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Area of Science:

  • Medical Education
  • Cognitive Psychology
  • Assessment Science

Background:

  • Multiple-choice questions (MCQs) are widely used in medical education and for physician licensure.
  • The validity of MCQs relies on the assumption that they elicit cognitive processes similar to real-world clinical reasoning.
  • Dual-process theory provides a framework for understanding cognitive processes in reasoning.

Purpose of the Study:

  • To explore the cognitive processes elicited by clinical-vignette MCQs.
  • To investigate the alignment between MCQ-elicited reasoning and dual-process theory.
  • To examine the validity of using MCQs to assess clinical reasoning.

Main Methods:

  • Fourteen medical professionals (students, residents, staff physicians) completed 15 timed MCQs.
  • Participants engaged in retrospective think-aloud (TA) protocols after answering MCQ sets.
  • Qualitative thematic analysis using constant comparative analysis (CCA) informed by dual-process theory was performed.

Main Results:

  • Examinee behaviors were categorized into clinical reasoning, test-taking, and reactions to MCQs.
  • Clinical reasoning behaviors aligned with dual-process theory, showing both analytical and non-analytical reasoning.
  • Test-taking behaviors and reactions to MCQs were also observed, some appearing inauthentic to real-world practice.

Conclusions:

  • Findings provide validity evidence supporting the use of MCQs to measure clinical reasoning.
  • MCQs appear to elicit cognitive processes consistent with dual-process theory.
  • Further research is needed to explore authenticity of behaviors in other assessment formats and their relation to MCQ performance.