Stem and lead-in (multiple choice questions)

The stem and lead-in are the first parts of [multiple choice questions](multiple-choice-questions) and are sometimes rolled into one short sentence or phrase. 

These have dual purposes: 

1. provide context for the question and provide any relevant information

2. instruct the examinee exactly what needs to be done to answer the question correctly

Examples

Example 1: separate stem and lead-in

• A 5-year-old Dachshund presents with acute paraparesis. [stem]

• What is the most likely cause? [lead-in]

Example 2: combined stem and lead-in

• What is the term for heart failure caused by pericardial effusion?? [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 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: "Which neoplasia is most likely to affect the skull in dogs?" 

    • negative: "Which neoplasia is least likely to affect the skull in dogs?"

• sometimes the learning goal is a negative answer and if this is the case the negative term should be in ALL CAPS and emboldened (e.g. "Which of the following is FALSE?") to avoid misreading

• read more about negative questions

• 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 5-year-old neutered male pug 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:

1. age/sex/breed

2. relevant history

3. presenting signs and symptoms

4. what was done

5. 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 tributary of the portal vein closest to the liver 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 diagnostic test would you recommend next?"

• completion-type lead-ins should finish with an ellipsis ( ... )

  • e.g. "The differential diagnoses for a cranial mediastinal mass are... "

• if the lead-in is asking to pick the single wrong answer negative question the negative word should be in ALL CAPS and emboldened, to make it harder to misread

  • e.g. "Which of the following is FALSE?"