ACP Guidelines for Writing Multiple-Choice MOC Questions  ​

  • Write only single-best-answer questions, which includes
    • Stem or clinical scenario. This may not be necessary for a very short question.
    • Actual question that is being asked
    • Option set (a correct answer and three distracters)
    • Rationale for the correct answer
    • One (1) Citation.
 
  • Do not write questions with more than one correct answer.
    • Incorrect answers (distracters) should be plausible and should appear correct to less-well-prepared learners.
    • Distracters may be partially correct and may reflect commonly confused ideas and outdated information.
  • Do not write negative questions (e.g., “Each of the following is true EXCEPT,” “Which of the following is NOT likely?”). 
  • Make options similar in length, complexity, and grammatical construction
  • avoid using absolute terms such as “never” and “always.”
  • Do not use “all of the above” or “none of the above” as options.
Following are examples of questions in the format appropriate for submission to the College.

Sample Question 1
Which of the following is the most appropriate initial diagnostic test for a patient presenting with new-onset heart failure?
  1. B-type natriuretic peptide measurement
  2. Cardiac CT
  3. Cardiac MRI
  4. Echocardiogram

Answer: D
Rationale:
An echocardiogram should be obtained in all patients with newly diagnosed or suspected heart failure to define whether the heart failure is systolic or diastolic and whether there are any structural or functional abnormalities that may be the cause (such as regional wall abnormalities, pericardial disease, or valvular abnormalities). All of these findings may have a significant impact on management and prognosis. For example, several studies have shown that the extent of left ventricular cavity size, left and right ventricular ejection fractions, and the presence of diastolic dysfunction are predictors of survival.
 
Citation:
Heart Failure Society of America, Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16(6):e1-194. PMID: 20610207
 
Sample Question 2
In the Opioid Risk Tool, which age grouping is associated with highest risk of aberrant opioid-taking behaviors that are concerning for opioid misuse?

  1. Age less than 15 years
  2. Age less than 45 years
  3. Age less than 55 years
  4. Age less than 65 years
 
Answer: B
 
Rationale:
The Opioid Risk Tool (ORT) predicts that patients whose age is less than 45 years have the highest risk for opioid-related aberrant behaviors. The ORT measures the following risk factors associated in the scientific literature with substance abuse: personal and family history of substance abuse, age of patients, history of preadolescent sexual abuse, and history of certain psychological disorders. Patients received scores of 0-3 (low risk), 4-7 (moderate risk), or greater than/equal to 8 (high risk), indicating the probability of their displaying these aberrant behaviors.
 
Citation:
Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432-42. PMID: 16336480
 
Sample Question 3
 
A 62-year-old man with COPD uses inhaled tiotropium once daily and as-needed inhaled albuterol.  Oral glucocorticoids have been prescribed three times in the past year for COPD exacerbations. 
 
Continuous therapy with which of the following medications is most appropriate to prevent exacerbations of COPD in this patient?

  1. Inhaled fluticasone
  2. Inhaled fluticasone-salmeterol combination
  3. Oral prednisone
  4. Oral theophylline
 
Answer: B
 
Rationale:
Combination inhaled fluticasone-salmeterol should be prescribed. Acute exacerbations of COPD are important causes of morbidity and mortality.  Exacerbations can be prevented by several interventions, including smoking cessation and influenza and pneumococcal pneumonia vaccination.  Combination inhaled glucocorticoids and long-acting β-agonists, one of which is fluticasone-salmeterol, are important pharmacotherapies that reduce the frequency of COPD exacerbations and should be considered in patients with two or more exacerbations per year.
 
Citation:
Papalia R, Franceschi F, Vasta S, Gallo A, Maffulli N, Denaro V. Shoulder stiffness and rotator cuff repair. Br Med Bull. 2012;104:163-74. PMID: 22334282.