Now, we're going to discuss type P questions. There aren't many type P questions on the American Board of Dermatology exams right now, and those that exist are mainly found on the applied exam. Because some assignments you may receive for the AAD or other organizations are to prepare test takers for the applied exam, we want to explain what a type P question is. A type P question is a multiple answer, multiple choice question. So, there might be a list of choices, and two or three of those choices are correct. So, it's trying to determine which of the multiple answers are correct on a particular question. Now, in my brain, I think of type P as having two different sorts of question types. The first is what I call the possible roads type P question, where you're given a scenario, and you're given a number of choices about that scenario, oftentimes about what would you do next. And in real life, we know in clinical medicine, many times there are many different possible acceptable routes to go. And at the same time, many unacceptable routes to go. And this is really the kind of question where you're trying to ensure confidence that you're not making terrible choices. You're making acceptable choices, or recognizing what the acceptable choices are in a given scenario. But in the possible roads type P questions, you will never as a clinician pick all of the correct possibilities for one particular patient. It's a this or that kind of a question. That's not what we're really talking about is picking all of the right possible answers, because that's what you would do clinically. So, for an example, it might be like, how would you treat a skin cancer in a particular situation? Well, we know that there are choices that exist, and maybe one is better than the others, but it's still in certain patient circumstances, an acceptable way to treat it this way or that way. And then there might also be choices where it's absolutely not what you would ever do to treat that skin cancer. So, that's what I'm talking about when I say the possible road scenario. The second type of type P question is what I classify as a cluster of good clinical decisions kind of type P question. And what this would be is a multiple choice question with many, many different possibilities. And it also might be a next step in care of this particular patient kind of question. But this would be one where there are many answers that you would want to do next for this particular patient, all of which are appropriate. Maybe you have a complex patient scenario, and you want to order this blood test and that blood test and a biopsy and an x-ray and get this culture. And all of those would be appropriate part of what you would do next. So, that's what I call a cluster of good clinical decisions type P question. So, both of these are type P questions. It's just that it depends on the mindset of the test taker as to which kind of question am I being asked, and we don't want to confuse them. And that's actually why I think that sometimes the type P question can be a little confusing because some type P questions, you're not really ever going to pick all of the things that are correct. In other cases, you would always want to pick the things that are correct. So, these are the kind that on a test by the American Board would be more likely to be clustered together so that the mind of the test taker wasn't flip-flopping back and forth between what kind of type P question am I being faced with here. So, I'm going to give you a couple of examples here. So, here's a possible Rhodes type P question. I'll read it to you. A 97-year-old patient presents with asymptomatic clinically diagnosed 4-millimeter basal cell skin cancer on the lateral neck. He lives alone and requires assistance to get to his appointments. Which of the following options would be appropriate to discuss as treatment for his lesion? And so, you have a whole lot of different choices here. And so, although many of the choices are possible and appropriate to offer in a 97-year-old patient with a small basal cell on the neck, all of them aren't correct for one patient to say yes. We would do excision and electrodesication and curatage and Mohs, all in the same 4-millimeter basal cell. So, that's an example of many possible Rhodes type P question that we can pick those that would be appropriate. Here's another example of a type P question. But this is a cluster of good decisions type P question. Here's a case of an immunocompromised patient presenting with fever and a draining red nodule on the right leg, where he scratched his leg with a tree branch. So, what would you do for further evaluation? And it says pick three of the things below. Well, in this scenario, it's a cluster of good clinical decisions. So, there really are three things on here you really ought to do next, not mutually exclusive to the choice. So, those are the kinds of differences between type P questions. Now, as I mentioned earlier, type P questions are found in the applied exam. And in counseling patients about their options or selecting treatment options to manage skin disease, there can be many directions one might take in a real-world scenario of medicine. And that's what you should be thinking of when you're doing applied exam questions. Think about real-world examples that you face in clinic. We know all the time there are options that are acceptable. And part of why we pick what we pick might be because of drug coverage or patient preference or side effect avoidance or whatever. It's not always just the best treatment. It's so much more than that in real-world medicine, in fact. So, identifying multiple appropriate diagnostic or treatment options is one of the goals of the applied exam. It's how you think through your options. That's what we're getting at. When you're creating an applied exam type P question, there's a general rule of thumb when you're asking for multiple answer questions. Have a three-to-one ratio of choices to correct answers. So, if you're saying pick three of the following choices or pick three answers from among the following choices, you ought to have nine choices. If you're going to have three correct answers, that's the ratio. So, that's a general rule of thumb. You should not have less than that. You can certainly have more than that, but in general, it's hard sometimes to come up with reasonable distractors when you're starting to talk about more and more and more distractors. So, you're probably going to want to hit the number of three-to-one ratio of choices to correct the answer. And then, remember, I would not make a wholesale effort to make type P questions a major part of what you're trying to develop. They're really hard to write. I've been working at that for several years. It's very difficult to write a good type P question. So, I would still encourage you to spend most of your time trying to write excellent clinical scenarios for the type A question types where there is one correct answer that is best out of the five choices. Type P questions have a tendency to be a little bit more confusing. When you're trying to say I'm going to have multiple different pathways here, but on this question, just think of different options, only one of which you would actually do, but what are the options versus what do I want to do, all these options I'm picking. It can be very confusing how you spring these on the test taker. So, you want to be minimally confusing if you're trying to assess knowledge. You want to assess knowledge, not logic of the question. So, when constructing applied exam questions, think of real clinical scenarios faced in clinical practice. The best example of this is a type A question that gives you a clinical and gives you a pathologic correlation, and you've got to make that clinical path correlation to get the right answer. That's a great example of an applied type, an applied exam type A question construction, clinical path correlation.

type P questions

American Board of Dermatology exams

multiple answer

multiple choice

real-world scenarios