knowledge and their ways of practice. Self-reflection is a critical and we should practice it every day, but it is always easier said than done. Collaborative design teams create the opportunities for constructive conflict and stimulate self-reflection.

One may agree that collaborative teaching can improve teachers’ knowledge, but the more important question is: Can it improve learner outcomes? That’s the ultimate goal that every educator should strive to achieve — improvements in students performance. This means that at the end of the course, we want our students to not only understand or recall but also be able to apply the materials in a variety of circumstances. Theoretically, all teachers should have a tool to assess the students’ performance to guide their teaching. With collaborative teaching design teams, teachers can work together to create these tools. Everyone can contribute based on their experience and what’s available in the educational literature. 

In a recent study, the investigators examined three specific forms of collaboration in teaching: (1) instruction-related, (2) project-related, and (3) organization, performance, and problems-related. Their study is a secondary analysis of the German Program for International Assessment (PISA) data. A sample of 869 schoolteachers was matched with a corresponding sample of 869 students. Students’ achievement in this study was measured by comparing their grades in the first half-year of the academic period. The relationship between the different forms of teacher collaboration and student achievement was estimated through a structural equation model. They found that the third form of collaboration—modified teaching based on students’ performance—positively influenced students’ achievement. However, an interesting aspect of this study was that the subject matter taught were primarily sciences (like maths, biology, physics, and chemistry). This might explain why the third form of collaboration focusing on practice problems would produce a positive outcome. In other subjects involving more discussions and debates, the knowledge-sharing and planning process might play a more important role.

Collaborative teaching design teams can theoretically improve other aspects of the learning process. For example, I remember when my class was divided into groups to do group assignments. From time to time, the professor would be occupied with one group and unavailable to others. This quickly led to frustration among students who had a hard time understanding the materials. Instructions that may seem easy to follow for the professor might not be interpreted the same way by the students. To finish the assignment within the class period, the students would turn in poorly done work and minimal learning occurred. Collaborative teaching would give students greater access to more instructors. This benefit also applies to practical labs where one professor cannot supervise the whole class to ensure everybody follows the instructions.

How do we implement effective collaboration? This process can be time-consuming since it requires team members to gather, discuss, and revise the course materials. A course may need to be developed a year in advance and regularly revised based on students’ feedback and performance. Another strategy for effective collaboration is to allow time to build relationships and foster a culture of trust, respect, and humility between the teachers on the team.³ It is best if each team member is willing and able to contribute in meaningful ways to the work of the group. Here is my favorite quote about teaching collaboration: “As a successful co-teacher, you need to (a) know yourself, (b) know your partner(s), (c) know your students, and (d) know your ‘stuff’.”⁴  Teachers will vary in their ability to effectively collaborate. Some may find it hard to work with partners who have different beliefs and teaching styles.  Others may find it hard to assess how well the students understand the materials. If teachers know their strengths and weaknesses, they can complement each other and support one another. While team teaching can be great, forcing collaboration when teachers are not on the same page will create more classroom confusion and negatively affect learners’ outcomes.

Collaborative teaching is an ongoing process with evidence that it can improve teachers’ and learners’ outcomes. Teachers may find the collaboration not only a beneficial way to enhance their knowledge but also an opportunity to update what and how they teach.  Like any form of collaboration, the process will take time, effort, and commitment to achieve success.

References

1. Voogt JM, Pieters JM, Handelzalts A. Teacher collaboration in curriculum design teams: effects, mechanisms, and conditions. Educational Research and Evaluation. 2016; 22: 121-140.
2. Mora-Ruano JG, Heine JH, Gebhardt M. Does teacher collaboration improve student achievement? Analysis of the German PISA 2012 sample. Frontiers in Education. 2019; 13: Article 3389. (Accessed 2021 Oct 12).
3. Lauren D. Teacher collaboration: how to approach it in 2020. Schoology Exchange. 2020. https://www.schoology.com/blog/teacher-collaboration (Accessed 2021 Oct 12).
4. Keefe EB, Moore V, Duff F. The four “knows” of collaborative teaching. Teaching Exceptional Children. 2004; 36 (5): 36-42.

Listen, Clarify, and Appreciate! Best Practices When Receiving Feedback

by Camron Jones, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

 “It takes humility to seek feedback. It takes wisdom to understand it, analyze it and appropriately act on it”
-Stephen Covey.¹

What do you feel when you hear the word feedback? Do you feel nervous?  Perhaps scared about what the person might say? Do you clam up thinking you have done something wrong? I have a love/hate relationship with feedback. I love knowing how I am performing.  But I sometimes fixate on the things I did “wrong.” It can be intimidating and sometimes we get stressed out about the small things. For many people, it’s hard to accept feedback because it’s perceived as a negative judgment. I have grown to appreciate feedback because it helps me understand what I am doing well and what I need to work on. I think it’s intimidating to ask for feedback. This is something that I am working on. Not only is feedback hard to ask for, but it’s hard to give.

Feedback is the act of someone providing information about a person’s performance of a task and the recipient using the information as a basis for improvement.² Frequently we talk about how to formulate feedback so that we can help another person excel. But receiving feedback is a critical skill too. All of us need to learn to receive feedback graciously and not jump to conclusions. Both giving and receiving feedback are difficult! If we use the right techniques, we can learn as well as teach others. Let’s take a deep dive into receiving feedback by examining the best practices and how to teach it.

There are three crucial steps that should be adhered to if we want to maximize the benefits of receiving feedback. These include actively listening, clarifying the feedback, and expressing gratitude.^3,4  Listening with an open mind is a huge part of the feedback process. Listening promotes our personal and professional growth. Too quickly we jump the gun and interrupt the person providing the feedback. In the Christian Bible, there is a saying that resonates with that I believe applies to receiving feedback: “..let every man be swift to hear, slow to speak.” When receiving feedback, we must consider all of it before responding. Reflecting on the feedback is so important because it helps us grow.

When you hear words that you interpret as negative it can bring you down. But it’s important to ask questions because without getting clarification, you can create an injustice and take feedback too personally. The feedback is about your performance, not about you as a person. I feel like this is critical to understanding how to receive feedback. The person giving the feedback is only trying to help us succeed and grow.  If we dismiss or reject the feedback, we are disadvantaging ourselves.  So, ask clarifying questions!  Make certain you fully understand what the person giving the feedback is telling you. Ask for specific examples.

Finally, it’s important to express appreciation to the person providing the feedback. Remember, the person giving the feedback is usually uncomfortable.  Giving feedback and telling someone something they might perceive as negative can be intimidating. It's easier just to not say anything.  Or to tell someone everything is perfect. But the person giving feedback took the time to carefully consider how to help you improve and they want you to succeed! If we show appreciation, they will feel encouraged and more willing to share with us. 

Tips for Receiving Feedback:3

Be a good listener When in doubt, ask for clarification Embrace the feedback session as a learning opportunity Remember to pause and think before responding Avoid jumping to conclusions, and show that you are invested in the learning process and keen to improve Think positively and be open to helpful hints Learn from your mistakes and be motivated Be a good sport and show appreciation Be proactive – ask for feedback!

Studies have repeatedly shown that effective feedback has a powerful influence on how people learn. In one study involving medical students, they looked at methods to teach how to use feedback. They developed a 2-hr workshop that focused on writing goals in a learning contract, defining effective characteristics of feedback and practicing the use of feedback in response to feedback received. Following the workshop, student group scores increased significantly. They also looked at how coaching improved students' perception of their feedback skills. They noted how students' feedback interactions improved, especially during informal interactions. In a model that defines the communication pathway, they described how the process of feedback could falter. This could be due to previous experiences from the receiver, also the fear of damaging relationships between the giver and receiver.⁴

Another study enrolled second and third-year internal medicine residents. This study focused on a One-Minute Preceptor model. This was a conversation between the resident and the teacher to help improve the resident's clinical skills. One of the greatest benefits of the One-Minute Preceptor model is feedback. At baseline, feedback was ranked as one of the weaker areas. Significant improvements were reported at the end of the study. Feedback was shown to have the greatest impact on performance.⁵ 

Another good resource is the ask-tell-ask feedback model.⁶ For example, say you are a student, and you provided education to a patient about anticoagulation therapy. With the first ask, the preceptor asks the student to talk about how they thought the experience went. The preceptor then gives feedback on what was observed, both positive and negative aspects of the performance.  This is the tell component of the model. During the last ask, the student then reflects on what the preceptor has told them and they both set goals moving forward.⁶ This allows the receiver to actively participate in the conversation and formulate an action plan. I personally experienced this method of feedback in my last year of pharmacy school. Not only did it help me improve, but it also helped me be more open to feedback.

As teachers, we must learn to give feedback in a way that positively affects our students. We should allow students time to self-reflect before giving feedback. This gives the students an opportunity to think about the strengths and weaknesses of their performance. As a learner, we must learn from the feedback and use it as a tool for us to improve. Be sure to listen, clarify, and appreciate!

References

1. Covey, SR. Stephen R. Covey interactive reader-4 books in 1: The 7 habits of highly effective people, first things first, and the best of the most renowned leadership teacher of our time (Internet). Mango Media. 2015 (Cited 2021Oct1)
2. “Feedback”. Merriam-webster.com dictionary, merriam-webster. www.merriam-webster.com/dictonary/feedback. (Cited 2021Sept29).
3. Hardavella G, Aamil-Gaagnat A, Saad N, et. al. How to give and receive feedback effectively. Breathe 2017; 13:327-333. 
4. Bing-You RG, Bertsch T, Thompson JA. Coaching medical students in receiving effective feedback. Teaching and Learning in Medicine 1998; 10(4):228-231. 
5. Furney SL, Orsini AN, Orsetti KE, et al. Teaching the one-minute preceptor. J Gen Intern Med. 2001;16:620-624.
6. Jug R, Jiang X, Bean S. Giving and receiving effective feedback: a review article and how to guide. Arch Pathol Lab Med 2019; 143 (2):244-250.

The Flipped Classroom Model in the Age of Virtual Learning

by Emily Plauche, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Virtual learning played a huge role in higher education during the COVID-19 pandemic. In March 2020 when the pandemic first began to spread in the United States, educators had little time to transition to an online learning environment. Some schools gave students a few weeks off to allow time for administrators and teachers to make plans and learn how to use the technology while others immediately transitioned to an online platform with little guidance. Virtual teaching can be done synchronously via platforms such as Zoom and asynchronously using pre-recorded lectures or other online resources. Live classes allow for more interactive learning but may be limited by technical difficulties and students’ access to technology. Pre-recorded lectures provide students with more flexibility in terms of how and when they prefer to study, but students may feel disconnected from their classmates and instructors.¹  In order to best recreate the flipped classroom model, asynchronous pre-class assignments with synchronous/ live in-class activities would be ideal. Now that the education system has had more time to adapt and is able to provide almost all features of an in-person classroom experience in a virtual platform, it raises the question of whether the flipped classroom model is still effective in a virtual learning setting.  Giving students the option to attend class in person or online may become common practice as the COVID-19 pandemic persists, technology advances, and our comfort with virtual learning grows. 

The flipped classroom model is a somewhat new teaching strategy that focuses on in-class application, rather than lecturing. Instead of homework after class, students complete pre-class assignments in order to prepare for class and class time is reserved for discussions, case studies, and other activities that require students to apply what they learned prior to class. The flipped class has become increasingly popular over the last decade. A meta-analysis studying the flipped classroom model in health professions education found that the model provided several benefits including a statistically significant improvement in learner performance compared with traditional teaching methods, more time for active learning during class time, and the opportunity for students to study at their own pace before class. The analysis also found that more students favored this method of learning over traditional lecturing. However, this model requires students to prepare ahead of time in order for the activities in class to be productive. The increased burden on the student can be a limitation to its success and should be considered when teachers assign out-of-class activities.²

Traditionally, pre-class assignments are done remotely via pre-recorded lectures and required readings, and the interactive classroom activity is done in person. However, COVID-19 required all learning activities to be done virtually. Educators wanting to implement this model while teaching virtually should provide both pre-recorded lectures and live but virtual classes in order to effectively mimic the model. The question is whether a flipped classroom model is still effective in an online learning environment. A study performed in Spain specifically compared performance and emotions towards the flipped classroom model in undergraduate STEM courses before and after the COVID-19 pandemic comparing two groups: “face to face” and “face to screen.” The course consisted of three hours of live class with pre-recorded lessons to watch in preparation for class in both groups. The instruction methodologies, syllabi, and structure were identical in both groups. The study did not disclose what type of assessments were used but the “pass rate” was similar in the two groups with 67.1% of students in the face-to-face group achieving a “passing” score compared with 70.3% in the face-to-screen group.  The difference was not statistically significant. Face-to-face instruction was associated with more positive emotions such as enthusiasm, confidence, tranquility, and fun while face-to-screen instruction was associated with more negative emotions including concern, nervousness, fear, and boredom.³

Some of these negative emotions observed in the face-to-screen group were likely influenced by the uncertainties at the beginning of the pandemic and were not solely due to virtual learning. As students become more acquainted with distant learning, it is likely the virtual classroom will be perceived less negatively. However, student engagement and attention in the virtual classroom may be persistent challenges. It is promising that there was not a statistically significant difference in performance between the groups, suggesting that the flipped classroom is an acceptable approach to teaching in a virtual setting.

Instructors can work to increase virtual student engagement by offering a variety of ways for students to participate. Some may prefer to use the microphone, type in a chat box, or use the raise hand feature. By offering multiple options, students are able to interact in a way that they feel most comfortable. Breakout rooms can also be used to facilitate work in small groups, which might reduce students' anxiety about taking in front of a large group. Teachers can also ask their students for feedback throughout the semester to better understand students’ needs and concerns. To minimize technical difficulties, teachers should perform test runs before live class sessions to ensure Zoom links, internet connection, and sound are working properly.

The flipped classroom model allows for more interactive classroom experiences between students and teachers and has been shown to improve student performance when compared to more traditional methods to teach. While we have limited data from studies, the flipped classroom method still works in a virtual classroom setting. Teachers planning to utilize the flipped classroom model in an online class may face challenges including technical difficulties along with reduced student engagement, attention, and attitude towards virtual learning. Teachers should keep this in mind as they develop material to teach virtually. As more research is published about online teaching methods, educators will have a better understanding of how to approach teaching in virtual classrooms.

References:

1. Camargo CP, Tempski PZ, Busnardo FF, Martins M de A, Gemperli R. Online learning and COVID-19: a meta-synthesis analysis. Clinics 2020;75: e2286.
2. Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ. 2018;18(1):38.
3. Jeong JS, González-Gómez D. A STEM Course Analysis During COVID-19: A Comparison Study in Performance and Affective Domain of PSTs Between F2F and F2S Flipped Classroom. Front Psychol. 2021;12:669855.

Get Down with the Feeling: Teacher Empathy

by Taylor Adcock, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Empathy involves understanding another person’s experiences by imagining oneself in the other person’s situation.¹ We live in an increasingly diverse society today and empathy improves social cohesiveness.  For this reason, empathy is particularly important in classrooms and influences how teachers and students interact. Studies have shown that cognitive and emotional empathy can promote students’ learning as well as help teachers have a more positive mindset and avoid burnout.^2,3,4 Teacher empathy is not a widely talked about subject. This article will look at how teacher empathy can help promote student learning and success.

The term empathy originates from a German word that means "feeling into.” There are two forms of empathy: emotional and cognitive. Most people conceptualize empathy as emotional empathy whereby the individual feels the same emotion as another person.  When a person has personal distress, emotional empathy enables us to feel compassion or empathic concern. Empathic concern is typically developed later in life as it builds off and requires more self-control. Empathic concern also triggers prosocial and helping behaviors.  Emotional empathy is positively correlated with a willingness to help people even if it requires personal sacrifices.¹ Intense emotional empathy is often called empathic accuracy. Empathic accuracy allows a person to have more accurate and complete knowledge about what is going on in a person’s mind and how they feel.

Cognitive empathy is the extent to which we perceive or presuming another person's thoughts and feelings.  This can involve an understanding of what someone might be thinking during tasks – from simple tasks to more complex ones. Simple tasks can include visually perceiving standing in a classroom teaching and imagining what another person walking by the classroom might see (observe). Complex tasks can include thinking about what a group might perceive or think. Cognitive empathy still requires sensitivity and knowledge of what other people are thinking and feeling but does not necessarily mean that a person cares about the other person.  This means cognitive empathy can be used to harm others. Con artists, for example, have well-developed cognitive empathy in that they understand what others are likely thinking and feeling but they don’t care about the welfare of the person they are taking advantage of. Cognitive empathy is part of our mental development because we grow to understand that another person's thoughts differ from our own.¹ 

Studies that have looked at teacher empathy toward students have found that it can have a positive influence on both students and teachers. One study looked at empathetic climates in the classroom and measured student success.² Empathetic climates are created when the teacher pays attention to student opinions, values what students have to say, and when students believe the teacher “understands our frame of references”. The study enrolled nearly 500 middle and high-school students. Results from this study showed that an empathetic climate was positively correlated with students’ success even if a class was deemed particularly hard. Success was defined by students ranking their performance in the course using a 6-point Likert scale. The students succeeded, even in difficult classes, if they felt unconditional regard from the teacher.

Another study followed 178 elementary school teachers and looked at the benefits teachers received based on their level of cognitive empathy. Results showed that higher levels of cognitive empathy were associated with lower job burnout, positive mindsets about student behavior, better relationship closeness, and better competence in handling students’ problem behaviors. On the other hand, teachers who experienced high empathetic distress, such as becoming overwhelmed by the student’s emotional experiences, showed that there was higher job burnout, less competence with students’ problem behavior, negative mindsets with misbehavior, and fewer problem-solving strategies.³

There are 4 ways that teachers (you) can create a more empathic climate:⁴

1. Perspective-taking –this means putting aside your perspective and looking at the situation from a different angle. Consider asking, “Do I believe my students are doing the very best they can?”  Every student is not going to have the same skill set when it comes to learning which means they may be trying their best already. Encouraging them through a challenging subject is important.
2. Putting aside judgment – this means to step back and not jump to conclusions solely based on what is seen. Consider asking, “What more do I need to learn and understand about the situation?”  For example, if you have a student who is struggling with assignments and submitting them on time, do not assume that they are lazy. Come in at a different angle and make sure that home life is okay first.
3. Trying to understand the student’s feelings – tap into your own experiences to try to find a way to understand what the student is going through or to remember when you went through a similar experience; however, remember that everyone does not feel the same things, and we each have unique experiences. Consider asking, “What more do I need to learn and understand about how other people are reacting to or perceiving the situation?” If a student loses a family member, it is important to try and understand how you felt at this time and then give leniency as the student may or may not have difficulty coping.
4. Communicate that you understand – talk to students with reflective phrases such as “It sounds like you…” or “I hear that you…”; this can help build trust and can help students to solve problems, with you in the beginning and eventually on their own. This step requires self-reflection so consider asking, “What more do I need to learn and understand about how I react?” and “What more do I need to learn about how to communicate to others that I hear them, even while experiencing my own emotions?” For example, if a student has many tests one week and is late on assignments, reaching out and say “It sounds like this week may have been overwhelming for you.”

Empathy is understanding what others are feeling and thinking and is associated with helping behaviors even it involves some personal sacrifice. Empathy also involves an understanding that we do not all think in the same manner. Teachers who cultivate an empathetic climate can achieve positive outcomes not only for the student but also for themselves.

References:

1. Hodges SD, Myers MW. Empathy. 2007 (Accessed 2021 Sept 11).
2. Bozkurt T, Ozden MS. The relationship between empathetic classroom climate and students’ success. Procedia - Social and Behavioral Sciences. 2010;5:231–4.
3. Wink MN, LaRusso MD, Smith RL. Teacher empathy and students with problem behaviors: Examining teachers’ perceptions, responses, relationships, and burnout. Psychology in the Schools. 2021;58(8):1575–96.
4. Morin A. Teaching With Empathy: Why It’s Important. Understood.org [Internet]. (Accessed 2021 Sep 11).

Creating Valid Multiple-Choice Exams

by Scott Ross, PharmD, PGY1 Pharmacy Practice Resident, Mississippi State Department of Health

With increased class sizes and teacher load, multiple-choice exams have become the primary method for evaluating health professions students. There are many pros and cons to using multiple-choice tests. This article aims to investigate the cons and improper techniques and offer potential solutions to improve the quality of questions and enhance student learning.

Multiple-choice exams remain a popular form of assessment because they have several advantages, including ease of grading, standardization, the objectiveness of scoring, and the ability to test many discrete concepts. And teachers can administer multiple versions of the same test.^1,2 Furthermore, evidence suggests that a well-constructed multiple-choice exam is just as effective as a short-answer test in terms of promoting the retention of material.^3,4 However, a poorly constructed multiple-choice exam will not accurately measure learning and can lead to frustration. There are several best practices that many teachers fail to follow, including using "all of the above" or "none of the above" answer choices, writing "throw-away" answers as potential choices, asking students questions that focus on their ability to memorize and recall trivial details, and authoring stems that are unclear/vague.^1,5

While seen commonly on multiple-choice exams, the "none of the above" answer choice leaves students wondering what the correct answer is. Indeed, it could be argued that the best possible answer is not among the answer choices, and thus "none of the above" would always be the best option. In many cases, students view "none of the above" as a throw-away answer that can be ignored. Similar but different issues arise with the "all of the above" answer choice. Using the "all of the above" answer choice may have the benefit of determining if the student is aware that more than one choice is correct, but this quickly results in guessing and relying on partial knowledge of the material to answer correctly.⁶ When the "all of the above" choice frequently appears on an exam, students will likely pick up on trends and will lean towards selecting this answer even when they lack an understanding of the material. Thus, "none of the above" and "all of the above" answer choices should be avoided.⁶ Instead, consider using "select all that apply" questions because they thwart guessing — but admittedly, they are more difficult. To discourage guessing, some instructors award points for each correct response but take off points if a student selects an incorrect answer or does not select a correct response.¹ While this is undoubtedly more challenging, it is more efficient and less cognitively demanding than asking students to respond to series of open-ended questions.

Another common issue when constructing multiple-choice tests is including "throw-away" answers — answers that are so obviously incorrect that even those who do not know the subject matter can quickly eliminate them. Including these answer choices is harmful because it increases the odds of guessing correctly. It is a best practice to include at least 3 but no more than 5 plausible answer choices.⁷  The key word here is plausible – at least they should seem reasonable to the learner who is not sufficiently knowledgeable about the subject matter.

Some critics of multiple-choice testing state that exam scores using this format do not always correlate to the learner's understanding of the material — the method simply asks students to memorize and recall information.⁵ This is important to keep in mind when forming questions as many instructors rely too heavily on "recall" or knowledge-based type questions. While they are more challenging to write, it is possible to create questions that require critical thinking. Forming thoughtful questions that require students to analyze, apply, and evaluate is vital to ensuring they develop the skills needed in their future careers.

Another common problem is forming misleading or vague question stems or answer choices that lead to confusion or misunderstandings. It is also best to avoid negative phrasing (e.g., "which of the following is not true …") in exams since this can cause students to misread the question. If a question truly cannot be phrased positively, it is best to make the negative wording stand out by using italics, capitalization, or bolding of the word(s). Having clear answer choices is just as important as forming clear question stems. An excellent way to ensure that questions and answers are worded clearly and concisely is to send the material to someone else to review. It is crucial to keep in mind how the answer choices relate to each other. Answer choices should be homogenous in the sense that they relate to the same content and have a similar sentence structure and length. This is to prevent giving clues to students as to what the correct answer is. Another strategy to prevent clues is to always present the choices in numerical or alphabetical order.

Perhaps the biggest concern with multiple-choice tests is the format itself. Most choices will not be provided to the health professional.  Rather they must recall and weigh the potential options themselves.  Thus, multiple-choice exams are not authentic assessments — they do not reflect real life. Real-life decision-making comes from generating choices for ourselves and formulating our own answers by considering multiple pieces of information and then making a judgment. Thus, relying solely on multiple-choice assessments to determine a student's progress does not accurately reflect whether a student is competent.  Other forms of assessment, including objective structured clinical exams (OSCE), evaluations of authentic work products, and observations during field-based activities, must also be used.

Creating valid multiple-choice exams is a vital skill that all teachers should master to ensure their students have mastered the material. However, there are several common problems that should be avoided, and multiple-choice assessments have several limitations. Using a combination of assessment strategies is essential to get a comprehensive view of each student's knowledge, skill, and abilities.

 

References

1. Weimer M. Multiple-choice tests: Revisiting the pros and cons [Internet]. Faculty Focus. 2019 [cited 2021Sep19].
2. Medawela RMS, Ratanayake DRDL, Abesinghe W, et al. Effectiveness of "fill in the blanks" over multiple choice questions in assessing final year dental undergraduates. Educación Médica 2017, 19 (2): 72-76.
3. Khan JS, Mukhtar O, Tabasum S, et al. Relationship of Awards in multiple choice questions and structured answer questions in the undergraduate years and their effectiveness in evaluation. Journal of Ayub Medical College 2010; 22 (2): 191-195.
4. Haynie W. Effects of Multiple-Choice and Short-Answer Tests on Delayed Retention Learning [Internet]. Journal of Technology Education 1994; 6 (1): 32-44.
5. Fors K. Opinion: Multiple choice tests don't prepare students [Internet]. The Utah Statesman. 2020 [cited 2021Sep19].
6. Butler A. Multiple-choice testing: Are the best practices for assessment also good for learning? [Internet]. The Learning Scientists. 2017 [cited 2021Sep19].
7. Butler AC. Multiple-choice testing in education: Are the best practices for assessment also good for learning?. Journal of Applied Research in Memory and Cognition 2018; 7 (3): 323-331.