Comparison of the level of cognitive processing between case-based items and non-case-based items on the Interuniversity Progress Test of Medicine in the Netherlands

Purpose: It is assumed that case-based questions require higher-order cognitive processing, whereas questions that are not case-based require lower-order cognitive processing. In this study, we investigated to what extent case-based and non-case-based questions followed this assumption based on Bloom's taxonomy. Methods: In this article, 4,800 questions from the Interuniversity Progress Test of Medicine were classified based on whether they were case-based and on the level of Bloom's taxonomy that they involved. Lower-order questions require students to remember or/and have a basic understanding of knowledge. Higher-order questions require students to apply, analyze, or/and evaluate. The phi coefficient was calculated to investigate the relationship between whether questions were case-based and the required level of cognitive processing. Results: Our results demonstrated that 98.1% of case-based questions required higher-level cognitive processing. Of the non-case-based questions, 33.7% required higher-level cognitive processing. The phi coefficient demonstrated a significant, but moderate correlation between the presence of a patient case in a question and its required level of cognitive processing (phi coefficient = 0.55, P < 0.001). Conclusion: Medical instructors should be aware of the association between item format (case-based versus non-case-based) and the cognitive processes they elicit in order to meet the desired balance in a test, taking the learning objectives and the test difficulty into account.