Construction of effective SBA
for exploring deep learning
Prof. Dr. Kazi Yesmin
Professor of Microbiology
Green Life Medical College
Learning objectives
Define SBA
State the structure of SBA question
Guidelines for construction of effective SBA
Typical SBA layout
Types of SBA question
Things to avoid in construction of SBA
SBA in new curriculum
Single Best Answer (SBA)
Single Best Answer (SBA or One Best Answer) is a written
examination form of multiple choice questions used extensively
in medical education.
SBA questions have become increasingly popular because they
can test a wide range of topics with high reliability and are the
ideal format for machine marking.
They also have a definitive correct answer which is therefore not
subject to interpretation on the part of the examiner.
Prior to the widespread introduction of SBAs into medical
education, the typical form of examination was true-false
multiple choice questions. But during the 2000s, educators
found that SBAs would be superior.
Structure of SBA question
SBA
Stem Lead-in Options
Key/Answer Distractors
Examples
A 50 years man presented with multiple, non-
indurated ulcer which are very painful in nature in
the external genitalia and tender unilateral inguinal Stem
lymphadenopathy. He had a history of exposure.
What is the probable diagnosis? Lead-in
a. Primary syphilis
b. Genital herpes
c. Chancroid
Options
d. Lymphogranuloma venerum
e. Granuloma inguinale
Options
a. Primary syphilis Distractor
b. Genital herpes
c. Chancroid Key
d. Lymphogranuloma venerum
e. Granuloma inguinale
Justification for correct answer
d e a b c
Least correct Most correct
Justification of correct answer
Leison Options Lesion Ulcer Pain Lymph node INF.
Painful Ulcer Primary Ulcer Single, indurated painless Painless lymph D
syphilis adenopathy
Multiple Genital Ulcer Multiple with an Painful Tender D
herpes erythematous base lymphadenopa
thy
Non-indurated Chancroid Ulcer Multiple, non- Very Tender K
indurated with painful unilateral
exudate at the lymphadenopa
base thy
Site: external Lymphogra Ulcer Small, shallow ulcer painless Bilateral D
genitalia nuloma lymphadenopa
venerum thy
Unilateral Granuloma Ulcer Vascular ulcer with Painless Not a major D
tender inguinal inguinale granulomatous feature
lymphadenopa
thy
Single best answer question
A single best answer question has a clinical scenario (the stem), a
question, and five answer options.
Unlike traditional MCQs, the incorrect answers (distractors) may be
plausible or partially correct.
the correct answer is the ‘best’ answer (key) to the scenario and
posed question.
The candidate has to use higher order thinking and reasoning skills
to identify the correct answer, instead of just relying on factual
recall.
Example
Arterial blood gas revealed, HCO2 18 mmol/l, pH 7.30,
Stem PCO2 110 mm Hg and RBS- 20 mmol/l, ketone bodies
present in urine.
Lead What is your diagnosis?
in
a) Acidosis
b) Acid base disorder
Key: c
Options
c) Diabetic ketoacidosis
d) Metabolic acidosis
e) Ketoacidosis
b a d e c
Guidelines for construction of effective SBA
1. Identify an area of the blueprint which is in need of more
questions or the area of the blueprint which you have been
allocated.
2. Identify the topic area and the level of knowledge
you want to test
Ideally, questions should be pitched at the level of
understanding the reason behind the problem or the
application of the knowledge by means of background
science.
Example of recall questions as stem, to avoid:
What is the organism responsible of X?
Which of the following is the nerve supply of X?
Enumerate the main causes of Y?
Which of the following is correct?
3. Construct the stem.
This should present a single, clearly formulated problem, possibly
in the form of a patient vignette.
Focus on problems that would be encountered in real life.
Avoid trivial, tricky or overly complex questions.
Wherever possible, items should assess application of knowledge,
rather than simple recall of an isolated fact.
The stem should contain enough information to allow candidates
to answer without referring to the options.
Patient vignettes may include any subset to the following
information-
a. The patient (age, gender), the presenting complaint and its
duration; any other relevant information those typically need to
determine the best course of action.
b. Relevant details of the patient's history including details of
family history if needed.
c. Relevant physical findings, results of diagnostic studies, etc.
4. Construct the lead-in in such a way that it builds on the information
in the stem and poses a clear question.
Candidates should be able to answer without looking at the
options, and should not be able to answer if the information in the
stem is masked.
Possible AVOID as lead-in:
“Which of the following statements is true/correct?”
“Each of the following statements is correct EXCEPT.”
“Which of the following is not a feature of?”
“Which of the following should not be done?”
5. Write the options, these should be of
a. near similar length,
b. along a continuum,
c. grammatically consistent
d. plausible
e. logically compatible and
f. avoid using “double options”
If appropriate, order the options in a logical order (e.g.
numeric, alphabetical, or anatomical).
All the distractors must be plausible or very close to the correct
one.
Acid fast bacilli is-
Key: b
a. E. coli
b. M. tuberculosis Incorrect
c. C. tetani Example of SBA
d. T. pallidum
e. C. diphtheriae
Single Correct
Answer
Which microorganism resist
decolorization by 20% H2SO4 in Stem
Ziehl-Neelsen staining
M. leprae Key: b
M. tuberculosis
N. asteroids
Options
P. jiroveci
C. parvum
Typical SBA layout
Blue print code and level (integration/interpretation, problem
solving/clinical scenario)
Stem and image if relevant
Lead in
Options (all on a continuum, all plausible to some extent)
a
a.
b.
c.
d.
e.
Justification for correct answer
A. Vermiform appendix will be gangrenous , if
blockage of the artery is in
a. Ileocaecal artery Key: b
b. Ileocolic artery
c. Right colic artery
d. Inferior mesenteric artery Incorrect
e. Superior mesenteric artery SBA
B. The same question can be restructured by
A 50-year-old male underwent laparotomy for severe Stem
right iliac fossa pain and found gangrenous vermiform
appendix .
The blood vessel likely to be affected is Lead-in
a. Ileocaecal artery
b. Ileocolic artery
c. Right colic artery
Options
d. Inferior mesenteric artery
e. Superior mesenteric artery
Reviewing the item (Stem, lead-in & options)
Does it focus on important problems relevant to clinical
practice?
Can it be answered without looking at the options?
Are all the relevant facts included in the stem?
Can it be read and answered within approximately one and
half minute ?
Are all the options plausible, with one of them standing out as
being the best option?
Does the question successfully avoid the pitfalls listed in the
Question Writing Checklist?
Example
Stem A male patient presents to his GP with cough. The patient
describes feeling unwell. He had a past medical history of
an appendectomy.
Lead-in What is the most likely diagnosis?
a. COPD
Options
b. Hypersensitivity pneumonitis
Incorrect
c. Lung cancer
SBA
d. Pneumonia
e. Tuberculosis Key: d
To get the right answer, it helps to ask the right question
Types of SBA
Low quality SBA
High quality SBA
• Writing good single best answer questions can be challenging.
Which joint disease is associated with
Stem
morning stiffness that improves with activity
a) Ankylosing spondilitis
b) Gout
c) Osteoarthritis Options Key: d
d) Rheumatoid arthritis
This is poor quality question-
e) Psoriatic arthritis 1. It is an MCQ type question
rather than SBA
2. There is no clinical
background information
3. Morning stiffness is seen in AS,
RA & Psoriatic arthritis
A 41 years old lady presented at Medicine OPD with
Stem complain of pain in both hands for 6 weeks associated with
morning stiffness. Her pain often improves with some light
activity
Lead
in What is the most likely diagnosis in this patient?
Ankylosing spondilitis
Gout
Key: d
Options Osteoarthritis
Rheumatoid arthritis
Psoriatic arthritis
Answer options
Tips for writing high-quality answer options:
Provide 5 short answer options.
Answer options should be homogeneous (e.g. they should all
be a diagnosis/treatment/anatomical location etc)
All answer options should be plausible and familiar, but one
should be BETTER than the others.
The correct answer should be evidence-based and widely
agreed upon by experts (e.g. NICE guidance).
NICE (National Institute for Health and Care Excellence)
Things to avoid in construction of SBA
The inclusion of irrelevant background information such as
vital signs.
The inclusion of the reader in the question (e.g. “You are a
junior doctor working in A&E when a 37-year-old patient
presents with…”) – a better format would be (e.g. “A 37-year-
old male presents to the A&E department with…”).
The use of negative questions (e.g. ‘What is the LEAST likely
diagnosis’).
Too absolute terms ( never / always)
All or none of the above
SBA in new curriculum
In professional examination
Written =100 (MCQ 20 +SAQ 70+ Formative Assessment Marks 10)
MCQ=20 (Multiple T-F 10+ SBA 10)
Take home massages
Most undergraduate and postgraduate medical examinations
of knowledge now use the single best answer (SBA) format for
multiple-choice questions.
A single best answer question has a clinical scenario (the stem),
a question, and five answer options.
Assess application of knowledge, rather than simple recall of an
isolated fact
The correct answer should be evidence-based and widely
agreed upon by experts.
Thank
You
References
Tan, LT; McAleer, JJ (2008). "The introduction of single
best answer questions as a test of knowledge in the final
examination for the fellowship of the Royal College of
Radiologists in Clinical Oncology". Clin Oncol (R Coll
Radiol). 20 (8): 571–6. doi:10.1016/j.clon.2008.05.010.
PMID 18585017.
