Advances in Health Sciences Education

, Volume 10, Issue 2, pp 133–143

The Effects of Violating Standard Item Writing Principles on Tests and Students: The Consequences of Using Flawed Test Items on Achievement Examinations in Medical Education


DOI: 10.1007/s10459-004-4019-5

Cite this article as:
Downing, S.M. Adv Health Sci Educ Theory Pract (2005) 10: 133. doi:10.1007/s10459-004-4019-5


The purpose of this research was to study the effects of violations of standard multiple-choice item writing principles on test characteristics, student scores, and pass–fail outcomes. Four basic science examinations, administered to year-one and year-two medical students, were randomly selected for study. Test items were classified as either standard or flawed by three independent raters, blinded to all item performance data. Flawed test questions violated one or more standard principles of effective item writing. Thirty-six to sixty-five percent of the items on the four tests were flawed. Flawed items were 0–15 percentage points more difficult than standard items measuring the same construct. Over all four examinations, 646 (53%) students passed the standard items while 575 (47%) passed the flawed items. The median passing rate difference between flawed and standard items was 3.5 percentage points, but ranged from −1 to 35 percentage points. Item flaws had little effect on test score reliability or other psychometric quality indices. Results showed that flawed multiple-choice test items, which violate well established and evidence-based principles of effective item writing, disadvantage some medical students. Item flaws introduce the systematic error of construct-irrelevant variance to assessments, thereby reducing the validity evidence for examinations and penalizing some examinees.


achievement testing in medical educationconstruct-irrelevant variance (CIV)flawed test itemsitem difficulty effects from flawed itemsitem writing principlesmultiple-choice questions (MCQs)pass–fail effects from flawed itemsstandard test itemswritten tests

Copyright information

© Springer 2005

Authors and Affiliations

  1. 1.Department of Medical Education (MC 591), College of MedicineUniversity of Illinois at ChicagoChicagoUSA