. 2015 Sep 8;4(5):244–251. doi: 10.1007/s40037-015-0212-x

Table 2.

Example of the intervention (italics) performed on items in Experimental Subgroup A (removal of item writing flaws and enhancement of tested cognitive level) and Experimental Subgroup B (replacement of non-functioning distractors)

Before	After
Experimental Subgroup A Which of the following best describes the location of the prostate gland? A: Inferior and posterior to the neck of the bladder in the rectovesical pouch B: At the neck of the bladder superior to the pelvic diaphragm** C: At the neck of the bladder inferior to the pelvic diaphragm D: In the superficial perineal pouch E: In the deep perineal pouch The topic of interest in this item was ‘location of the prostate gland’. The item was found to be testing low cognitive level owing to plain recall of a fact (i.e., location of the prostate gland). Moreover, the following flaws were identified in this item: a. Long or complicated options b. Non-logical order of options	SHA studied the topic ‘location of the prostate gland’ from recommended texts and developed the following clinical vignette to assess knowledge of the same topic at a higher cognitive level. A 72-year-old male, in relatively good health, complains of frequent urination, weak stream, and post-void feeling of residual urine. Digital rectal exam reveals an enlarged organ. Which of the following describes the location of this organ? A: Deep perineal pouch B: Inferior to pelvic diaphragm C: Rectovesical pouch D: Superficial perineal pouch E: Superior to pelvic diaphragm** Item flaw ‘long or complicated options’ was removed by simplifying the distractors. Note that the distractors underwent only simplification, and not removal or replacement with another distractor. Item flaw ‘non-logical order of options’ was removed by arranging the options in an alphabetical order. The item’s original writer was consulted who agreed with these changes. The revised version of the item was administered in the end-of-curricular block exam during the next academic year.
Experimental Subgroup B A very premature infant is administered oxygen in the neonatal intensive care unit. Knowing that premature infants can also be cysteine-deficient, the patient is also given supplements of this amino acid to combat oxidative damage associated with oxygen toxicity. Cysteine is therapeutic because it is a precursor for what important intracellular antioxidant? A: Carnitine B: Glutathione** C: Histamine D: Phosphocreatine E: Serotonin The topic of interest in this item is ‘Therapeutic basis of cysteine as an intracellular antioxidant’. Four distractors (A, C, D, E) in this item were found to be non-functioning (i.e., showed < 5 % selection frequencies)	SHA studied the topic ‘Therapeutic basis of cysteine as an intracellular antioxidant’ from recommended texts and developed four new distractors. A: Melatonin B: Glutathione** C: Uric acid D: Vitamin C E: Vitamin E The item’s original writer was consulted who agreed with the replacement distractors. The revised version of the item was administered in the end-of-curricular block exam during the next academic year.

Before

After

Experimental Subgroup A

Which of the following best describes the location of the prostate gland?

A: Inferior and posterior to the neck of the bladder in the rectovesical pouch

B: At the neck of the bladder superior to the pelvic diaphragm**

C: At the neck of the bladder inferior to the pelvic diaphragm

D: In the superficial perineal pouch

E: In the deep perineal pouch

The topic of interest in this item was ‘location of the prostate gland’.

The item was found to be testing low cognitive level owing to plain recall of a fact (i.e., location of the prostate gland).

Moreover, the following flaws were identified in this item:

a. Long or complicated options

b. Non-logical order of options

SHA studied the topic ‘location of the prostate gland’ from recommended texts and developed the following clinical vignette to assess knowledge of the same topic at a higher cognitive level.

A 72-year-old male, in relatively good health, complains of frequent urination, weak stream, and post-void feeling of residual urine. Digital rectal exam reveals an enlarged organ. Which of the following describes the location of this organ?

A: Deep perineal pouch

B: Inferior to pelvic diaphragm

C: Rectovesical pouch

D: Superficial perineal pouch

E: Superior to pelvic diaphragm**

Item flaw ‘long or complicated options’ was removed by simplifying the distractors. Note that the distractors underwent only simplification, and not removal or replacement with another distractor.

Item flaw ‘non-logical order of options’ was removed by arranging the options in an alphabetical order.

The item’s original writer was consulted who agreed with these changes. The revised version of the item was administered in the end-of-curricular block exam during the next academic year.

Experimental Subgroup B

A very premature infant is administered oxygen in the neonatal intensive care unit. Knowing that premature infants can also be cysteine-deficient, the patient is also given supplements of this amino acid to combat oxidative damage associated with oxygen toxicity. Cysteine is therapeutic because it is a precursor for what important intracellular antioxidant?

A: Carnitine

B: Glutathione**

C: Histamine

D: Phosphocreatine

E: Serotonin

The topic of interest in this item is ‘Therapeutic basis of cysteine as an intracellular antioxidant’.

Four distractors (A, C, D, E) in this item were found to be non-functioning (i.e., showed < 5 % selection frequencies)

SHA studied the topic ‘Therapeutic basis of cysteine as an intracellular antioxidant’ from recommended texts and developed four new distractors.

A: Melatonin

B: Glutathione**

C: Uric acid

D: Vitamin C

E: Vitamin E

The item’s original writer was consulted who agreed with the replacement distractors. The revised version of the item was administered in the end-of-curricular block exam during the next academic year.