AKTs, MCQs and Introducing the Concept of Pivot Words

Writing an exam question is a lot harder than it looks.

They need to strike the right balance between not being too easy or too hard, and they also need to discriminate (aka be able to separate out candidates for the purposes of ranking).

One of the techniques that AKT and MCQ writers sometimes use is called Pivot Words - the concept simply means that changing a couple of crucial words can change the entire meaning of a question.

Consider this set of hypothetical questions:

Question 1: 

Margaret Woods, aged 47 years, has been experiencing right shoulder pain for the past eight weeks. The pain has been progressively worsening and has now reached a point where it disrupts her sleep. It has also prevented her from working this week. Margaret has been managing the pain by regularly taking paracetamol 1g orally as needed, and she has sought treatment from a physiotherapist. She denies any trauma. She is a painter decorator and desperate to return to work. On examination, it is observed that Margaret has overall limited mobility in her right shoulder when moved actively, with external rotation being particularly affected.

What is the most likely diagnosis?

(a) adhesive capsulitis (Score: 1) 

(b) supraspinatus tendinopathy

(c) osteoarthritis

(d) calcific tendinopathy

(e) polymyalgia rheumatica

Versus this one:

Question 2: 

Margaret Woods, aged 47 years, has been experiencing right shoulder pain for the past eight weeks. The pain has been progressively worsening and has now reached a point where it disrupts her sleep. It has also prevented her from working this week. Margaret has been managing the pain by regularly taking paracetamol 1g orally as needed, and she has sought treatment from a physiotherapist. She denies any trauma. She is a painter decorator and desperate to return to work. On examination, it is observed that Margaret has overall limited mobility in her right shoulder when moved actively, however external rotation is fully preserved.

What is the most likely diagnosis?

(a) adhesive capsulitis

(b) supraspinatus tendinopathy (Score: 1) 

(c) osteoarthritis

(d) calcific tendinopathy

(e) polymyalgia rheumatica

What is the difference between the two questions - can you spot the pivot words?

Look again at the last sentence:

Question 1 states : "On examination, it is observed that Margaret has overall limited mobility in her right shoulder when moved passively, with external rotation being particularly affected."

Question 2 states: "On examination, it is observed that Margaret has overall limited mobility in her right shoulder when moved passively, however external rotation is fully preserved."

Those words at the end change the entire meaning of the question, as in adhesive capsulitis external rotation is lost as a hallmark feature, whereas it is preserved in supraspinatus tendinopathy.

This is a crucial piece of examination technique - I would estimate that it is the most predominant reason as to why good candidates who know their medicine fail.

In my experience pivot words are used all the time - and so getting good at spotting them is a crucial skill. If it is helpful I can post another question showing this.