This document discusses key feature questions (KFQs), which are designed to assess clinical decision-making skills rather than factual knowledge recall. KFQs present clinical scenarios and assess examinees' ability to recognize diagnoses, prescribe appropriate treatment, and make clinical decisions. The document defines key features as critical steps in problem resolution, areas where examinees often err, or difficult aspects of identification and management. Key features are case-specific. When developing KFQs, examiners first define the key features and then construct questions around clinical conditions and tasks to test those features.

1. Key Feature
Questions:
An Introduction
Dr. Chew Keng Sheng
Universiti Sains Malaysia

2. What is a Key-Features Question? (KFQ)
• KFQ are designed to specifically assess decision-making
skills rather than simple recall of factual
knowledge.
• While knowledge is obviously a very important
requisite for effective problem solving, the
challenge posed by key features cases is the
application of knowledge to the resolution of a
problem
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3. Elicit
clinical
clues
Application
of
knowledge
Formulate
Dx
Order Ix
Acquire
data for
monitoring
Select
course of
action
Evaluate
severity/
outcome

4. Example
• For example, KFQ should not assess examinees’
ability "to describe features of pulmonary
embolism" (a knowledge issue); rather, they should
assess their ability "to recognize pulmonary
embolism in a specific patient" (a clinical
reasoning issue) and "to prescribe appropriate
emergency measures” (a clinical decision issue).

5. A general rule to keep in mind when
developing key features cases is that if
the question asked can be answered
without reference to the attached
clinical scenario, then it is not a good
question and is likely not measuring
clinical decision making.
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6. Definition of Key-Feature
• The term “key feature” was introduced by Bordage
& Page (1987) and is defined as:
1. a critical or essential or key step(s) in the
resolution of a problem,
2. a step(s) in which examinees are most likely to
make errors in the resolution of the problem, or
3. a difficult or challenging aspect in the identification
and management of the problem in practice.

7. Definition of Key-Feature
Problem
A Key-Feature
Step Resolution
of problem

8. Therapeutic Measure
VF
Defibrillation Resolution
of VF

9. Clinical clues
Headache
Thunder-clap,
Worst ever
headache
Think of
SAH

10. Investigative Procedure
Acute
AMS in
a
diabetic
Urgent blood
sugar check Hypoglyce-mia

11. All key-feature answers are
correct answers but not all
correct answers are key-feature
answers
Missing a key feature (critical step)
may prove fatal to the case!
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12. Definition of Key-Feature
Acute
SOB
following
trauma Did not consider
Tension
pneumothorax
Patient
Died!!

13. Ask:
“What are the critical, essential,
or challenging elements in the
resolution of this problem?”
“What are this problem’s key
features that should be
assessed?”
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14. Key Features are case-specific
• Key features are often unique to different cases or
presentations of a clinical problem, as they may
vary relative to the clinical presentation of the
problem and relative to other issues such as the
patient's age and gender.
• It is therefore unusual to have a “generic” set of
key features for a specific clinical problem.
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15. Key Features are case-specific
• For example, the critical elements in the resolution
of a diabetic problem as a life-threatening event are
quite different from those of a diabetic problem
presenting as an undifferentiated complaint in an
adolescent
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16. How an examiner sets a KFQ
• First, define the key features of the case
• Each key feature has two/three basic elements:
1. a set of conditions: “Given a pregnant woman
experiencing third-trimester vaginal bleeding with
no abdominal pain”;
2. a task (i.e., a clinical action or decision): “Consider
placenta previa as a leading diagnosis”; and
3. some qualifiers (optional): “leading diagnosis.”
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17. Example of a key-feature
• Given that a pregnant women with third-trimester
bleeding with no abdominal pain in Emergency
department, a candidate at the level of
undergraduate medical curriculum will
1. Consider placenta previa as a leading diagnosis
2. Avoid performing a pelvic examination
3. Avoid discharging home from emergency
department
4. Order pelvic ultrasound
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18. The conditions
Given that <patient age
group>
with <clinical
situations>
in <sites of care>
Pregnant undifferentiated
complaint
a prehospital setting
Neonate a single, typical
problem
Green zone
Pediatric A multiple/multi-system
problems
Yellow zone
General
adult
A life-threatening
event
Resus zone
elderly Emergency
department

19. The tasks (optimally 2 – 3 per case)
Task (a critical step, decision,
action that is a key feature
in the diagnosis/
management specific to
this problem)
Domain tested
Ask/examine (History/PE)
Consider (Diagnosis)
Order (Investigation)
Prescribe/
(Treatment)
administer/give
Admit/discharge Disposition
Avoid (taking precaution)

20. Setting up the case scenario
• Once key features are defined, the case scenario is
set:
• “A 24-year-old G3P2 woman, 31/52 POA, comes to the
emergency room at 8:00 pm complaining of bright red
bleeding per vagina for the past 2 hrs. Three sanitary
napkins that she used were completely soaked. No
contractions or abdominal pain. The fetus is moving as
usual. Her BP is 110/70 mm Hg, and pulse is 92/min. The
examination of the abdomen reveals a uterine height of 31
cm with a soft and non-tender uterus. The fetus is in a
breech position and has a heart rate of 150/min. No active
bleeding has occurred since she arrived 25 minutes ago.”

21. Question Formats
• Two response formats are recommended for
clinical decision-making cases:
– short-answer "write-in" (WI) responses and
– "short-menu" (SM) responses.
• In the WI format, examinees supply their
responses.
• In the SM format, examinees select their responses
from prepared lists of options accompanying the
question.

22. In SM Format
• The number of options in these lists varies
depending on what the question is testing.
• In general there are typically 15-20 options.
• There should be ~ 2-3 times the total number of
choices in the list as there are number of correct
responses
• List of choices may contain correct non-scored
responses (not a key-feature), incorrect distractors,
and dangerous options if chosen (“killer
responses”).

23. In SM Format
• "Select up to x" is a suitable instruction for
questions in which one or more answers are sought
and for which the number of opportunities for
examinees to provide these answers should be
capped.
• The number “x” considers the number of correct
keyed responses sought, together with other factors
such as responses that would be reasonable but
are not keyed (e.g., general screening questions in
a history-taking question).

24. In SM Format
• Also, the number “x“ commonly provides a buffer
for examinees to select some incorrect responses
(e.g., if four correct responses are sought, five or
six responses might be permitted).

25. Types of Response Limits in SM Format
Response limit Description
List (select) only one. This type of limit is suitable for requesting a single
definitive answer, such as a leading diagnosis or a most
important management step.
List (select) up to x This type of limit is suitable for questions in which one or
more answers are sought and for which the number of
opportunities for examinees to provide these answers
should be capped (i.e., forcing the issue).
The “x” (number of allowable responses) takes into
account the number of correct keyed responses sought,
together with other factors such as responses that would
be reasonable but not in the keyed responses as well as
incorrect responses that might be appealing to weaker
candidates
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26. Types of Response Limits in SM Format
Response limit Description
List (select) as many as
are appropriate
This type of limit is used in situations where it is useful to
determine how many actions an examinee might take,
as in the case of limiting the investigation or treatment
(i.e., not over investigating or treating).
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27. References
• Page G, Bordage G, Allen T. Developing Key-feature
Problems And Examinations To Assess Clinical Decision-making
Skills. Acad Med. 1995;70(3):194-201.
• Medical Council Of Canada. Guidelines For The
Development Of Key Feature Problems & Test Cases
August 2012. Available At:
http://mcc.ca/wp-content/uploads/cdm-guidelines.pdf
Accessed 11 July 2014