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Taking the Hematology Exam - How Exams are Developed

How Exams are Developed


All questions appearing for the first time in an examination are pretested, which means they are not counted in candidate scores. Pretesting is a standard practice in the testing industry that allows testing of new, unproven questions without risk to the candidate. Pretest questions, which are not identifiable to the candidate, are distributed across several forms (versions of the examination), each of which contains pretest questions. After assessing how each pretest question performs, the Board determines which of these to include in the live (scored) portion of the next examination.


Test Committee

The development process for the pretest portion of an examination begins with a test committee that writes new questions. Each committee is composed to reflect the breadth and variety of its specialty area. Academicians and practitioners are included to ensure adequate content coverage and to include the perspectives of both training and practice environments.


Examination Blueprint

The content of each examination adheres to the examination blueprint, a pre-established table of content specifications developed and reviewed annually. It is based on analyses of practice in the specialty area, modified to reflect the breadth and relative importance of the clinical problems encountered. After reviewing the blueprint distribution of questions available in the pool for each content area, ABIM test development staff determines how many new questions are needed for each content area and makes assignments according to the committee membersā€™ expertise and interests.


Question Format

Each examination is composed of single-best-answer multiple-choice questions, which are the most widely applicable question type used in the testing industry and are particularly suited for simulating clinical decision making. Although the single-best-answer format can effectively address a specific knowledge point without the use of a clinical stem (patient-based case scenario), the overwhelming majority of ABIM examination questions use patient-based formats assessing the higher-order cognitive abilities required for clinical decision making.


Question Content Criteria

In choosing content areas for new questions, question authors are guided by topic lists of available pool questions in order to target any underrepresented areas. Authors survey the general content domain for their assignment and highlight the most important areas for new questions, particularly those in which practice has changed recently, and compile a list of specific testing points, each of which will be addressed with a new question.

In choosing specific testing points for a proctored, secure examination, the test committee is mindful of assessing only what the certified internist is expected to know without access to medical resources or references, as opposed to knowledge that is appropriate or even mandatory to "look up." The level of difficulty for each testing point is targeted to the measurement goal of the examination, which is to discriminate between candidates who possess the cognitive expertise required for Certification from candidates who do not possess this expertise.


Question-Writing Process

ABIM question authors follow a stepwise procedure when writing new questions. For each testing point, the author selects a cognitive task (such as diagnosis or treatment) and a cognitive ability (such as clinical judgment) to be tested. Then the author writes the lead line (the actual question to be posed), the correct answer, and the distractors (incorrect response options). The correct answer must be clearly correct and uncontroversial, evidence-based, and a better choice than any of the distractors. The distractors are designed to reflect plausible options likely to be selected by less able candidates. Next, the author constructs a clinical stem designed to set up the specific testing point addressed by the lead line and response options. Finally, the author writes a question rationale, which relates the testing point to the specific information in the question, and cites any applicable references from the medical literature.


Question Review/Editing Process

Newly written questions are reviewed by the entire test committee at a meeting in which questions are read aloud, one by one. The committee decides by consensus opinion to accept them for further consideration, revise them at the meeting, assign them to individual members for more extensive revision after the meeting or reject them.

After the first review meeting, accepted questions are edited by the test development editorial staff, who standardize question style, format and terminology, correct grammar, and identify problems with ambiguity and technical flaws such as cues to the answer. Editing occurs after each meeting; editorial changes are checked for medical accuracy, and editorā€™s queries are resolved by the committee at a subsequent meeting. All pretest questions are reviewed a minimum of two times by the exam-writing committee.

Illustrations are prepared by the test development production staff from pre-processed glossy prints, transparencies or, in some cases, original clinical material (such as electrocardiographic tracings) supplied by the question authors. The committee reviews all illustration proofs before they are produced for the examination.

At the second review meeting, the test committee reviews the edited new questions and revisions and selects the final set of pretest questions. The selected questions are then proofread and prepared for examination production along with the selected live questions (see below).


Relevance Review

After the examination is administered, the pretest questions are sent to a large group of diplomate-volunteers, who review the questions and rate them for clinical relevance on a scale of one (not relevant to practice) to five (very relevant to practice). Clinical relevance is self-defined by the reviewers, all of whom are full-time practitioners (>70 percent time spent in direct patient care based on self-reported survey data). On average, each reviewer sees about 15 questions; correct answers are not provided. Each question is rated by at least 12 reviewers practicing in various areas of the country.


Answer Key Validation

Concurrent with the relevance review, staff psychometricians complete the performance analyses of the pretest and live questions. Prior to final scoring, a key validation process is conducted to determine if any answers have been mis-keyed or need to be modified. This is accomplished by a Board review of questions that were overly difficult, nondiscriminating or that performed differently than in their previous examination use; questions that received critical comments from candidates; and questions addressing topics for which new information has emerged that may affect their correct answers. If the Board determines that any live questions are unfair, multiple answers (up to and including all possible answers) are scored as correct during the final scoring process, and these questions are removed from the live question pool.


Certification Examination Selection Process

The test committee regularly reviews the live question pool to ensure that it remains current. After the pool has been supplemented with the pretest questions that performed well from the previous examination, the committee selects the questions for the next live portion of the Certification examination, following the content blueprint and considering the performance statistics and relevance ratings.


Standard Setting

An absolute (content-based) standard is set during the live examination selection meeting using a modification of the Angoff method, which is a multi-step process. First, the standard setters define the characteristics of minimally certifiable or ā€œborderlineā€ candidates. As the committee reviews each question on the examination, each committee member identifies his/her estimate of the percentage of borderline candidates that will answer the question correctly. The initial estimates from these content experts are recorded, and those whose estimates differ significantly from the groupā€™s average are asked to offer reasons underlying their decision. Discussion follows with all members free to change their estimates; final judgments are recorded, and the average percentage for each question is calculated. The average percentages for all questions are translated to proportions, and the sum of these proportions (rounded up to the next whole number) becomes the number of questions candidates must answer to pass the examination.


Maintenance of Certification Examination Selection Process

Unlike Certification examinations, Maintenance of Certification secure examinations are composed entirely of previously tested live questions. Maintenance of Certification examinations are selected separately from Certification examinations. The same general content criteria and focus on patient-based problems and clinical relevance apply to the Maintenance of Certification examination as to the Certification examination. However, the Board recognizes that there are training and practice differences that must be reflected in the selection of Maintenance of Certification examination questions; in general, questions are excluded from the Maintenance of Certification examination if they fall into categories such as the following:

  • Basic science/pathophysiology topics not directly related to a clinical problem;
  • Clinical problems normally referred in practice but widely incorporated in the training experience;
  • Recent clinical advances incorporated in training before they are widely used in practice.

The Board continuously monitors candidate performance in both the Certification and Maintenance of Certification examinations. Initial Certification and Maintenance of Certification candidates perform the same on the vast majority of questions appearing in both examinations. However, their performance differs on a small proportion of shared questions: Certification candidates perform better than Maintenance of Certification candidates on some questions, while Maintenance of Certification candidates perform better than Certification candidates on other questions. The Board continues to analyze these differences to further refine the Maintenance of Certification examination.


Taking the Hematology Exam - How Exams are Developed

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