Do extended matching multiple-choice questions measure clinical reasoning?

PURPOSE At the Faculty of Medicine at the Katholieke Universiteit Leuven, Belgium, we have developed a final examination that consists of extended matching multiple-choice questions. Extended matching questions (EMQs) originate from a case and have 1 correct answer within a list of at least 7 alternatives. If EMQs assess clinical reasoning, we can assume there will be a difference between the ways students and experienced doctors solve the problems within the questions. This study compared students' and residents' processes of solving EMQs. METHODS Twenty final year students and 20 fourth or fifth year residents specialising in internal medicine solved 20 EMQs aloud. All questions concerned diagnosis or pathogenesis. Ten EMQs related to internal medicine and 10 questions to other medical disciplines. The session was audio-taped and transcribed. RESULTS The residents correctly answered significantly more questions concerning internal medicine than did the students. Their reasoning was more 'forward' and less 'backward'. No difference between residents and students was found for the other questions. The residents scored better on internal medicine than on the other questions. They used more backward and less forward reasoning when solving the other questions than they did with the internal medicine questions. The better half of the respondents used significantly more forward and less backward reasoning than did the poorer half. CONCLUSION In accordance with the literature, medical expertise was characterised by forward reasoning, whereas outside their area of expertise, the subjects switched over to backward reasoning. It is possible to assess processes of clinical reasoning using EMQs.