Stem and lead-in (multiple choice questions)
The stem and lead-in are the first parts of multiple choice questions and are sometimes rolled into one short sentence or phrase.
These have a dual purpose:
- provide context for the question and provide any relevant information
- instruct the examinee exactly what needs to be done to answer the question correctly
On this page:
Examples
Example 1: separate stem and lead-in
- A 45-year-old man complains of back pain and hematuria. [stem]
- What is the most likely cause? [lead-in]
Example 2: combined stem and lead in
- What is the most common cause of hematuria? [combined stem and lead-in]
Best practice
Stem
- clear: the stem should be clearly written, and unambiguous; do not try and trick the examinee
- short: try and keep the stem as short as possible without, however, diminishing comprehension (e.g. avoid acronyms)
-
avoid negatives
- in most instances, stems should be worded to achieve a positive/true answer, as this reinforces knowledge.
- positive: "In what demographic is MS most common?"
- negative: "In what demographic is MS least common?"
- sometimes the learning goal is a negative answer and if this is the case the negative term should be ALL CAPS and emboldened (e.g. "Which of the following is FALSE?") to avoid misreading
- read more about negative questions
- in most instances, stems should be worded to achieve a positive/true answer, as this reinforces knowledge.
- avoid double negatives: double negatives are never needed and should be avoided
-
use the present tense
- generally, the stem should be in the present tense (e.g. "A 50-year-old male presents with abdominal pain and a CT scan is performed")
- avoid teaching: questions are questions, not didactic teaching. Therefore avoid including non-question specific facts within stems.
Content order
When writing the stem, try to stick to a natural order that places content in an order that has maximal readability and limits confusion:
- age/sex
- relevant history
- presenting signs and symptoms
- what was done
- lead in question
Lead-in
The lead-in follows the stem and is used to instruct the examinee as to exactly what is required to answer the question correctly. It can either be in the form of a question or a phrase needing completion.
- question-type lead-in
- "What is the most likely diagnosis?"
- "Which of the following is FALSE?"
- completion-type lead in
- "The third branch from the arch of the aorta is..."
- "All of the following are reasonable diagnoses EXCEPT..."
It is essential that for the completion type lead-in, that the alternatives (see below) are phrased in such a way that they grammatically finish the lead-in appropriately – in other words, you should be able to read the lead-in followed by each alternative, and it should make sense.
Style
Both the stem and lead-in should have normal sentence capitalization and punctuation. There are a few special notes specific to multiple choice questions:
- question-type lead-ins should finish with a question mark ( ? )
- e.g. "What is the most likely diagnosis?"
- completion-type lead-ins should finish with an ellipsis ( ... )
- e.g. "The most common cause of a headache is... "
- if the lead-in is asking to pick the single wrong answer (negative question) the negative word should in be in ALL CAPS and emboldened, to make it harder to misread
- e.g. "Which of the following is FALSE?"
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