Clinical decision making (CDM) questions are now included in the summative examinations of the University of Ottawa undergraduate medical curriculum beginning with the very first midterm exam. However, students need practice in applying their new knowledge within the context of clinical situations before tackling this new questions style in formal exams. QuandaryR (http://www.halfbakedsoftware.com/quandary_download.php) is an action maze software that was used to develop weekly online formative exams for Foundations, the first major unit of the medical curriculum. This software supported the construction of interactive practice exams in both French and English that prompt students to keep trying each question until they have found all of the correct answers while simultaneously receiving instructional feedback for each choice made, be it correct or incorrect. Of particular relevance to CDM questions, Quandary allowed an unlimited number of answer choices and correct answers per question and included a flexible scoring system that provided instructional guidance regarding the relative value of each correct answer and the seriousness of critical misconceptions.
The exams were first created in English as word documents, using tables to organize the presentation of the cases, the case-specific questions and answer choices, the scoring, and the explanatory feedback. Each weekly exercise consisted of a mix of CDM, multiple choice and true/false questions. In total, 12 exercises (15-20 questions each) were created, one for each week of Foundations. The exercises were translated into French and then both sets of exercises were inserted into Quandary and made available to students via One45R, the curriculum mapping software used for all course materials. Student use of the formative exams during the weeks approaching the final exam was tracked via Google Analytics.
Students welcomed the opportunity to self-test and extensive use of the formative exams was noted during the two weeks before the Foundations final exam (Table 1).
In conclusion, the flexibility of Quandary supports the development of interactive CDM questions that are useful for the medical curriculum. Students use feedback-oriented interactive exercises to self-assess, without penalty, their ability to apply new knowledge (both basic and clinical sciences) within the context of healthcare scenarios before writing critically-important summative exams.