A qualitative exploration of student cognition when answering text-only or image-based histology multiple-choice questions.

A qualitative exploration of student cognition when answering text-only or image-based histology multiple-choice questions. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A qualitative exploration of student cognition when answering text-only or image-based histology multiple-choice questions. Jane Holland, Alice McGarvey, Michelle Flood, Pauline Joyce, Teresa Pawlikowska This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4200329/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Interpretation of images and spatial relationships is essential in medicine, but the evidence-base on how to assess these skills is sparse. Thirty medical students were randomized into two groups (A and B), and invited to “think aloud” while completing 14 histology MCQs. All students answered six identical MCQs, three with only text and three requiring image interpretation. Students then answered eight “matched” questions, where a text-only MCQ on Version A was “matched” with an image-based MCQ on Paper B, or vice versa . Students’ verbalizations were coded with a realist, inductive approach and emerging codes were identified and integrated within overarching themes. High-performing students were more likely to self-generate an answer as compared to middle and lower-performing students, who verbalized more option elimination. Images had no consistent influence on item statistics, and students’ self-identified visual-verbal preference (“learning style”) had no consistent influence on their results for text or image-based questions. Students’ verbalizations regarding images depended on whether interpretation of the adjacent image was necessary to answer the question or not. Specific comments about the image were present in 95% of student-item verbalizations (142 of 150) if interpreting the image was essential to answering the question, whereas few students referred to images if they were an unnecessary addition to the vignette. In conclusion, while assessing image interpretation is necessary for authenticity and constructive alignment, MCQs should be constructed to only include information and images relevant to answering the question, and avoid adding unnecessary information or images that may increase extraneous cognitive load. Educational Psychology Assessment histology images multiple-choice questions cognitive load Introduction Visuospatial skills are an intrinsic element of medicine and medical sciences, and the disciplines of anatomy and histology are typically the first areas of the medical curriculum where students will experience the need to develop and display skills of identification and interpretation. How these skills are introduced, internalized and ultimately assessed has direct relevance to educators, particularly as technological advances have led to image-based resources and assessments being more easily, and so increasingly, incorporated into curricula. Much education has moved online in recent years, with many institutions now teaching histology by means of virtual microscopy or computer-based programs [ 1 – 7 ]. The use of images in teaching and learning is well described, where the dual channels assumption of the multiple representation principle proposes that learners process information primarily through separate auditory-verbal and visual-pictorial channels [ 8 – 11 ]. Students will have differences in cognitive ability, learning styles and preferences along the visualizer–verbalizer dimension, and the concept of teaching to learning styles or preferences is still pervasive in education [ 12 – 14 ]. However, there is a dearth of evidence to support teaching to individual learning styles or preferences [ 15 , 16 ], with “no adequate evidence base to justify incorporating learning styles assessments into general educational practice” [ 17 ]. Instead, the evidence-base demonstrates that students benefit from learning with a combination of images and verbal information, to balance incoming information between these two main channels [ 18 , 19 ]. Information on the effect of images in assessments is more limited, perhaps in part due to the historical challenges in preparing and including images in unique examinations. Nowadays, digital photography, printing and online assessments means that image reproduction and inclusion has become a straightforward task [ 20 – 24 ]. While all assessment methods have different strengths and weaknesses Multiple Choice Questions (MCQs) are extremely time-efficient, allowing broad sampling across the curriculum, and so remain a core component of most programs of assessment [ 25 – 27 ]. Medicine and the medical sciences require accurate identification of clinical signs, anatomical parts and histological features, and while precise verbal descriptions could be included within clinical vignettes, doing so may make text overly grammatically convoluted or complex [ 25 , 27 – 29 ]. This issue is even more relevant for institutions with substantial numbers of non-native English speakers, studying medicine in their second (or third) language, and so conscious consideration should be given to only include construct-relevant language, an inherent part of the technical vocabulary of medical sciences, while minimizing linguistic clutter and irrelevant grammatical complexity [ 10 , 27 , 30 ]. Many learning outcomes in histology also require that students identify structures by visual inspection and interpretation [ 31 ]. While principles of constructive alignment require that these learning outcomes be assessed using images, the evidence-base on how to do so is sparse, with variable outcomes [ 23 , 32 ]. The bespoke 70-plate booklet of illustrations used by Hunt et al in the 1970s was undoubtedly of high quality, and improved the authenticity of the assessment, but its use negatively impacted candidates’ scores, as they repeatedly switched focus between this booklet and reading the questions on the examination paper [ 20 ]. This phenomenon is described as the spatial continuity effect and can be avoided by placing text and images adjacent to each other in either printed or online assessments [ 9 , 33 ]. More recent studies with well-aligned text and images found no evidence of a consistent effect on item difficulty or discrimination [ 24 , 34 , 35 ]. So, where lies the balance within authentic assessment of an undergraduate histology curriculum? Inclusion of some images within assessments is now a simple matter, but does an accompanying image provide candidates with an additional advantage or cue when answering a question, or is it a distracting increase to cognitive load [ 36 , 37 ]? This study examines (1) the cognitive processes and critical thinking of students while answering Single Best Answer MCQs in histology, (2) whether images influence the verbalized cognitive processes of participants and (3) whether self-identified verbal and visual learners display different verbalizations or cognitive processes when answering text and image-based MCQs. Materials and Methods Ethics approval, student recruitment & anonymization Ethical approval for this study was received from the Research Ethics Committee of the Royal College of Surgeons in Ireland (reference RCSI-REC1132). Students in their first year of both the Direct (Undergraduate, DEM, 340 students) and Graduate Entry Medical (GEM, 80 students) programs were invited to participate by means of a forum post (with attached Participant Information Leaflet) and to contact the Principal Investigator by e-mail if they wished to volunteer. All students who did so were assigned a unique participant number for pseudoanonymization by a gatekeeper, with no role or responsibility in teaching or assessing medical students. Within RCSI’s School of Medicine, the histology course was taught by self-directed online tutorials, within the first year of the curriculum, integrated into the systems-based, multidisciplinary modules, and students were advised to study the “Endocrine System” online histology tutorial prior to their interview (which was part of their normal course content for the semester) [ 35 , 38 ]. Preparation of Multiple-Choice Questions Two examination papers with fourteen multiple-choice questions were prepared by two content experts, with six identical anchor MCQs on each test (Table 1 ; Supplementary Information). Three anchor MCQs had textual vignettes only, and three items required interpretation of an adjacent image (“ required image ”). The remainder of MCQs on each test were matched, where one test had an MCQ with a textual vignette, and the matched MCQ on the other test included an image (Table 1 ; Supplementary Information). The image-based MCQ was contained either (a) identical text along with an image containing information complementary but non-essential to answering the question (“ redundant image ”) or (b) a modified textual vignette, with removal of details critical to answering the question, and an image added to provide that required information or context (“ required image ”). Table 1 Overview of assessment items completed by students in Version A and Version B of the tests in this study vA vB Q1 Anchor item Diabetes insipidus Textual vignette Q2 Anchor item Testes & Leydig cells Text & required histological image Q3 Matched item Endoplasmic reticulum Textual vignette Identical text & redundant image (diagram) Q4 Matched item Placental Human Chorionic Gonadotrophin (HCG) Identical text & redundant histological image Textual vignette Q5 Matched item Thyroid parafollicular cell function Textual vignette Modified text & required histological image Q6 Matched item Pancreatic Islet of Langherhan’s function Modified text & required histological image Textual vignette Q7 Anchor item Pregnancy & progesterone Textual vignette Q8 Anchor item Adrenal medulla & Potassium dichromate Text & required histological image Q9 Matched item Pituitary acidophils Identical text & redundant histological image Textual vignette Q10 Matched item Neuroendocrine cells & adrenal medulla Textual vignette Identical text & redundant image (diagram) Q11 Matched item Oxytoxin secretion Modified text & required image (diagram) Textual vignette Q12 Matched item Adrenal cortex & androgens Textual vignette Modified text & required histological image Q13 Anchor item Holocrine secretion Textual vignette Q14 Anchor item Pituitary gland Text & required histological image Interviews Students then met individually with one of the interviewers, and were given an opportunity to ask questions before giving formal consent, then randomly assigned to either Version A or Version B of the test (Table 1 ; Supplementary Information). Students completed demographic questions regarding their educational level and linguistic abilities (native & known languages), and then the Verbal–Visual Learning Style Rating (VVLSR; 7-point Likert), to identify whether they self-identified as predominantly verbal or visual learners [ 12 ]. Students were given some guidance on verbalizing their thoughts (“think-aloud”) and asked to answer two practice questions, voicing their thoughts as they completed these questions. Students then completed their fourteen MCQs, while continuing to verbalize their thoughts for recording and transcription. Analyses Quantitative data All demographic and test data were collated & tabulated in MS Excel, then imported to STATA 17.0 for statistical analysis (StataCorp., College Station, TX). A caveat must be stated that the primarily qualitative focus of this study, and the small number of participants (n = 30), limits the statistical power and thus the interpretation of quantitative statistical analyses. Differences were considered significant for values of p < 0.05 for all (parametric) statistical analyses performed in this study, with the mean and standard deviation used to summarize students’ scores. For analysis of the Verbal–Visual Learning Style Rating, the mean was again chosen as the measure of central tendency, and comparisons were performed by means of independent t-tests [ 39 – 43 ]. Item psychometrics were calculated in STATA, with item discrimination calculated by means of a point biserial correlation (pwcorr, a true Pearson product-moment correlation), with a higher positive correlation for an MCQ indicating that students who achieved a high score on the overall test also scored higher on that individual MCQ. Qualitative analysis Transcripts were imported into QSR International’s NVIVO 11 qualitative data analysis software (QSR International Pty. Ltd.), which was used for all further thematic analysis. While some codes and themes were anticipated from prior reading of the existing evidence-base, all transcripts were initially read for familiarity, then coded with a realist, inductive approach, with anticipated and additional emerging codes identified and integrated within themes [ 44 – 48 ]. The process was iterative, with the thematic structure undergoing revisions throughout, with coding and analysis shared and discussed between co-authors throughout the process [ 49 ]. Following development of the final thematic framework, a final formal analysis of 20% of scripts was performed by an additional coder for comparison with this final schema and themes. Results Quantitative analyses & item statistics: All students completed the interview well within the 30 minutes allotted, with a mean recording length of 14 minutes & 5.5 seconds. Cronbach’s alpha (Scale reliability coefficient) for Version A of the test was 0.68, while Version B was 0.67. Comparing students’ scores on the test papers overall, there was no statistically significant difference observed between students who completed Version A of the test (M = 10, SD = 1.77) as compared to those who completed Version B (M = 10.5, SD = 2.03; t(28) = -0.7663, p = 0.45). Item statistics for the six identical anchor MCQs showed no statistically significant difference in the item facility observed on Version A of the test (M = 0.63, SD = 0.23) as compared to Version B (M = 0.67, SD = 0.29; t(5) = -0.8076, p = 0.46). Similarly, no significant differences were observed in point-biserial correlation (0.266 ± 0.28 vs 0.384 ± 0.19; t(5) = -0.8611, p = 0.43) of these six anchor MCQs as answered by students completing either Version A or B of the test. For the remainder of the MCQs on the paper, these matched image MCQs either had (a) identical text and an additional (redundant) image that was not essential to answering the question or (b) modification of the vignette and substitution of textual information with an image (Table 1 ; Supplementary Information). Comparing the text-only MCQs with their match that had an identical textual vignette and an additional “redundant” image attached, a slight and non-significant reduction in item facility (0.75 vs 0.67; p = 0.08) was observed, but with no demonstrable impact on point-biserial correlation (0.43 vs 0.42; p = 0.96). Comparing text-only MCQs with their match containing modified text & an image requiring interpretation, showed no statistically significant difference in either item facility (0.88 vs 0.88; p = 1.00) or point-biserial correlation (0.25 vs 0.20; p = 0.84). There was no difference observed in the students’ self-identified VVLSR when comparing students who completed Version A of the test (M = 4.67, SD = 1.5) with those who completed Version B (M = 4.47, SD = 1.85; t(28) = 0.3259, p = .75). There was no significant difference between those who identified as more verbal, more visual or equal learners with regard to overall score, or subscores on anchor MCQs, text-only MCQs or on MCQs with images overall (Table 2 ). For scores on the MCQs with redundant images, self-identified visual learners received a lower score on these two MCQs (1.1 ± 0.72) than either verbal (1.5 ± 0.53) or equal learners (1.67 ± 0.52), but this did not reach statistical significance (F (2, 27) = 1.93; p = 0.165; Table 2 ). Table 2 Scores & subscores on different item types by students with self-identified visual, verbal or no learning preferences (VVLSR) VVLSR – Equal (n = 6) VVLSR - more verbal (n = 8) VVLSR – more visual (n = 16) F p value* Participants’ test metrics & scores - Mean (SD) Overall Score 11.17 (± SD 0.75) 10.5 (± SD 1.85) 9.81 (± SD 2.13) (2, 27) 1.22 0.312 Anchor items (n = 6) 4.33 (± SD 0.52) 3.75 (± SD 1.49) 3.81 (± SD 1.04) (2, 27) 0.58 0.576 Items – text (n = 7) 6 (± SD 0.63) 5 (± SD 1.07) 4.94 (± SD 1.24) (2, 27) 2.14 0.137 Items – image (n = 7) 5.17 (± SD 1.17) 5.5 (± SD 1.2) 4.88 (± SD 1.36) (2, 27) 0.64 0.535 Image required (n = 5) 3.5 (± SD 1.05) 4 (± SD 1.07) 3.75 (± SD 0.93) (2, 27) 0.44 0.648 Image redundant (n = 2) 1.67 (± SD 0.52) 1.5 (± SD 0.53) 1.1 (± SD 0.72) (2, 27) 1.93 0.165 *(One-way ANOVA) Qualitative exploration of cognitive processes: All thirty students each verbalized their responses to fourteen questions, resulting in 420 student-item verbalizations. The verbalizations and cognitive processes observed are organized under three main themes within which sub-themes were developed (Table 3 ). The first theme concerned non-inferential description of the students’ vocalizations or observed behaviors, including sub-themes of reading the vignette fully (verbatim), linguistic or language mispronunciations, admitting knowledge deficits, or returning to review or reread MCQs prior to completing the paper [ 48 ]. The second theme involved identification of reasoning or cognitive strategies that students used to answer the question, incorporating sub-themes including generating a correct answer from ready knowledge before reviewing options, using option elimination to select an answer, or selecting an incorrect option with no obvious verbalization or consideration of the correct option (premature closure) [ 34 , 48 ]. Another sub-theme was whether students noticed and used the deliberate vertical cues that were inserted into the papers, whereby information in one MCQ aided in answering another MCQ on the paper. The third theme included all observed verbalizations and inferred cognitive processes specifically related to image identification or analysis; analytical, non-analytical and image not mentioned [ 46 , 47 ]. Analytical observations made specific reference to features such as scale, shape or color to deduce the answer. Non-analytical observations gave no indication as to how (named) features were identified, and for many of the image-based MCQs, there were simply no verbalizations related to the image at all. Table 3 Themes & sub-themes with indicative examples of recorded verbalizations Definition Total count* Examples Observed vocalizations & behaviors (14 x 30 = 420 student-item verbalizations) Reading vignette fully Reading the vignette verbatim 403 / 420 Question 2, what is produced by the cells indicated by the arrow in the image to the right? P14 Language - minor misspeaking or mispronunciation Mispronunciations - does not infer conceptual misunderstanding 20 / 420 I think they’re the ledwig [sic] cells. So I’m going to pick E – testosterone there. P21 Right, so you have your GFR. So you have, your reticularis, your fascicularis [sic] and your glomerulus [sic]. P23 Systematically reading or listing all options aloud Listing all options systematically 59 / 420 … the condition is typically caused by disease or damage to which of the following structures? A – adrenal medullary, B – anterior pituitary, C – hypothalamus, D – pancreas, E – renal cortex. P14 Returned & reviewed items & answers Returned to reconsider or check an item answer for a second (or third) time before completing test 153 / 420 Okay, I’ll check them one last time. P10 So there was two then, two or three I wanted to go back over and none which had questions later on in the test that helped. P11 Admitting knowledge deficits Explicitly expressing unfamiliarity or lack of knowledge 85 / 420 Potassium dichromate, dichromate was made, like something salt based or whatever it’s called. Em, then I don’t know, I don’t know. P10 I just can’t think of what cells they are. (Short pause). Oh maybe (short pause) because all the options don’t seem familiar. P16 Reasoning or cognitive strategies (14 x 30 = 420 student-item verbalizations) Generates (correct) answer before reviewing options Upon reading the vignette the participant immediately generates the correct answer, before reading the option list. 194 / 420 Question two, what is produced by cells, the cells indicated by the following arrow so they’re, em, the testis (laughs) and the cells in between are leydig cells or interstitial cells and they produce testosterone. P13 While attending the obstetric clinic, you see and examine a number of ladies attending their routine pre-natal visit. Which of the following hormones is produced by the placenta during pregnancy? (Sighs) I’m going to go with HCG. P22 Eliminating options - no initial self-generation No initial correct answer is verbalized, and the participant reads through the option list, systematically eliminating options to arrive at an answer 151 / 420 Endocrine cells manufacture hormones, which are then exported to act on receptors at distant sites in the body. Which of the following organelles plays a significant role in the manufacturing of hormones within the cell? It’s not the mitochondria. It’s not vesicles is what exports it, em, (short pause); endoplasmic reticulum should put it all together. They come together. Packages are the vesicles. Nucleus is the site is the site of gene expression so it should be the Golgi apparatus. P19 Reaching (incorrect) closure prematurely Failure to consider the correct alternative in answering the test item 43 / 420 Within the endocrine system, what is the mode of secretion in which the cell membrane ruptures and the entire contents of the cells are shed? So membrane is the apocrine, apocrine. P7 Reaching closure with difficulty or delay (1) pattern of thinking failing to help answer the question (2) excessive length of time & commentary to answer the question (3) excessive pauses & (4) taking tangents. 53 / 420 Word count prohibitive to include concise examples. Noticing a vertical cue (inserted intentionally!) Using information provided in one item to assist in answering another item on the paper 8 / 420 Okay, I won’t go for thyroid. Pancreas we’ve seen pictures of it before, so it’s not that. Adrenal, okay, I’ll guess pituitary because I don’t really know. (Turns pages). P27 This is where I remember that on a previous page, neuroendocrine derivative cells have been mentioned, so I’ll go back and (turns page) and check and question eight says the polyhedral cells… P30 Image identification and / or analysis (7 x 30 = 210 student-item verbalizations) Analytical observations Verbalizations regarding scale, size, shape, 108 / 210 That’s two millimetres so it’s probably, what gland is that is it the parathyroid or the pituitary. I’m going to say the pituitary gland because it look like it’s a very tiny gland but I’m not… P15 …Em, I think it’s either eosin or haematoxylin because they look kind of blue and pink, so eosin is the pink one. They look kind of pink. Because I wrote my notes in pink for eosin. P16 Non-analytical observations The tissue or a structure is named, but with no indication as to how it was recognized or interpreted 44 / 210 … What is produced by the cells indicated by the arrow in the image to the right? It’s the leydig cells in the testes so its testosterone. P7 Question twelve, the adrenal cortex has three distinguishable zones that secrete steroid hormones. Which of the following hormones are secreted by the layer of the cortex labelled “B” in the image on the right? B is zona reticularis which produces sex hormones so its androgens I think. P16 Image not mentioned No verbalization about the image 58 / 210 No verbalizations to include as examples. Redundant image (2 x 30 = 60 maximum) 50 / 60 No verbalizations to include as examples. Required image (5 x 30 = 150 maximum) 8 / 150 No verbalizations to include as examples. *Referring to the number of student-item verbalizations in which this code was observed Student performance Most students read the vignette and question aloud, fully and verbatim (403 of 420 student-item verbalizations; Tables 3 & 4 ), but the list of options was seldom read in the same systematic manner (59 of 420 student-item verbalizations). High performing students were more likely to self-generate an immediate answer to MCQs, without any verbalization indicating that they had read the full option list (74 of 126 student-item verbalizations; 59%), than medium (94 of 210; 44.8%) or lower (26 of 84; 31%) performing students (F (2, 27) = 6.60, p = 0.0046; Tables 3 & 4 ). Not all apparently self-generated answers were correct. There were 43 verbalizations where a student reached (incorrect) closure prematurely, generating an answer by selecting an incorrect option, without any verbal indication that the correct option had been read or considered (Table 3 ). Premature closure was observed more frequently in verbalizations from lower-performing students (16 of 84 student-item verbalizations; 19.1%) as compared to medium (23 of 210; 11%) or high (4 of 126; 3.2%) performing students (F (2, 27) = 7.33, p = 0.0029; Table 4 ). Table 4 Comparison of verbalizations from High, Medium and Lower-performing students. Count (percentage) of test items demonstrating a behavior or cognitive strategy according to student performance High performer (score ≥ 12; n = 9) Medium performer (score 9–11; n = 15) Low performer (score ≤ 8; n = 6) Observed vocalizations & behaviors p value* Reading vignette fully 122 / 126(96.8%) 198 / 210 (94.3%) 83 / 84(98.8%) 0.4724 Language - minor misspeaking or mispronunciation 1 / 126(0.8%) 16 / 210 (7.6%) 3 / 84(3.6%) 0.1192 Systematically reading or listing all options aloud 19 / 126(15.1%) 30 / 210 (14.3%) 10 / 84(11.9%) 0.9655 Returned & reviewed answers 17 / 126(13.5%) 78 / 210 (37.1%) 58 / 84(69.1%) 0.0577 Admitting knowledge deficits 9 / 126(7.1%) 49 / 210 (23.3%) 27 / 84(32.1%) 0.0114 Reasoning or cognitive strategies Generates (correct) answer before reviewing options 74 / 126(58.7%) 94 / 210 (44.8%) 26 / 84(31%) 0.0046 No verbalization of reviewing alternative options 55 / 126(43.7%) 71 / 210(33.8%) 18 / 84(21.4%) Checks options after generating (correct) answer 19 / 126(15.1%) 23 / 210(11%) 8 / 84(9.5%) Eliminating options - no initial self-generation 38 / 126(30.2%) 78 / 210 (37.1%) 35 / 84(41.7%) 0.3997 Reaching (incorrect) closure prematurely 4 / 126(3.2%) 23 / 210 (11%) 16 / 84(19.1%) 0.0029 Reaching closure with difficulty or delay 1 / 126(0.8%) 30 / 210 (14.3%) 22 / 84(26.2%) 0.0034 Noticing a vertical cue 1 / 126(0.8%) 7 / 210 (3.3%) 0.00(00.0%) 0.3515 *One-way ANOVA between high-medium-low performing groups Image interpretation (Image items n = 7) Analytical observations (scale, size, shape, color etc.) 31 / 63(49.2%) 58 / 105(55.2%) 19 / 42(45.2%) p = 0.612** Non-analytical observations 12 / 63(19.1%) 20 / 105(19.1%) 12 / 42(28.6%) Image not mentioned 20 / 63(31.8%) 27 / 105(25.7%) 11 / 42(26.2%) Redundant image (n = 2) 14 / 18(77.8%) 25 / 30(83.3%) 11 / 12(91.7%) Required image (n = 5) 6 / 45(13.3%) 2 / 75(2.7%) 0 / 75(0%) **X 2 (4) = 2.6818, p = 0.612 Unsurprisingly, lower performing students were more likely to verbalize about knowledge deficits, or being uncertain, than medium or high performing students (F (2, 27) = 5.31, p = 0.0114; Tables 3 & 4 ). Lower performing students also appeared to have more difficulty or delay in answering MCQs (22 of 84 student-item verbalizations; 26.2%), compared to medium (30 of 210; 14.3%) or high (1 of 126; 0.8%) performing students (F (2, 27) = 7.05, p = 0.0034; Tables 3 & 4 ). Lower performing students were also more likely to return and review MCQs for a second, or even a third time, before completing the test (F (2, 27) = 3.18, p = 0.0577; Tables 3 & 4 ). This study was designed to include a small number of vertical cues on each paper, but few students appeared to notice these, as they were remarked upon in only eight verbalizations (three of which were from one individual student (Tables 3 & 4 ). Image interpretation Students verbalized more observations when answering MCQs containing an image which was necessary or essential to answering the question, whereas redundant images were unlikely to be mentioned by students at all (X 2 (2) = 133.0720, p < 0.001; Fisher's exact test, p < 0.001; Table 5 ). Students who identified as verbal learners were more likely to have a verbally analytical approach to answering MCQs with images, making specific comments about the scale, shape, features or colors within the image (*X 2 (4) = 17.8040, p = 0.001; Fisher's exact test, p = 0.001; Table 6 ). Table 5 Comparison of verbalizations from students when answering image-based MCQs with either a “ redundant image ” or a “ required image ”. Count (percentage) of verbalizations, according to image type Redundant image (n = 2) Required image (n = 5) Analytical observations (scale, size, shape, color etc.) 3 / 60 (5%) 105 / 150 (70%) p < 0.001** Non-analytical observations 7 / 60 (11.7%) 37 / 150 (24.7%) Image not mentioned 50 / 60 (83.3%) 8 / 150 (5.3%) *X 2 (2) = 133.0720, p < 0.001; Fisher's exact test, p < 0.001 Table 6 Comparison of verbalizations according to students’ self-identified Verbal–Visual Learning Style Rating (VVLSR) when answering image-based MCQs Number of student-item verbalizations demonstrating a particular behavior or cognitive strategy according to self-identified VVLSR Visual learners (n = 16) No preference (n = 6) Verbal learners (n = 8) Image identification and / or analysis (7 x 30 = 210 student-item verbalizations) Analytical 45 / 112 (40.2%) 24 / 42 (57.1%) 39 / 56 (69.6%) p = 0.001* Non-analytical 31 / 112 (27.7%) 10 / 42 (23.8%) 3 / 56 (5.4%) Image not mentioned 36 / 112 (32.1%) 8 / 42 (19%) 14 / 56 (25%) Redundant image (2 per participant) 30 / 32(93.8%) 7 / 12(58.3%) 13 / 16(81.3%) Required image (5 per participant) 6 / 80(7.5%) 1 / 30(3.3%) 1 / 40(2.5%) *X 2 (4) = 17.8040, p = 0.001; Fisher's exact test, p = 0.001 “Right it’s not methylene blue because I don’t see any blue indications in the image.” P01 “So, I know that the predominant stain for an awful lot of the slides was the H&E one and what I’m looking at doesn’t look as pink as some of those. I’m going to scratch out A which is eosin and B which is haematoxylin. Definitely not methylene blue because they look kind of red.” P11 “Okay, I have to analyse this image because there is no colloid, so I don’t think it will be thyroid. No follicles evident. It does look like it has two lobes though so it could be pituitary. It’s probably pancreas, no I don’t think it would be pancreas. It has no follicles as well. I don’t think it would be adrenal either, just because split in two I’ll go with pituitary.” P12 “Em, okay, this looks like its pointing at a thing in between the big things, so I’m going to guess that it’s interstitial cell or a leydig cell, so testosterone is what I will choose..” P21 “Well it looks like there is two distinct stains, one is lighter than the other, em, and one’s bigger than the other. So it looks like an anterior and a posterior pituitary to me, so I’m going to say pituitary.” P29 Visual learners were more likely to make non-analytical comments about the image, where students would mention the image, perhaps even naming a structure seen within it, but giving no verbal indication as to how they had identified, interpreted or analyzed it. “I’m going to go with testosterone because I feel like they look like leydig cells.” P01 “so the arrow’s pointing the posterior pituitary which makes oxytocin and ADH, so the only answer is oxytocin.” P13 “Em, there’s a picture as well, em, so I suppose the picture is just to remind you” P17 “ So I know that this is going to be the glomerulus, this is the glom, this is the fasculata and this is reticularis so that’s going to be your androgens.” P18 “…for this question I didn’t really use the image on the right since it wasn’t really useful to me, since it didn’t relate to the actual thought process.” P30 Discussion This study sought to explore (1) the cognitive processes and critical thinking of students while answering Single Best Answer MCQs in histology, (2) whether images influence the verbalized cognitive processes of students and (3) whether self-identified verbal and visual learners display different verbalizations or cognitive processes when answering text and image-based MCQs. The “think-aloud” method explores metacognition through the lens of viewing thinking as inner speech, where people externally vocalize their inner monologue, and is accepted as a valid research methodology to explore reasoning and problem-solving in many fields, including medicine [ 34 , 47 , 48 , 50 – 52 ]. There are some criticisms, such as the potential for this ongoing verbalization to cause people to use limited cognitive resources on incidental processing, leaving less cognitive capacity for essential processing, or to potentially interrupt or influence the internal voice [ 9 , 53 , 54 ]. Another potential issue is that not all thinking or cognition is performed in an analytical manner, subject to being easily verbalized. Intuitive leaps, unconscious biases, subconscious pattern recognition – these subconscious thoughts will not be captured by verbalization of an inner monologue, although they may still heavily influence decision making, particularly when addressing complex questions or contexts [ 53 , 55 – 58 ]. The finding that high-performing students were more likely to self-generate an answer as compared to middle and lower performing students is consistent with observations in related studies of reasoning [ 46 , 48 , 59 ] and is the theoretical basis for the development and use of the very-short-answer question format [ 60 ]. Lower performers were not only more likely to verbalize about knowledge deficits, but also more likely went back to check or change answers than other students, which is also a finding consistent with previous studies [ 48 ]. Image recognition and interpretation are key skills in many of the medical sciences [ 31 , 34 , 61 – 65 ]. Therefore, the principles of constructive alignment mean that visual interpretation and analysis should be an integral, albeit proportional, part of assessment strategy and design [ 32 ]. While few assessments may specifically assess these skills of visual interpretation and analysis, those that do are typically well received by students, who appreciate their authenticity in preparing them for clinical practice, sentiments mirrored by students in this study [ 11 , 66 , 67 ]. While much prior research has reported that inserting images to a single best answer MCQ has no influence overall item psychometrics per se [ 35 , 68 – 71 ], other studies have reported inconsistent effects and hypothesized that these effects are due to the qualities or characteristics of the image used [ 24 ]. Other studies have contrasting findings, reporting that students’ scores are higher when answering MCQs images [ 67 ], or conversely that the inclusion of images reduces item facility (the inverse of item difficulty), lowering scores, potentially due to increasing extraneous cognitive load or spatial contiguity effects [ 18 , 20 ]. Despite the small of MCQs with redundant images in this study, the manner in which these images went mostly unmentioned in students’ verbalizations, along with the reduced Item facility for these MCQs, strongly suggests that redundant images are a hindrance in assessments, not a help, and should not be included within MCQ vignettes. While no other comparable research has been done to date within medical assessment, the inclusion of “ irrelevant, redundant or interacting sources of information” in arithmetic examinations is also suggested to slow down the speed at which students are able to process information, leading to increased testing time and item difficulty (the inverse of item facility) [ 37 ]. This coherence effect strongly suggests that over-excessive detail reduces capacity for essential information processing, and thus potentially detrimental to students’ performance in assessments [ 9 , 19 , 72 , 73 ]. However, this study also demonstrated that the inclusion of an image that was essential to correctly answering an MCQ did not appear to have any significant influence on item psychometrics or observed verbalizations as compared to text-alone vignettes. Thus, the use of images in MCQ vignettes written to specifically test the ability of candidates’ ability to identify or interpret required images is not only no threat to validity, but is logically required according to the principles of constructive alignment [ 27 , 32 , 68 – 71 ]. Furthermore, students’ self-identified VVLSR had no discernable influence on their scores when answering verbal or visual MCQs. Verbal learners were significantly more analytical in their verbalizations when answering image-based MCQs than visual learners, but learners who self-identify as being verbal learners may de facto experience a more analytical inner verbal monologue than those who self-identify as visual learners [ 12 , 16 , 17 , 58 ]. Additional factors, such as the quality of the images provided for candidates, along with their spatial (or temporal) relationship to the placement of the question text, does merit some conscious consideration when writing MCQs [ 9 , 19 , 20 , 27 , 33 , 34 , 74 ]. Where text and image are spatially separated on separate sheets or screens, some processing capacity will be diverted from image interpretation by the necessity to switch visual focus, looking back and forth between text and image [ 19 , 20 , 73 ]. Where this is not possible, and the image and text are separated, research on cognition suggests text should be placed to precede the image to provide context, with a caveat that this is as yet not definitively researched in MCQ assessments [ 19 , 33 ]. The hypothesis that the characteristics or complexity of the images used in MCQ vignettes will effect item statistics and metacognition has been recognized by numerous authors [ 11 , 19 , 24 , 34 , 75 ]. Sagoo et al found that students scored significantly higher on questions with images (both anatomical and radiological) compared to questions without images [ 11 ]. Further analysis considering image subtypes demonstrated that “students performed significantly better on questions referring to bones than to soft tissues regardless of the image type [anatomical or radiological]” suggesting that visual interpretation of an isolated structure (a bone) is less complex than the synthesis of information required to interpret images of interrelated and intersecting soft tissues [ 11 ]. The simplicity or complexity of both verbal vignettes and images may be accounted for within assessment strategies or processes, for example mapping to cognitive taxonomies [ 23 , 76 – 78 ]. Analysis of histological and cross-sectional images requires interpreting complex “categorical spatial relations”, whereby the relationships between objects must be judged [ 34 , 79 ]. Students seem to struggle more with MCQs displaying cross-sectional illustrations, as compared to those which use simpler diagrams or line drawings [ 24 ], and to demonstrate different cognitive processes when answering MCQs nested within cross-sectional themes, with more reliance on option elimination, and less visualizing or verbal reasoning being described [ 34 ]. It is essential for students to consciously develop and improve these visual and spatial interpretive skills by training and practice, as opposed passively noting what is pointed out to them, or only memorizing a limited set of exemplars, so that they can apply their knowledge when viewing unfamiliar or novel images, whether in assessments or in future independent practice [ 14 , 19 , 75 , 79 , 80 ]. For this reason, perhaps a number of novel images should be used within assessments if the required aim is to truly test the students’ abilities of image interpretation, even aside from the argument that the use of familiar images may promote positive cueing [ 24 , 34 , 36 ], an item flaw that may also be present in purely textual vignettes [ 81 ] Interpretation of images and spatial relationships is essential in many disciplines and so including images within assessments aid authenticity and constructive alignment. While the effects of visual or multimedia learning have been explored in many contexts, guidelines for assessment are still sparse, but some basic principles can be considered. Firstly, is the image relevant and essential to answering the question? Redundant information, including images, may simply increase extraneous cognitive load to no benefit, potentially influencing student performance [ 19 , 37 , 72 , 80 ]. Secondly, does the image show the relevant structure in isolation, such as an individual bone, or is it seen in relation to surrounding structures, as is the case with a histological cross section, or an abdominal CT scan? Interpreting spatial relations is certainly appropriate for many assessments, but increases the difficulty of the task or question. The third point of recognition considers whether the candidate is presented with a familiar image, seen and studied during their learning activities, or an entirely unfamiliar one. Novel images can be true tests of a candidate’s ability to demonstrate their knowledge and skill at image interpretation, but is potentially more cognitively demanding than recognizing a familiar image, or at least one similar to previous images studied. The realism of the image could also be considered; is the image a simple diagram, or is it a photograph of an actual histological or anatomical specimen [ 82 ]? Finally, for formatting, the spatial contiguity principle states that images should be as close as possible to their corresponding text, so that they may be viewed simultaneously without a need to switch focus, as opposed to being on a separate page or screen [ 19 , 33 ]. Limitations of the study This research study was designed as a qualitative think-aloud exploration of cognitive processes. While quantitative statistical analyses were performed and reported, the small number of participants (n = 30), limits the statistical power of these quantitative analyses. Furthermore, the cohort of students who participated were all volunteers, and so entirely self-selecting. While it was conducted in one institution, RCSI encompasses highly diverse student and staff bodies, and in this study of thirty students only eleven recorded their nationality as being within the EU, and students from Asia, North America and the Middle East were all represented. Only twelve students were monolingual English speakers, fifteen identified as bilingual, with two students speaking three languages fluently and one individual fully confident in four. However, the authors’ hope that the findings of this study will stimulate further interest and provide some supporting evidence for future investigation in this field. Conclusions In summary, high-performing students were significantly more likely to self-generate an answer as compared to middle and lower-performing students, who relied to a greater degree on option elimination. Adding images to MCQs did not have a consistent influence on item statistics, and the students’ self-identified visual-verbal preference (“learning style”) had no consistent bearing on their results for text or image based questions. Students’ verbalizations regarding images very highly dependent on whether the image was necessary or unnecessary to answering the question. For MCQs where interpretation of the image was required, specific reference to the image were noted for 95% of student-item verbalizations (142 of 150 maximum). In contrast, for MCQs where the image was redundant or unnecessary to answering the MCQ, reference to the image was recorded in only 17% of student-item verbalizations (10 of 60 maximum). The finding does align with the principles of question writing, whereby MCQ vignettes should not be cluttered with unnecessary information that do not help with cueing or answering MCQs, and may instead be detrimental distractions, adding to extraneous cognitive load. Declarations Notes on contributors Jane Holland, M.B., B.Ch., B.A.O., M.A., M.Sc., Pg.Dip.Ed., M.D., Ph.D., M.R.C.S.I., F.A.S., is a senior lecturer in the Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences in Ireland. She teaches both undergraduate students and postgraduate surgical trainees, and her research interests include assessment, medical education and eLearning. Alice McGarvey B.N.S., M.Sc., Ph.D., is Assistant Secretary General with the Irish Hospital Consultants Association and an honorary senior lecturer in the Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences in Ireland. She has extensive experience with assessment, education and particularly the initiation and implementation of complex people-centred projects. Michelle Flood B.Sc. (Pharm), M.Sc., Ph.D., M.P.S.I., is a senior lecturer in the School of Pharmacy and Biomolecular Sciences RCSI University of Medicine and Health Sciences in Ireland. She is deputy director for the MPharm programme and teaches at undergraduate and postgraduate levels. Her educational research interests include assessment, competency based education, workplace-based assessment, and curriculum reform. PAULINE JOYCE Ed.D, M.Sc., B.N.S., is Director of Quality & Clinical Engagement for the M.Sc. program in Physician Associate Studies at the RCSI University of Medicine and Health Sciences in Ireland. She teaches professional issues, research and leadership/management. Her research interests include leadership, teaching, learning and the physician associate role. Teresa Pawlikowska M.B., B.S., M.Sc., Ph.D., M.R.C.P., D.R.C.O.G., F.R.C.P.I. is Foundation Professor of the Health Professions Education Centre, RCSI University of Medicine and Health Sciences in Ireland. She has taught, researched, and practiced medicine throughout her career; additional research interests include inter-professional education, communication and consultation skills, and research methodology in medical education. Compliance with Ethical Standards Funding: This work was supported by an Education Research Grant from the Irish Network of Healthcare Educators (INHED). Conflict of interest: The authors declare that there is no conflict of interest. References Heidger PM, Dee F, Consoer D et al (2002) Integrated approach to teaching and testing in histology with real and virtual imaging. Anat Rec 269:107–112 Bloodgood RA, Ogilvie RW (2006) Trends in histology laboratory teaching in United States medical schools. Anat Rec B 289:169–175. https://doi.org/10.1002/ar.b.20111 Paulsen FP, Eichhorn M, Bräuer L (2010) Virtual microscopy—The future of teaching histology in the medical curriculum? Ann Anat 192:378–382. https://doi.org/10.1016/j.aanat.2010.09.008 Blake CA, Lavoie HA, Millette CF (2003) Teaching medical histology at the University of South Carolina School of Medicine: Transition to virtual slides and virtual microscopes. Anat Rec B 275B:196–206. https://doi.org/10.1002/ar.b.10037 Thompson AR, Lowrie DJ (2017) An evaluation of outcomes following the replacement of traditional histology laboratories with self-study modules. Anat Sci Educ 10:276–285. https://doi.org/10.1002/ase.1659 McBride JM, Drake RL (2018) National survey on anatomical sciences in medical education. Anat Sci Educ 11:7–14. https://doi.org/10.1002/ase.1760 Then SM, Kokolski M, Mbaki Y et al (2023) An international collaborative approach to learning histology using a virtual microscope. Anat Histol Embryol 52:21–30. https://doi.org/10.1111/ahe.12888 Levie WH, Lentz R (1982) Effects of text illustrations: A review of research. ECTJ 30:195–232. https://doi.org/10.1007/bf02765184 Mayer RE, Moreno R (2003) Nine Ways to Reduce Cognitive Load in Multimedia Learning. Educ Psychol 38:43–52. https://doi.org/10.1207/s15326985ep3801_6 Mayer RE (2010) Applying the science of learning to medical education. Med Educ 44:543–549. https://doi.org/10.1111/j.1365-2923.2010.03624.x Sagoo MG, Vorstenbosch MA, Bazira PJ et al (2021) Online assessment of applied anatomy knowledge: the effect of images on medical students' performance. Anat Sci Educ 14:342–351. https://doi.org/10.1002/ase.1965 Mayer RE, Massa LJ (2003) Three Facets of Visual and Verbal Learners: Cognitive Ability, Cognitive Style, and Learning Preference. J Educ Psychol 95:833. https://doi.org/10.1037/0022-0663.95.4.833 Newton PM, Miah M (2017) Evidence-Based Higher Education – Is the Learning Styles ‘Myth’ Important? Front Psychol 8. https://doi.org/10.3389/fpsyg.2017.00444 Höffler TN (2010) Spatial Ability: Its Influence on Learning with Visualizations—a Meta-Analytic Review. Educ Psychol Rev 22:245–269. https://doi.org/10.1007/s10648-010-9126-7 Rogowsky BA, Calhoun BM, Tallal P (2020) Providing Instruction Based on Students’ Learning Style Preferences Does Not Improve Learning [Brief Research Report]. Front Psychol 11. https://doi.org/10.3389/fpsyg.2020.00164 Artino ARJ, Zafar Iqbal M, Crandall SJ (2023) Debunking the Learning-Styles Hypothesis in Medical Education. Acad Med 98:289. https://doi.org/10.1097/acm.0000000000004738 Pashler H, McDaniel M, Rohrer D et al (2008) Learning styles: Concepts and evidence. Psychological science in the public interest. 9:105–119. https://doi.org/10.1111/j.1539-6053.2009.01038.x Mayer RE (2014) The Cambridge Handbook of Multimedia Learning. Cambridge University Press; ISBN: 978-1-107-61031-6 Mayer RE (2020) Designing multimedia instruction in anatomy: An evidence-based approach. Clin Anat 33:2–11. https://doi.org/10.1002/ca.23265 Hunt DR (1978) Illustrated multiple choice examinations. Med Educ 12:417–420. https://doi.org/10.1111/j.1365-2923.1978.tb01420.x Buzzard A, Bajsdaranayake R, Harvey C (1987) How to Produce Visual Material for Multiple Choice Examinations. Med Teach 9:451–456. https://doi.org/10.3109/01421598709008341 Dwyer F, De Melo H (1984) A systematic assessment of the effect of visual testing of visualized instruction: A Justification for Instructional Congruency. J Vis Verbal Lang 4:53–66. https://doi.org/10.1080/23796529.1984.11674379 Phillips AW, Smith SG, Straus CM (2013) Driving Deeper Learning by Assessment: An Adaptation of the Revised Bloom's Taxonomy for Medical Imaging in Gross Anatomy. Acad Radiol 20:784–789. https://doi.org/10.1016/j.acra.2013.02.001 Vorstenbosch MA, Klaassen TP, Kooloos JG et al (2013) Do images influence assessment in anatomy? Exploring the effect of images on item difficulty and item discrimination. Anat Sci Educ 6:29–41. https://doi.org/10.1002/ase.1290 Case SM, Swanson DB (2002) Constructing written test questions for the basic and clinical sciences. National Board of Medical Examiners Philadelphia, PA van der Vleuten CP, Schuwirth LW (2005) Assessing professional competence: from methods to programmes. Med Educ 39:309–317. https://doi.org/10.1111/j.1365-2929.2005.02094.x Holland J, Stevens N (2020) Guidelines for the development of multiple choice items & assessments. Dublin, Ireland: RCSI University of Medicine and Health Sciences; ISBN: 978-1-9996983-0-0. https://repository.rcsi.com/articles/book/Guidelines_for_the_development_of_multiple_choice_items_assessments_/13947164 Downing SM (2002) Construct-irrelevant Variance and Flawed Test Questions: Do Multiple‐choice Item‐writing Principles Make Any. Difference? Acad Med 77:S103–S104 Haladyna TM, Downing SM (2004) Construct-Irrelevant Variance in High-Stakes Testing. Educ Meas Issues Pract 23:17–27. https://doi.org/10.1111/j.1745-3992.2004.tb00149.x Abedi J (2006) Language issues in item development. In: Haladyna TM, Downing SM, editors. Handbook of test development: Routledge; pp 377–398. ISBN: 9780203874776 Das M, Ettarh R, Lowrie D et al (2019) A guide to competencies, educational goals, and learning objectives for teaching medical histology in an undergraduate medical education setting. Med Sci Educ 29:523–534. https://doi.org/10.1007/s40670-018-00688-9 Biggs J (2003) Aligning teaching and assessing to course objectives. Teach Learn High Educ 2:13–17 Eitel A, Scheiter K (2015) Picture or Text First? Explaining Sequence Effects when Learning with Pictures and Text. Educ Psychol Rev 27:153–180. https://doi.org/10.1007/s10648-014-9264-4 Vorstenbosch MA, Bouter ST, Hurk MM et al (2014) Exploring the validity of assessment in anatomy: Do images influence cognitive processes used in answering extended matching questions? Anat Sci Educ 7:107–116. https://doi.org/10.1002/ase.1382 Holland J, O’Sullivan R, Arnett R (2015) Is a picture worth a thousand words: an analysis of the difficulty and discrimination parameters of illustrated vs. text-alone vignettes in histology multiple choice questions. BMC Med Educ 15:184. https://doi.org/10.1186/s12909-015-0452-9 Crisp V, Sweiry E (2006) Can a picture ruin a thousand words? The effects of visual resources in exam questions. Educ Res (Windsor) 48:139–154. https://doi.org/10.1080/00131880600732249 Berends IE, van Lieshout EC (2009) The effect of illustrations in arithmetic problem-solving: Effects of increased cognitive load. Learn Instr 19:345–353. https://doi.org/10.1016/j.learninstruc.2008.06.012 Holland J, Clarke E, Glynn M (2016) Out of sight, out of mind: Do repeating students overlook online course components? Anat Sci Educ 9:555–564. https://doi.org/10.1002/ase.1613 De Winter JC, Dodou D (2010) Five-point Likert items: t test versus Mann-Whitney-Wilcoxon. Pract Assess Res Eval 15:1–12. https://doi.org/10.7275/BJ1P-TS64 Carifio J, Perla RJ (2007) Ten common misunderstandings, misconceptions, persistent myths and urban legends about Likert scales and Likert response formats and their antidotes. J Soc Sci 3:106–116. https://doi.org/10.3844/jssp.2007.106.116 Conroy RM (2012) What hypotheses do nonparametric two-group tests actually test? Stata J 12:182. https://doi.org/10.1177/1536867X1201200202 Norman G (2010) Likert scales, levels of measurement and the laws of statistics. Adv Health Sci Educ 15:625–632. https://doi.org/10.1007/s10459-010-9222-y Sullivan GM, Artino AR (2013) JGME 5:541–542. https://doi.org/10.4300/JGME-5-4-18 . Analyzing and Interpreting Data From Likert-Type Scales Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3:77–101. https://doi.org/10.1191/1478088706qp063oa Clarke V, Braun V, Hayfield N (2015) Thematic analysis. In: Smith JA, editor. Qualitative psychology: A practical guide to research methods. Vol. 3: SAGE Publications Ltd; pp 222–248. ISBN: 978-1-4462-9846-6 Coderre S, Mandin H, Harasym PH et al (2003) Diagnostic reasoning strategies and diagnostic success. Med Educ 37:695–703. https://doi.org/10.1046/j.1365-2923.2003.01577.x Heemskerk L, Norman G, Chou S et al (2008) The effect of question format and task difficulty on reasoning strategies and diagnostic performance in internal medicine residents. Adv Health Sci Educ 13:453–462. https://doi.org/10.1007/s10459-006-9057-8 Heist BS, Gonzalo JD, Durning S et al (2014) Exploring clinical reasoning strategies and test-taking behaviors during clinical vignette style multiple-choice examinations: a mixed methods study. JGME 6:709–714. https://doi.org/10.4300/JGME-D-14-00176.1 Kiger ME, Varpio L (2020) Thematic analysis of qualitative data: AMEE Guide 131. Med Teach 42:846–854. https://doi.org/10.1080/0142159X.2020.1755030 Coderre S, Harasym P, Mandin H et al (2004) The impact of two multiple-choice question formats on the problem-solving strategies used by novices and experts. BMC Med Educ 4:23. https://doi.org/10.1186/1472-6920-4-23 Gorard S (2013) Research design: Creating robust approaches for the social sciences. Sage; ISBN: 1446290859 Durning SJ, Dong T, Artino AR et al (2015) Dual processing theory and expertsʼ reasoning: exploring thinking on national multiple-choice questions. Perspect Med Educ 4:168–175. https://doi.org/10.1007/s40037-015-0196-6 Durning SJ, Artino AR, Beckman TJ et al (2013) Does the think-aloud protocol reflect thinking? Exploring functional neuroimaging differences with thinking (answering multiple choice questions) versus thinking aloud. Med Teach 35:720–726. https://doi.org/doi:10.3109/0142159X.2013.801938 Ericsson KA, Simon HA (1998) How to study thinking in everyday life: Contrasting think-aloud protocols with descriptions and explanations of thinking. Mind Cult Act 5:178–186. https://doi.org/10.1207/s15327884mca0503_3 Aczel B, Lukacs B, Komlos J et al (2011) Unconscious intuition or conscious analysis? Critical questions for the Deliberation-Without-Attention paradigm. Judgm Decis Mak 6:351–358. https://doi.org/10.1017/S1930297500001960 Rey A, Goldstein RM, Perruchet P (2009) Does unconscious thought improve complex decision making? Psychol Res PRPF 73:372–379. https://doi.org/10.1007/s00426-008-0156-4 Gigerenzer G, Brighton H (2009) Homo heuristicus: Why biased minds make better inferences. Top Cogn Sci 1:107–143. https://doi.org/10.1111/j.1756-8765.2008.01006.x Kelsey JM (2016) Inner experience and self-ratings of inner speaking. University of Nevada, Las Vegas: University of Nevada, Las Vegas; https://digitalscholarship.unlv.edu/thesesdissertations/2691 Durning SJ, Ten Cate OTJ (2007) Peer teaching in medical education. Med Teach 29:523–524. https://doi.org/10.1080/01421590701683160 Sam AH, Field SM, Collares CF et al (2018) Very-short‐answer questions: reliability, discrimination and acceptability. Med Educ 52:447–455. https://doi.org/10.1111/medu.13504 Hołda MK, Stefura T, Koziej M et al (2019) Alarming decline in recognition of anatomical structures amongst medical students and physicians. Ann Anat 221:48–56. https://doi.org/10.1016/j.aanat.2018.09.004 Langlois J, Bellemare C, Toulouse J et al (2016) Spatial abilities and anatomy knowledge assessment: A systematic review. Anat Sci Educ. https://doi.org/10.1002/ase.1655 . n/a-n/a Luursema J-M, Vorstenbosch M, Kooloos J, Stereopsis (2017) Visuospatial Ability, and Virtual Reality in Anatomy Learning. Anatomy research international. ; 2017. https://doi.org/10.1155/2017/1493135 O'Brien KE, Cannarozzi ML, Torre DM et al (2008) Training and Assessment of CXR/Basic Radiology Interpretation Skills: Results From the 2005 CDIM Survey. Teach Learn Med 20:157–162. https://doi.org/10.1080/10401330801991840 Phillips AW, Smith SG, Straus CM (2013) The role of radiology in preclinical anatomy: a critical review of the past, present, and future. Acad Radiol 20:297–304e1. https://doi.org/10.1016/j.acra.2012.10.005 Rathan R, Hamdy H, Kassab SE et al (2022) Implications of introducing case based radiological images in anatomy on teaching, learning and assessment of medical students: a mixed-methods study. BMC Med Educ 22:723. https://doi.org/10.1186/s12909-022-03784-y Magi M, Jayagandhi S, Dinesh Kumar V et al (2022) Analysing the Effect of Incorporating Images While Framing MCQs For Online Clinical Anatomy Assessment Among First Year Medical Students. Int J Anat Res 10:8482–8488. https://doi.org/10.16965/ijar.2022.225 Notebaert AJ (2016) The effect of images on item statistics in multiple choice anatomy examinations. Anat Sci Educ 68–78. https://doi.org/10.1002/ase.1637 Sagoo MG, Smith CF, Gosden E (2016) Assessment of anatomical knowledge by practical examinations: The effect of question design on student performance. Anat Sci Educ 9:446–452. https://doi.org/10.1002/ase.1597 Bahlmann O (2018) Illustrated versus non-illustrated anatomical test items in anatomy course tests and German Medical Licensing examinations (M1). GMS J Med Educ 35. https://doi.org/10.3205/zma001172 Rutgers DR, van Raamt F, van der Gijp A et al (2018) Determinants of Difficulty and Discriminating Power of Image-based Test Items in Postgraduate Radiological Examinations. Acad Radiol 25:665–672. https://doi.org/10.1016/j.acra.2017.10.014 Leppink J, van den Heuvel A (2015) The evolution of cognitive load theory and its application to medical education. Perspect Med Educ 4:119–127. https://doi.org/10.1007/s40037-015-0192-x Sweller J (2016) Story of a research program. Educ Rev 23. https://doi.org/10.14507/er.v23.2025 Doyle M, Boyle B, Holland J et al (2022) The trainee experience: a candidate feedback from the pilot European exam in medical microbiology. Poster presented at: 11c -Medical education for CM/ID. ECCMID. ; Lisbon, Portugal 2022 Ben Awadh A, Clark J, Clowry G et al (2022) Multimodal Three-Dimensional Visualization Enhances Novice Learner Interpretation of Basic Cross‐Sectional Anatomy. Anat Sci Educ 15:127–142. https://doi.org/10.1002/ase.2045 Stringer JK, Santen SA, Lee E et al (2021) Examining Bloom’s Taxonomy in Multiple Choice Questions: Students’ Approach to Questions. Med Sci Educ 31:1311–1317. https://doi.org/10.1007/s40670-021-01305-y Tiemeier AM, Stacy ZA, Burke JM (2011) Using multiple choice questions written at various Bloom's Taxonomy levels to evaluate student performance across a therapeutics sequence. INNOVATIONS Pharm 2. https://doi.org/10.24926/iip.v2i2.224 Zaidi NB, Hwang C, Scott S et al (2017) Climbing Bloom's taxonomy pyramid: Lessons from a graduate histology course. Anat Sci Educ 10:456–464. https://doi.org/10.1002/ase.1685 Pettersson AF, Karlgren K, Al-Saadi J et al (2023) How students discern anatomical structures using digital three-dimensional visualizations in anatomy education. Anat Sci Educ 00:1–13. https://doi.org/https://doi.org/10.1002/ase.2255 Cook MP (2006) Visual representations in science education: The influence of prior knowledge and cognitive load theory on instructional design principles. Sci Educ 90:1073–1091. https://doi.org/10.1002/sce.20164 Schuwirth L, Vleuten Cvd, Donkers H (1996) A closer look at cueing effects in multiple-choice questions. Med Educ 30:44–49. https://doi.org/10.1111/j.1365-2923.1996.tb00716.x Erolin C (2023) Preference for realism in 3D anatomical scans. J Vis Commun Med 46:85–96. https://doi.org/10.1080/17453054.2023.2226690 Additional Declarations The authors declare no competing interests. Supplementary Files SupplInfoInterviewsSheetsMCQs.pdf Interview sheets & MCQs Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4200329","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":286145461,"identity":"27a59f1f-3068-4f40-b652-489dbf33c72d","order_by":0,"name":"Jane Holland","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYBACxhkMjAceAOl+EC+BQYIoLQwHEoD0zAZitYDUgLVsOECsw5hnNx84kFBzR3bz7cOPPzxgsJAj7LA5xxIOJBx7ZrztXJqZBNBhxoS1zMgxOJDAdjhx2xkeNpBfEhuI0/LvcOLmHh7mD0At9cRpSWw7nLiBh4cB5LAEIhyWlnAgse+w8YwzbEC/GEgYErTFcEbywQcfvh2W7e9hfvzxR0WdPEFb0Aw1IKiBgYGwoaNgFIyCUTAKAFsqQaOXSYgqAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-8784-6169","institution":"RCSI University of Medicine and Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Jane","middleName":"","lastName":"Holland","suffix":""},{"id":286145462,"identity":"3e053ac0-dd18-4ed2-9e00-cb897ee55a2e","order_by":1,"name":"Alice McGarvey","email":"","orcid":"https://orcid.org/0000-0003-4681-9938","institution":"RCSI University of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Alice","middleName":"","lastName":"McGarvey","suffix":""},{"id":286145463,"identity":"51b857b4-cdca-442c-bbd2-a94438baa502","order_by":2,"name":"Michelle Flood","email":"","orcid":"https://orcid.org/0000-0002-8284-1780","institution":"RCSI University of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Flood","suffix":""},{"id":286145464,"identity":"db77a0aa-e6d2-4681-8bc4-4ad04c17e55a","order_by":3,"name":"Pauline Joyce","email":"","orcid":"https://orcid.org/0000-0002-6220-9753","institution":"RCSI University of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Pauline","middleName":"","lastName":"Joyce","suffix":""},{"id":286145465,"identity":"026b309c-8a3f-42a0-911d-5a0f029eb9ff","order_by":4,"name":"Teresa Pawlikowska","email":"","orcid":"https://orcid.org/0000-0001-8432-3488","institution":"RCSI University of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Teresa","middleName":"","lastName":"Pawlikowska","suffix":""}],"badges":[],"createdAt":"2024-04-01 11:32:41","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4200329/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4200329/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53907594,"identity":"cc425dbb-961b-48a3-9d27-254c1c4803db","added_by":"auto","created_at":"2024-04-02 05:30:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":513151,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4200329/v1/5a4c0b19-9041-4d4a-97a7-176897653942.pdf"},{"id":53907524,"identity":"feb0b1cd-cfb1-4f8e-8045-b2e414b3122f","added_by":"auto","created_at":"2024-04-02 05:30:14","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":623988,"visible":true,"origin":"","legend":"\u003cp\u003eInterview sheets \u0026amp; MCQs\u003c/p\u003e","description":"","filename":"SupplInfoInterviewsSheetsMCQs.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4200329/v1/61c3e2e3515cbf565f5af06d.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eA qualitative exploration of student cognition when answering text-only or image-based histology multiple-choice questions.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVisuospatial skills are an intrinsic element of medicine and medical sciences, and the disciplines of anatomy and histology are typically the first areas of the medical curriculum where students will experience the need to develop and display skills of identification and interpretation. How these skills are introduced, internalized and ultimately assessed has direct relevance to educators, particularly as technological advances have led to image-based resources and assessments being more easily, and so increasingly, incorporated into curricula.\u003c/p\u003e \u003cp\u003eMuch education has moved online in recent years, with many institutions now teaching histology by means of virtual microscopy or computer-based programs [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The use of images in teaching and learning is well described, where the \u003cem\u003edual channels assumption\u003c/em\u003e of the \u003cem\u003emultiple representation principle\u003c/em\u003e proposes that learners process information primarily through separate auditory-verbal and visual-pictorial channels [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Students will have differences in cognitive ability, learning styles and preferences along the visualizer\u0026ndash;verbalizer dimension, and the concept of teaching to learning styles or preferences is still pervasive in education [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, there is a dearth of evidence to support teaching to individual learning styles or preferences [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], with \u003cem\u003e\u0026ldquo;no adequate evidence base to justify incorporating learning styles assessments into general educational practice\u0026rdquo;\u003c/em\u003e [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Instead, the evidence-base demonstrates that students benefit from learning with a combination of images and verbal information, to balance incoming information between these two main channels [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInformation on the effect of images in assessments is more limited, perhaps in part due to the historical challenges in preparing and including images in unique examinations. Nowadays, digital photography, printing and online assessments means that image reproduction and inclusion has become a straightforward task [\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. While all assessment methods have different strengths and weaknesses Multiple Choice Questions (MCQs) are extremely time-efficient, allowing broad sampling across the curriculum, and so remain a core component of most programs of assessment [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Medicine and the medical sciences require accurate identification of clinical signs, anatomical parts and histological features, and while precise verbal descriptions could be included within clinical vignettes, doing so may make text overly grammatically convoluted or complex [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This issue is even more relevant for institutions with substantial numbers of non-native English speakers, studying medicine in their second (or third) language, and so conscious consideration should be given to only include \u003cem\u003econstruct-relevant\u003c/em\u003e language, an inherent part of the technical vocabulary of medical sciences, while minimizing linguistic clutter and irrelevant grammatical complexity [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany learning outcomes in histology also require that students identify structures by visual inspection and interpretation [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. While principles of constructive alignment require that these learning outcomes be assessed using images, the evidence-base on how to do so is sparse, with variable outcomes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The bespoke 70-plate booklet of illustrations used by Hunt et al in the 1970s was undoubtedly of high quality, and improved the authenticity of the assessment, but its use negatively impacted candidates\u0026rsquo; scores, as they repeatedly switched focus between this booklet and reading the questions on the examination paper [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This phenomenon is described as the \u003cem\u003espatial continuity\u003c/em\u003e effect and can be avoided by placing text and images adjacent to each other in either printed or online assessments [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. More recent studies with well-aligned text and images found no evidence of a \u003cem\u003econsistent\u003c/em\u003e effect on item difficulty or discrimination [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSo, where lies the balance within authentic assessment of an undergraduate histology curriculum? Inclusion of some images within assessments is now a simple matter, but does an accompanying image provide candidates with an additional advantage or cue when answering a question, or is it a distracting increase to cognitive load [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]? This study examines (1) the cognitive processes and critical thinking of students while answering Single Best Answer MCQs in histology, (2) whether images influence the verbalized cognitive processes of participants and (3) whether self-identified verbal and visual learners display different verbalizations or cognitive processes when answering text and image-based MCQs.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthics approval, student recruitment \u0026amp; anonymization\u003c/h2\u003e \u003cp\u003eEthical approval for this study was received from the Research Ethics Committee of the Royal College of Surgeons in Ireland (reference RCSI-REC1132). Students in their first year of both the Direct (Undergraduate, DEM, 340 students) and Graduate Entry Medical (GEM, 80 students) programs were invited to participate by means of a forum post (with attached Participant Information Leaflet) and to contact the Principal Investigator by e-mail if they wished to volunteer. All students who did so were assigned a unique participant number for pseudoanonymization by a gatekeeper, with no role or responsibility in teaching or assessing medical students. Within RCSI\u0026rsquo;s School of Medicine, the histology course was taught by self-directed online tutorials, within the first year of the curriculum, integrated into the systems-based, multidisciplinary modules, and students were advised to study the \u0026ldquo;Endocrine System\u0026rdquo; online histology tutorial prior to their interview (which was part of their normal course content for the semester) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePreparation of Multiple-Choice Questions\u003c/h2\u003e \u003cp\u003eTwo examination papers with fourteen multiple-choice questions were prepared by two content experts, with six identical anchor MCQs on each test (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Supplementary Information). Three anchor MCQs had textual vignettes only, and three items required interpretation of an adjacent image (\u0026ldquo;\u003cem\u003erequired image\u003c/em\u003e\u0026rdquo;). The remainder of MCQs on each test were matched, where one test had an MCQ with a textual vignette, and the matched MCQ on the other test included an image (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Supplementary Information). The image-based MCQ was contained either (a) identical text along with an image containing information complementary but non-essential to answering the question (\u0026ldquo;\u003cem\u003eredundant image\u003c/em\u003e\u0026rdquo;) or (b) a modified textual vignette, with removal of details critical to answering the question, and an image added to provide that required information or context (\u0026ldquo;\u003cem\u003erequired image\u003c/em\u003e\u0026rdquo;).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of assessment items completed by students in Version A and Version B of the tests in this study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003evA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003evB\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnchor item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiabetes insipidus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnchor item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTestes \u0026amp; Leydig cells\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eText \u0026amp; required histological image\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMatched item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEndoplasmic reticulum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIdentical text \u0026amp; redundant image (diagram)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMatched item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePlacental Human Chorionic Gonadotrophin (HCG)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIdentical text \u0026amp; redundant histological image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMatched item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThyroid parafollicular cell function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModified text \u0026amp; required histological image\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMatched item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePancreatic Islet of Langherhan\u0026rsquo;s function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModified text \u0026amp; required histological image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnchor item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePregnancy \u0026amp; progesterone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnchor item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdrenal medulla \u0026amp; Potassium dichromate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eText \u0026amp; required histological image\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMatched item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePituitary acidophils\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIdentical text \u0026amp; redundant histological image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMatched item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeuroendocrine cells \u0026amp; adrenal medulla\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIdentical text \u0026amp; redundant image (diagram)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMatched item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOxytoxin secretion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModified text \u0026amp; required image (diagram)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMatched item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdrenal cortex \u0026amp; androgens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModified text \u0026amp; required histological image\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnchor item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHolocrine secretion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eTextual vignette\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnchor item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePituitary gland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eText \u0026amp; required histological image\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInterviews\u003c/h2\u003e \u003cp\u003eStudents then met individually with one of the interviewers, and were given an opportunity to ask questions before giving formal consent, then randomly assigned to either Version A or Version B of the test (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Supplementary Information). Students completed demographic questions regarding their educational level and linguistic abilities (native \u0026amp; known languages), and then the Verbal\u0026ndash;Visual Learning Style Rating (VVLSR; 7-point Likert), to identify whether they self-identified as predominantly verbal or visual learners [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Students were given some guidance on verbalizing their thoughts (\u0026ldquo;think-aloud\u0026rdquo;) and asked to answer two practice questions, voicing their thoughts as they completed these questions. Students then completed their fourteen MCQs, while continuing to verbalize their thoughts for recording and transcription.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAnalyses\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eQuantitative data\u003c/strong\u003e \u003cp\u003eAll demographic and test data were collated \u0026amp; tabulated in MS Excel, then imported to STATA 17.0 for statistical analysis (StataCorp., College Station, TX). A caveat must be stated that the primarily qualitative focus of this study, and the small number of participants (n\u0026thinsp;=\u0026thinsp;30), limits the statistical power and thus the interpretation of quantitative statistical analyses. Differences were considered significant for values of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all (parametric) statistical analyses performed in this study, with the mean and standard deviation used to summarize students\u0026rsquo; scores. For analysis of the Verbal\u0026ndash;Visual Learning Style Rating, the mean was again chosen as the measure of central tendency, and comparisons were performed by means of independent t-tests [\u003cspan additionalcitationids=\"CR40 CR41 CR42\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Item psychometrics were calculated in STATA, with item discrimination calculated by means of a point biserial correlation (pwcorr, a true Pearson product-moment correlation), with a higher positive correlation for an MCQ indicating that students who achieved a high score on the overall test also scored higher on that individual MCQ.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eQualitative analysis\u003c/strong\u003e \u003cp\u003eTranscripts were imported into QSR International\u0026rsquo;s NVIVO 11 qualitative data analysis software (QSR International Pty. Ltd.), which was used for all further thematic analysis. While some codes and themes were anticipated from prior reading of the existing evidence-base, all transcripts were initially read for familiarity, then coded with a realist, inductive approach, with anticipated and additional emerging codes identified and integrated within themes [\u003cspan additionalcitationids=\"CR45 CR46 CR47\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The process was iterative, with the thematic structure undergoing revisions throughout, with coding and analysis shared and discussed between co-authors throughout the process [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Following development of the final thematic framework, a final formal analysis of 20% of scripts was performed by an additional coder for comparison with this final schema and themes.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative analyses \u0026amp; item statistics:\u003c/h2\u003e \u003cp\u003eAll students completed the interview well within the 30 minutes allotted, with a mean recording length of 14 minutes \u0026amp; 5.5 seconds. Cronbach\u0026rsquo;s alpha (Scale reliability coefficient) for Version A of the test was 0.68, while Version B was 0.67. Comparing students\u0026rsquo; scores on the test papers overall, there was no statistically significant difference observed between students who completed Version A of the test (M\u0026thinsp;=\u0026thinsp;10, SD\u0026thinsp;=\u0026thinsp;1.77) as compared to those who completed Version B (M\u0026thinsp;=\u0026thinsp;10.5, SD\u0026thinsp;=\u0026thinsp;2.03; t(28) = -0.7663, p\u0026thinsp;=\u0026thinsp;0.45). Item statistics for the six identical anchor MCQs showed no statistically significant difference in the item facility observed on Version A of the test (M\u0026thinsp;=\u0026thinsp;0.63, SD\u0026thinsp;=\u0026thinsp;0.23) as compared to Version B (M\u0026thinsp;=\u0026thinsp;0.67, SD\u0026thinsp;=\u0026thinsp;0.29; t(5) = -0.8076, p\u0026thinsp;=\u0026thinsp;0.46). Similarly, no significant differences were observed in point-biserial correlation (0.266\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28 vs 0.384\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19; t(5) = -0.8611, p\u0026thinsp;=\u0026thinsp;0.43) of these six anchor MCQs as answered by students completing either Version A or B of the test.\u003c/p\u003e \u003cp\u003eFor the remainder of the MCQs on the paper, these matched image MCQs either had (a) identical text and an additional (redundant) image that was not essential to answering the question or (b) modification of the vignette and substitution of textual information with an image (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Supplementary Information). Comparing the text-only MCQs with their match that had an identical textual vignette and an additional \u0026ldquo;redundant\u0026rdquo; image attached, a slight and non-significant reduction in item facility (0.75 vs 0.67; p\u0026thinsp;=\u0026thinsp;0.08) was observed, but with no demonstrable impact on point-biserial correlation (0.43 vs 0.42; p\u0026thinsp;=\u0026thinsp;0.96). Comparing text-only MCQs with their match containing modified text \u0026amp; an image requiring interpretation, showed no statistically significant difference in either item facility (0.88 vs 0.88; p\u0026thinsp;=\u0026thinsp;1.00) or point-biserial correlation (0.25 vs 0.20; p\u0026thinsp;=\u0026thinsp;0.84).\u003c/p\u003e \u003cp\u003eThere was no difference observed in the students\u0026rsquo; self-identified VVLSR when comparing students who completed Version A of the test (M\u0026thinsp;=\u0026thinsp;4.67, SD\u0026thinsp;=\u0026thinsp;1.5) with those who completed Version B (M\u0026thinsp;=\u0026thinsp;4.47, SD\u0026thinsp;=\u0026thinsp;1.85; t(28)\u0026thinsp;=\u0026thinsp;0.3259, p\u0026thinsp;=\u0026thinsp;.75). There was no significant difference between those who identified as more verbal, more visual or equal learners with regard to overall score, or subscores on anchor MCQs, text-only MCQs or on MCQs with images overall (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For scores on the MCQs with redundant images, self-identified visual learners received a lower score on these two MCQs (1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72) than either verbal (1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53) or equal learners (1.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52), but this did not reach statistical significance (F (2, 27)\u0026thinsp;=\u0026thinsp;1.93; p\u0026thinsp;=\u0026thinsp;0.165; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eScores \u0026amp; subscores on different item types by students with self-identified visual, verbal or no learning preferences (VVLSR)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVVLSR \u0026ndash; Equal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVVLSR - more verbal (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVVLSR \u0026ndash; more visual (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eParticipants\u0026rsquo; test metrics \u0026amp; scores - Mean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.17 (\u0026plusmn;\u0026thinsp;SD 0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.5 (\u0026plusmn;\u0026thinsp;SD 1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.81 (\u0026plusmn;\u0026thinsp;SD 2.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2, 27)\u003c/p\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.312\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnchor items (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.33 (\u0026plusmn;\u0026thinsp;SD 0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.75 (\u0026plusmn;\u0026thinsp;SD 1.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.81 (\u0026plusmn;\u0026thinsp;SD 1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2, 27)\u003c/p\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems \u0026ndash; text (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (\u0026plusmn;\u0026thinsp;SD 0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (\u0026plusmn;\u0026thinsp;SD 1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.94 (\u0026plusmn;\u0026thinsp;SD 1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2, 27)\u003c/p\u003e \u003cp\u003e2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems \u0026ndash; image (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.17 (\u0026plusmn;\u0026thinsp;SD 1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.5 (\u0026plusmn;\u0026thinsp;SD 1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.88 (\u0026plusmn;\u0026thinsp;SD 1.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2, 27)\u003c/p\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eImage required\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(n\u0026thinsp;=\u0026thinsp;5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e3.5 (\u0026plusmn;\u0026thinsp;SD 1.05)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e4 (\u0026plusmn;\u0026thinsp;SD 1.07)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e3.75 (\u0026plusmn;\u0026thinsp;SD 0.93)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e(2, 27)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e0.44\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.648\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eImage redundant\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(n\u0026thinsp;=\u0026thinsp;2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e1.67 (\u0026plusmn;\u0026thinsp;SD 0.52)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e1.5 (\u0026plusmn;\u0026thinsp;SD 0.53)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e1.1 (\u0026plusmn;\u0026thinsp;SD 0.72)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e(2, 27)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e1.93\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.165\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e*(One-way ANOVA)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eQualitative exploration of cognitive processes:\u003c/h2\u003e \u003cp\u003eAll thirty students each verbalized their responses to fourteen questions, resulting in 420 student-item verbalizations. The verbalizations and cognitive processes observed are organized under three main themes within which sub-themes were developed (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The first theme concerned non-inferential description of the students\u0026rsquo; vocalizations or observed behaviors, including sub-themes of reading the vignette fully (verbatim), linguistic or language mispronunciations, admitting knowledge deficits, or returning to review or reread MCQs prior to completing the paper [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The second theme involved identification of reasoning or cognitive strategies that students used to answer the question, incorporating sub-themes including generating a correct answer from ready knowledge before reviewing options, using option elimination to select an answer, or selecting an incorrect option with no obvious verbalization or consideration of the correct option (premature closure) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Another sub-theme was whether students noticed and used the deliberate vertical cues that were inserted into the papers, whereby information in one MCQ aided in answering another MCQ on the paper. The third theme included all observed verbalizations and inferred cognitive processes specifically related to image identification or analysis; analytical, non-analytical and image not mentioned [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Analytical observations made specific reference to features such as scale, shape or color to deduce the answer. Non-analytical observations gave no indication as to how (named) features were identified, and for many of the image-based MCQs, there were simply no verbalizations related to the image at all.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes \u0026amp; sub-themes with indicative examples of recorded verbalizations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal count*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExamples\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eObserved vocalizations \u0026amp; behaviors\u003c/b\u003e \u003cem\u003e(14 x 30\u0026thinsp;=\u0026thinsp;420 student-item verbalizations)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReading vignette fully\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReading the vignette verbatim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e403 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuestion 2, what is produced by the cells indicated by the arrow in the image to the right? \u003csup\u003eP14\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage - minor misspeaking or mispronunciation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMispronunciations - does not infer conceptual misunderstanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI think they\u0026rsquo;re the \u003cem\u003eledwig [sic]\u003c/em\u003e cells. So I\u0026rsquo;m going to pick E \u0026ndash; testosterone there. \u003csup\u003eP21\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRight, so you have your GFR. So you have, your reticularis, your fascicularis [sic] and your glomerulus [sic].\u003csup\u003eP23\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystematically reading or listing all options aloud\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eListing all options systematically\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026hellip; the condition is typically caused by disease or damage to which of the following structures? A \u0026ndash; adrenal medullary, B \u0026ndash; anterior pituitary, C \u0026ndash; hypothalamus, D \u0026ndash; pancreas, E \u0026ndash; renal cortex. \u003csup\u003eP14\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReturned \u0026amp; reviewed items \u0026amp; answers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReturned to reconsider or check an item answer for a second (or third) time before completing test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e153 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOkay, I\u0026rsquo;ll check them one last time. \u003csup\u003eP10\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSo there was two then, two or three I wanted to go back over and none which had questions later on in the test that helped. \u003csup\u003eP11\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmitting knowledge deficits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplicitly expressing unfamiliarity or lack of knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePotassium dichromate, dichromate was made, like something salt based or whatever it\u0026rsquo;s called. Em, then I don\u0026rsquo;t know, I don\u0026rsquo;t know. \u003csup\u003eP10\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eI just can\u0026rsquo;t think of what cells they are. (Short pause). Oh maybe (short pause) because all the options don\u0026rsquo;t seem familiar. \u003csup\u003eP16\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReasoning or cognitive strategies\u003c/b\u003e \u003cem\u003e(14 x 30\u0026thinsp;=\u0026thinsp;420 student-item verbalizations)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenerates (correct) answer before reviewing options\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpon reading the vignette the participant immediately generates the correct answer, \u003cem\u003ebefore\u003c/em\u003e reading the option list.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e194 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuestion two, what is produced by cells, the cells indicated by the following arrow so they\u0026rsquo;re, em, the testis (laughs) and the cells in between are leydig cells or interstitial cells and they produce testosterone. \u003csup\u003eP13\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile attending the obstetric clinic, you see and examine a number of ladies attending their routine pre-natal visit. Which of the following hormones is produced by the placenta during pregnancy? (Sighs) I\u0026rsquo;m going to go with HCG. \u003csup\u003eP22\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEliminating options - no initial self-generation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo initial correct answer is verbalized, and the participant reads through the option list, systematically eliminating options to arrive at an answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e151 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndocrine cells manufacture hormones, which are then exported to act on receptors at distant sites in the body. Which of the following organelles plays a significant role in the manufacturing of hormones within the cell? It\u0026rsquo;s not the mitochondria. It\u0026rsquo;s not vesicles is what exports it, em, (short pause); endoplasmic reticulum should put it all together. They come together. Packages are the vesicles. Nucleus is the site is the site of gene expression so it should be the Golgi apparatus. \u003csup\u003eP19\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReaching (incorrect) closure prematurely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFailure to consider the correct alternative in answering the test item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWithin the endocrine system, what is the mode of secretion in which the cell membrane ruptures and the entire contents of the cells are shed? So membrane is the apocrine, apocrine. \u003csup\u003eP7\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReaching closure with difficulty or delay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1) pattern of thinking failing to help answer the question (2) excessive length of time \u0026amp; commentary to answer the question (3) excessive pauses \u0026amp; (4) taking tangents.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eWord count prohibitive to include concise examples.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoticing a vertical cue\u003c/p\u003e \u003cp\u003e\u003cem\u003e(inserted intentionally!)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUsing information provided in one item to assist in answering another item on the paper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 / 420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOkay, I won\u0026rsquo;t go for thyroid. Pancreas we\u0026rsquo;ve seen pictures of it before, so it\u0026rsquo;s not that. Adrenal, okay, I\u0026rsquo;ll guess pituitary because I don\u0026rsquo;t really know. (Turns pages). \u003csup\u003eP27\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis is where I remember that on a previous page, neuroendocrine derivative cells have been mentioned, so I\u0026rsquo;ll go back and (turns page) and check and question eight says the polyhedral cells\u0026hellip; \u003csup\u003eP30\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImage identification and / or analysis\u003c/b\u003e \u003cem\u003e(7 x 30\u0026thinsp;=\u0026thinsp;210 student-item verbalizations)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalytical observations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVerbalizations regarding scale, size, shape,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108 / 210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThat\u0026rsquo;s two millimetres so it\u0026rsquo;s probably, what gland is that is it the parathyroid or the pituitary. I\u0026rsquo;m going to say the pituitary gland because it look like it\u0026rsquo;s a very tiny gland but I\u0026rsquo;m not\u0026hellip; \u003csup\u003eP15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u0026hellip;Em, I think it\u0026rsquo;s either eosin or haematoxylin because they look kind of blue and pink, so eosin is the pink one. They look kind of pink. Because I wrote my notes in pink for eosin. \u003csup\u003eP16\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-analytical observations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe tissue or a structure is named, but with no indication as to how it was recognized or interpreted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 / 210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026hellip; What is produced by the cells indicated by the arrow in the image to the right? It\u0026rsquo;s the leydig cells in the testes so its testosterone. \u003csup\u003eP7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eQuestion twelve, the adrenal cortex has three distinguishable zones that secrete steroid hormones. Which of the following hormones are secreted by the layer of the cortex labelled \u0026ldquo;B\u0026rdquo; in the image on the right? B is zona reticularis which produces sex hormones so its androgens I think. \u003csup\u003eP16\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage not mentioned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo verbalization about the image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 / 210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eNo verbalizations to include as examples.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRedundant image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e(2 x 30\u0026thinsp;=\u0026thinsp;60 maximum)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 / 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eNo verbalizations to include as examples.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRequired image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e(5 x 30\u0026thinsp;=\u0026thinsp;150 maximum)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 / 150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eNo verbalizations to include as examples.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003e*Referring to the number of student-item verbalizations in which this code was observed\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStudent performance\u003c/h2\u003e \u003cp\u003eMost students read the vignette and question aloud, fully and verbatim (403 of 420 student-item verbalizations; Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), but the list of options was seldom read in the same systematic manner (59 of 420 student-item verbalizations). High performing students were more likely to self-generate an immediate answer to MCQs, without any verbalization indicating that they had read the full option list (74 of 126 student-item verbalizations; 59%), than medium (94 of 210; 44.8%) or lower (26 of 84; 31%) performing students (F (2, 27)\u0026thinsp;=\u0026thinsp;6.60, p\u0026thinsp;=\u0026thinsp;0.0046; Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Not all apparently self-generated answers were correct. There were 43 verbalizations where a student reached (incorrect) closure prematurely, generating an answer by selecting an incorrect option, without any verbal indication that the correct option had been read or considered (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Premature closure was observed more frequently in verbalizations from lower-performing students (16 of 84 student-item verbalizations; 19.1%) as compared to medium (23 of 210; 11%) or high (4 of 126; 3.2%) performing students (F (2, 27)\u0026thinsp;=\u0026thinsp;7.33, p\u0026thinsp;=\u0026thinsp;0.0029; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of verbalizations from High, Medium and Lower-performing students.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eCount (percentage) of test items demonstrating a behavior or cognitive strategy according to student performance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh performer\u003c/p\u003e \u003cp\u003e(score\u0026thinsp;\u0026ge;\u0026thinsp;12; n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedium performer\u003c/p\u003e \u003cp\u003e(score 9\u0026ndash;11; n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow performer\u003c/p\u003e \u003cp\u003e(score\u0026thinsp;\u0026le;\u0026thinsp;8; n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eObserved vocalizations \u0026amp; behaviors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep value*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReading vignette fully\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122 / 126(96.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e198 / 210 (94.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83 / 84(98.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.4724\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage - minor misspeaking or mispronunciation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 / 126(0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 / 210 (7.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 / 84(3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1192\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystematically reading or listing all options aloud\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 / 126(15.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 / 210 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 / 84(11.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.9655\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReturned \u0026amp; reviewed answers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 / 126(13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 / 210 (37.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 / 84(69.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0577\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmitting knowledge deficits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 / 126(7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 / 210 (23.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 / 84(32.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0114\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReasoning or cognitive strategies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenerates (correct) answer before reviewing options\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 / 126(58.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 / 210 (44.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 / 84(31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0046\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNo verbalization of reviewing alternative options\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e55 / 126(43.7%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e71 / 210(33.8%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e18 / 84(21.4%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eChecks options after generating (correct) answer\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e19 / 126(15.1%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e23 / 210(11%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e8 / 84(9.5%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEliminating options - no initial self-generation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 / 126(30.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 / 210 (37.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 / 84(41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.3997\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReaching (incorrect) closure prematurely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 / 126(3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 / 210 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 / 84(19.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReaching closure with difficulty or delay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 / 126(0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 / 210 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 / 84(26.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0034\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoticing a vertical cue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 / 126(0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 / 210 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00(00.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.3515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e*One-way ANOVA between high-medium-low performing groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImage interpretation\u003c/b\u003e \u003cb\u003e(Image items n\u0026thinsp;=\u0026thinsp;7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalytical observations (scale, size, shape, color etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 / 63(49.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 / 105(55.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 / 42(45.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026nbsp;= 0.612**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-analytical observations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 / 63(19.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 / 105(19.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 / 42(28.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage not mentioned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 / 63(31.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 / 105(25.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 / 42(26.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRedundant image (n\u0026thinsp;=\u0026thinsp;2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e14 / 18(77.8%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e25 / 30(83.3%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e11 / 12(91.7%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRequired image (n\u0026thinsp;=\u0026thinsp;5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e6 / 45(13.3%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e2 / 75(2.7%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0 / 75(0%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e**X\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u0026nbsp;\u003cb\u003e(4)\u0026thinsp;=\u0026thinsp;2.6818, p\u0026thinsp;=\u0026thinsp;0.612\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUnsurprisingly, lower performing students were more likely to verbalize about knowledge deficits, or being uncertain, than medium or high performing students (F (2, 27)\u0026thinsp;=\u0026thinsp;5.31, p\u0026thinsp;=\u0026thinsp;0.0114; Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Lower performing students also appeared to have more difficulty or delay in answering MCQs (22 of 84 student-item verbalizations; 26.2%), compared to medium (30 of 210; 14.3%) or high (1 of 126; 0.8%) performing students (F (2, 27)\u0026thinsp;=\u0026thinsp;7.05, p\u0026thinsp;=\u0026thinsp;0.0034; Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Lower performing students were also more likely to return and review MCQs for a second, or even a third time, before completing the test (F (2, 27)\u0026thinsp;=\u0026thinsp;3.18, p\u0026thinsp;=\u0026thinsp;0.0577; Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This study was designed to include a small number of vertical cues on each paper, but few students appeared to notice these, as they were remarked upon in only eight verbalizations (three of which were from one individual student (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImage interpretation\u003c/h2\u003e \u003cp\u003eStudents verbalized more observations when answering MCQs containing an image which was necessary or essential to answering the question, whereas redundant images were unlikely to be mentioned by students at all (X\u003csup\u003e2\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;133.0720, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fisher's exact test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Students who identified as verbal learners were more likely to have a verbally analytical approach to answering MCQs with images, making specific comments about the scale, shape, features or colors within the image (*X\u003csup\u003e2\u003c/sup\u003e (4)\u0026thinsp;=\u0026thinsp;17.8040, p\u0026thinsp;=\u0026thinsp;0.001; Fisher's exact test, p\u0026thinsp;=\u0026thinsp;0.001; Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of verbalizations from students when answering image-based MCQs with either a \u0026ldquo;\u003cem\u003eredundant image\u003c/em\u003e\u0026rdquo; or a \u0026ldquo;\u003cem\u003erequired image\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCount (percentage) of verbalizations, according to image type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eRedundant image (n\u0026thinsp;=\u0026thinsp;2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eRequired image (n\u0026thinsp;=\u0026thinsp;5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalytical observations\u003c/p\u003e \u003cp\u003e(scale, size, shape, color etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 / 60 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 / 150 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-analytical observations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 / 60 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 / 150 (24.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage not mentioned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 / 60 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 / 150 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e*X\u003csup\u003e2\u003c/sup\u003e\u0026nbsp;(2)\u0026thinsp;=\u0026thinsp;133.0720, p\u0026nbsp;\u0026lt; 0.001; Fisher's exact test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of verbalizations according to students\u0026rsquo; self-identified Verbal\u0026ndash;Visual Learning Style Rating (VVLSR) when answering image-based MCQs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eNumber of student-item verbalizations demonstrating a particular behavior or cognitive strategy according to self-identified VVLSR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisual learners\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo preference\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVerbal learners\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImage identification and / or analysis\u003c/b\u003e \u003cem\u003e(7 x 30\u0026thinsp;=\u0026thinsp;210 student-item verbalizations)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalytical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 / 112\u003cem\u003e(40.2%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 / 42\u003cem\u003e(57.1%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 / 56\u003cem\u003e(69.6%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-analytical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 / 112\u003cem\u003e(27.7%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 / 42\u003cem\u003e(23.8%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 / 56\u003cem\u003e(5.4%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage not mentioned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 / 112\u003cem\u003e(32.1%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 / 42\u003cem\u003e(19%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 / 56\u003cem\u003e(25%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRedundant image\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(2 per participant)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e30 / 32(93.8%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e7 / 12(58.3%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e13 / 16(81.3%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRequired image\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(5 per participant)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e6 / 80(7.5%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e1 / 30(3.3%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e1 / 40(2.5%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e*X\u003csup\u003e2\u003c/sup\u003e\u0026nbsp;(4)\u0026thinsp;=\u0026thinsp;17.8040, p\u0026nbsp;= 0.001; Fisher's exact test, p\u0026thinsp;=\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Right it\u0026rsquo;s not methylene blue because I don\u0026rsquo;t see any blue indications in the image.\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP01\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So, I know that the predominant stain for an awful lot of the slides was the H\u0026amp;E one and what I\u0026rsquo;m looking at doesn\u0026rsquo;t look as pink as some of those. I\u0026rsquo;m going to scratch out A which is eosin and B which is haematoxylin. Definitely not methylene blue because they look kind of red.\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP11\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Okay, I have to analyse this image because there is no colloid, so I don\u0026rsquo;t think it will be thyroid. No follicles evident. It does look like it has two lobes though so it could be pituitary. It\u0026rsquo;s probably pancreas, no I don\u0026rsquo;t think it would be pancreas. It has no follicles as well. I don\u0026rsquo;t think it would be adrenal either, just because split in two I\u0026rsquo;ll go with pituitary.\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP12\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Em, okay, this looks like its pointing at a thing in between the big things, so I\u0026rsquo;m going to guess that it\u0026rsquo;s interstitial cell or a leydig cell, so testosterone is what I will choose..\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP21\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Well it looks like there is two distinct stains, one is lighter than the other, em, and one\u0026rsquo;s bigger than the other. So it looks like an anterior and a posterior pituitary to me, so I\u0026rsquo;m going to say pituitary.\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP29\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eVisual learners were more likely to make non-analytical comments about the image, where students would mention the image, perhaps even naming a structure seen within it, but giving no verbal indication as to how they had identified, interpreted or analyzed it.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;m going to go with testosterone because I feel like they look like leydig cells.\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP01\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;so the arrow\u0026rsquo;s pointing the posterior pituitary which makes oxytocin and ADH, so the only answer is oxytocin.\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP13\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Em, there\u0026rsquo;s a picture as well, em, so I suppose the picture is just to remind you\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP17\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo; So I know that this is going to be the glomerulus, this is the glom, this is the fasculata and this is reticularis so that\u0026rsquo;s going to be your androgens.\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP18\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;for this question I didn\u0026rsquo;t really use the image on the right since it wasn\u0026rsquo;t really useful to me, since it didn\u0026rsquo;t relate to the actual thought process.\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003eP30\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study sought to explore (1) the cognitive processes and critical thinking of students while answering Single Best Answer MCQs in histology, (2) whether images influence the verbalized cognitive processes of students and (3) whether self-identified verbal and visual learners display different verbalizations or cognitive processes when answering text and image-based MCQs. The \u0026ldquo;think-aloud\u0026rdquo; method explores metacognition through the lens of viewing thinking as inner speech, where people externally vocalize their inner monologue, and is accepted as a valid research methodology to explore reasoning and problem-solving in many fields, including medicine [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan additionalcitationids=\"CR51\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. There are some criticisms, such as the potential for this ongoing verbalization to cause people to use limited cognitive resources on incidental processing, leaving less cognitive capacity for essential processing, or to potentially interrupt or influence the internal voice [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother potential issue is that not all thinking or cognition is performed in an analytical manner, subject to being easily verbalized. Intuitive leaps, unconscious biases, subconscious pattern recognition \u0026ndash; these subconscious thoughts will \u003cem\u003enot\u003c/em\u003e be captured by verbalization of an inner monologue, although they may still heavily influence decision making, particularly when addressing complex questions or contexts [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56 CR57\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. The finding that high-performing students were more likely to self-generate an answer as compared to middle and lower performing students is consistent with observations in related studies of reasoning [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] and is the theoretical basis for the development and use of the very-short-answer question format [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Lower performers were not only more likely to verbalize about knowledge deficits, but also more likely went back to check or change answers than other students, which is also a finding consistent with previous studies [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImage recognition and interpretation are key skills in many of the medical sciences [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR62 CR63 CR64\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Therefore, the principles of constructive alignment mean that visual interpretation and analysis should be an integral, albeit proportional, part of assessment strategy and design [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. While few assessments may specifically assess these skills of visual interpretation and analysis, those that do are typically well received by students, who appreciate their authenticity in preparing them for clinical practice, sentiments mirrored by students in this study [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. While much prior research has reported that inserting images to a single best answer MCQ has no influence overall item psychometrics \u003cem\u003eper se\u003c/em\u003e [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan additionalcitationids=\"CR69 CR70\" citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e], other studies have reported inconsistent effects and hypothesized that these effects are due to the qualities or characteristics of the image used [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Other studies have contrasting findings, reporting that students\u0026rsquo; scores are higher when answering MCQs images [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], or conversely that the inclusion of images \u003cem\u003ereduces\u003c/em\u003e item facility (the inverse of item difficulty), lowering scores, potentially due to increasing extraneous cognitive load or \u003cem\u003espatial contiguity\u003c/em\u003e effects [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the small of MCQs with redundant images in this study, the manner in which these images went mostly unmentioned in students\u0026rsquo; verbalizations, along with the reduced Item facility for these MCQs, strongly suggests that redundant images are a hindrance in assessments, not a help, and should not be included within MCQ vignettes. While no other comparable research has been done to date within medical assessment, the inclusion of \u0026ldquo;\u003cem\u003eirrelevant, redundant or interacting sources of information\u0026rdquo;\u003c/em\u003e in arithmetic examinations is also suggested to slow down the speed at which students are able to process information, leading to increased testing time and item difficulty (the inverse of item facility) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This \u003cem\u003ecoherence effect\u003c/em\u003e strongly suggests that over-excessive detail reduces capacity for essential information processing, and thus potentially detrimental to students\u0026rsquo; performance in assessments [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, this study also demonstrated that the inclusion of an image that \u003cem\u003ewas\u003c/em\u003e essential to correctly answering an MCQ did not appear to have any significant influence on item psychometrics or observed verbalizations as compared to text-alone vignettes. Thus, the use of images in MCQ vignettes written to specifically test the ability of candidates\u0026rsquo; ability to identify or interpret \u003cem\u003erequired\u003c/em\u003e images is not only no threat to validity, but is logically required according to the principles of constructive alignment [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan additionalcitationids=\"CR69 CR70\" citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. Furthermore, students\u0026rsquo; self-identified VVLSR had no discernable influence on their scores when answering verbal or visual MCQs. Verbal learners were significantly more analytical in their verbalizations when answering image-based MCQs than visual learners, but learners who self-identify as being verbal learners may \u003cem\u003ede facto\u003c/em\u003e experience a more analytical inner verbal monologue than those who self-identify as visual learners [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditional factors, such as the quality of the images provided for candidates, along with their spatial (or temporal) relationship to the placement of the question text, does merit some conscious consideration when writing MCQs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhere text and image are spatially separated on separate sheets or screens, some processing capacity will be diverted from image interpretation by the necessity to switch visual focus, looking back and forth between text and image [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. Where this is not possible, and the image and text are separated, research on cognition suggests text should be placed to precede the image to provide context, with a caveat that this is as yet not definitively researched in MCQ assessments [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe hypothesis that the characteristics or complexity of the images used in MCQ vignettes will effect item statistics and metacognition has been recognized by numerous authors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Sagoo et al found that students scored significantly higher on questions with images (both anatomical and radiological) compared to questions without images [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Further analysis considering image subtypes demonstrated that \u0026ldquo;students performed significantly better on questions referring to bones than to soft tissues regardless of the image type [anatomical or radiological]\u0026rdquo; suggesting that visual interpretation of an isolated structure (a bone) is less complex than the synthesis of information required to interpret images of interrelated and intersecting soft tissues [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The simplicity or complexity of both verbal vignettes and images may be accounted for within assessment strategies or processes, for example mapping to cognitive taxonomies [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR77\" citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. Analysis of histological and cross-sectional images requires interpreting complex \u0026ldquo;categorical spatial relations\u0026rdquo;, whereby the relationships between objects must be judged [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. Students seem to struggle more with MCQs displaying cross-sectional illustrations, as compared to those which use simpler diagrams or line drawings [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and to demonstrate different cognitive processes when answering MCQs nested within cross-sectional themes, with more reliance on option elimination, and less visualizing or verbal reasoning being described [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. It is essential for students to consciously develop and improve these visual and spatial interpretive skills by training and practice, as opposed passively noting what is pointed out to them, or only memorizing a limited set of exemplars, so that they can apply their knowledge when viewing unfamiliar or novel images, whether in assessments or in future independent practice [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. For this reason, perhaps a number of novel images should be used within assessments if the required aim is to truly test the students\u0026rsquo; abilities of image interpretation, even aside from the argument that the use of familiar images may promote positive cueing [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], an item flaw that may also be present in purely textual vignettes [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eInterpretation of images and spatial relationships is essential in many disciplines and so including images within assessments aid authenticity and constructive alignment. While the effects of visual or multimedia learning have been explored in many contexts, guidelines for assessment are still sparse, but some basic principles can be considered. Firstly, is the image \u003cem\u003erelevant and essential\u003c/em\u003e to answering the question? Redundant information, including images, may simply increase extraneous cognitive load to no benefit, potentially influencing student performance [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. Secondly, does the image show the relevant structure in isolation, such as an individual bone, or is it seen \u003cem\u003ein relation\u003c/em\u003e to surrounding structures, as is the case with a histological cross section, or an abdominal CT scan? Interpreting spatial relations is certainly appropriate for many assessments, but increases the difficulty of the task or question. The third point of \u003cem\u003erecognition\u003c/em\u003e considers whether the candidate is presented with a familiar image, seen and studied during their learning activities, or an entirely unfamiliar one. Novel images can be true tests of a candidate\u0026rsquo;s ability to demonstrate their knowledge and skill at image interpretation, but is potentially more cognitively demanding than recognizing a familiar image, or at least one similar to previous images studied. The \u003cem\u003erealism\u003c/em\u003e of the image could also be considered; is the image a simple diagram, or is it a photograph of an actual histological or anatomical specimen [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]? Finally, for formatting, the \u003cem\u003espatial contiguity\u003c/em\u003e principle states that images should be as close as possible to their corresponding text, so that they may be viewed simultaneously without a need to switch focus, as opposed to being on a separate page or screen [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study\u003c/h2\u003e \u003cp\u003eThis research study was designed as a qualitative think-aloud exploration of cognitive processes. While quantitative statistical analyses were performed and reported, the small number of participants (n\u0026thinsp;=\u0026thinsp;30), limits the statistical power of these quantitative analyses. Furthermore, the cohort of students who participated were all volunteers, and so entirely self-selecting. While it was conducted in one institution, RCSI encompasses highly diverse student and staff bodies, and in this study of thirty students only eleven recorded their nationality as being within the EU, and students from Asia, North America and the Middle East were all represented. Only twelve students were monolingual English speakers, fifteen identified as bilingual, with two students speaking three languages fluently and one individual fully confident in four. However, the authors\u0026rsquo; hope that the findings of this study will stimulate further interest and provide some supporting evidence for future investigation in this field.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, high-performing students were significantly more likely to self-generate an answer as compared to middle and lower-performing students, who relied to a greater degree on option elimination. Adding images to MCQs did not have a consistent influence on item statistics, and the students\u0026rsquo; self-identified visual-verbal preference (\u0026ldquo;learning style\u0026rdquo;) had no consistent bearing on their results for text or image based questions. Students\u0026rsquo; verbalizations regarding images very highly dependent on whether the image was necessary or unnecessary to answering the question. For MCQs where interpretation of the image was required, specific reference to the image were noted for 95% of student-item verbalizations (142 of 150 maximum). In contrast, for MCQs where the image was redundant or unnecessary to answering the MCQ, reference to the image was recorded in only 17% of student-item verbalizations (10 of 60 maximum). The finding does align with the principles of question writing, whereby MCQ vignettes should not be cluttered with unnecessary information that do not help with cueing or answering MCQs, and may instead be detrimental distractions, adding to extraneous cognitive load.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eNotes on contributors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJane Holland, M.B., B.Ch., B.A.O., M.A., M.Sc., Pg.Dip.Ed., M.D., Ph.D., M.R.C.S.I., F.A.S., is a senior lecturer in the Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences in Ireland. She teaches both undergraduate students and postgraduate surgical trainees, and her research interests include assessment, medical education and eLearning.\u003c/p\u003e\n\u003cp\u003eAlice McGarvey B.N.S., M.Sc., Ph.D., is Assistant Secretary General with the Irish Hospital Consultants Association and an honorary senior lecturer in the Department of Anatomy and Regenerative Medicine, RCSI University of Medicine and Health Sciences in Ireland. She has extensive experience with assessment, education and particularly the initiation and implementation of complex people-centred projects.\u003c/p\u003e\n\u003cp\u003eMichelle Flood B.Sc. (Pharm), M.Sc., Ph.D., M.P.S.I., is a senior lecturer in the School of Pharmacy and Biomolecular Sciences RCSI University of Medicine and Health Sciences in Ireland. She is deputy director for the MPharm programme and teaches at undergraduate and postgraduate levels. Her educational research interests include assessment, competency based education, workplace-based assessment, and curriculum reform.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePAULINE JOYCE Ed.D, M.Sc., B.N.S., is Director of Quality \u0026amp; Clinical Engagement for the M.Sc. program in Physician Associate Studies at the RCSI University of Medicine and Health Sciences in Ireland. She teaches professional issues, research and leadership/management. Her research interests include leadership, teaching, learning and the physician associate role.\u003c/p\u003e\n\u003cp\u003eTeresa Pawlikowska M.B., B.S., M.Sc., Ph.D., M.R.C.P., D.R.C.O.G., F.R.C.P.I. is Foundation Professor of the Health Professions Education Centre, RCSI University of Medicine and Health Sciences in Ireland. \u0026nbsp; She has taught, researched, and practiced medicine throughout her career; additional research interests include inter-professional education, communication and consultation skills, and research methodology in medical education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp; This work was supported by an Education Research Grant from the Irish Network of Healthcare Educators (INHED).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e\u0026nbsp; The authors declare that there is no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHeidger PM, Dee F, Consoer D et al (2002) Integrated approach to teaching and testing in histology with real and virtual imaging. Anat Rec 269:107\u0026ndash;112\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloodgood RA, Ogilvie RW (2006) Trends in histology laboratory teaching in United States medical schools. Anat Rec B 289:169\u0026ndash;175. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ar.b.20111\u003c/span\u003e\u003cspan address=\"10.1002/ar.b.20111\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaulsen FP, Eichhorn M, Br\u0026auml;uer L (2010) Virtual microscopy\u0026mdash;The future of teaching histology in the medical curriculum? Ann Anat 192:378\u0026ndash;382. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.aanat.2010.09.008\u003c/span\u003e\u003cspan address=\"10.1016/j.aanat.2010.09.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlake CA, Lavoie HA, Millette CF (2003) Teaching medical histology at the University of South Carolina School of Medicine: Transition to virtual slides and virtual microscopes. Anat Rec B 275B:196\u0026ndash;206. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ar.b.10037\u003c/span\u003e\u003cspan address=\"10.1002/ar.b.10037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson AR, Lowrie DJ (2017) An evaluation of outcomes following the replacement of traditional histology laboratories with self-study modules. Anat Sci Educ 10:276\u0026ndash;285. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1659\u003c/span\u003e\u003cspan address=\"10.1002/ase.1659\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcBride JM, Drake RL (2018) National survey on anatomical sciences in medical education. Anat Sci Educ 11:7\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1760\u003c/span\u003e\u003cspan address=\"10.1002/ase.1760\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThen SM, Kokolski M, Mbaki Y et al (2023) An international collaborative approach to learning histology using a virtual microscope. Anat Histol Embryol 52:21\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ahe.12888\u003c/span\u003e\u003cspan address=\"10.1111/ahe.12888\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevie WH, Lentz R (1982) Effects of text illustrations: A review of research. ECTJ 30:195\u0026ndash;232. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/bf02765184\u003c/span\u003e\u003cspan address=\"10.1007/bf02765184\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayer RE, Moreno R (2003) Nine Ways to Reduce Cognitive Load in Multimedia Learning. Educ Psychol 38:43\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1207/s15326985ep3801_6\u003c/span\u003e\u003cspan address=\"10.1207/s15326985ep3801_6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayer RE (2010) Applying the science of learning to medical education. Med Educ 44:543\u0026ndash;549. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1365-2923.2010.03624.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2923.2010.03624.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSagoo MG, Vorstenbosch MA, Bazira PJ et al (2021) Online assessment of applied anatomy knowledge: the effect of images on medical students' performance. Anat Sci Educ 14:342\u0026ndash;351. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1965\u003c/span\u003e\u003cspan address=\"10.1002/ase.1965\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayer RE, Massa LJ (2003) Three Facets of Visual and Verbal Learners: Cognitive Ability, Cognitive Style, and Learning Preference. J Educ Psychol 95:833. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/0022-0663.95.4.833\u003c/span\u003e\u003cspan address=\"10.1037/0022-0663.95.4.833\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNewton PM, Miah M (2017) Evidence-Based Higher Education \u0026ndash; Is the Learning Styles \u0026lsquo;Myth\u0026rsquo; Important? Front Psychol 8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyg.2017.00444\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2017.00444\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026ouml;ffler TN (2010) Spatial Ability: Its Influence on Learning with Visualizations\u0026mdash;a Meta-Analytic Review. Educ Psychol Rev 22:245\u0026ndash;269. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10648-010-9126-7\u003c/span\u003e\u003cspan address=\"10.1007/s10648-010-9126-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogowsky BA, Calhoun BM, Tallal P (2020) Providing Instruction Based on Students\u0026rsquo; Learning Style Preferences Does Not Improve Learning [Brief Research Report]. Front Psychol 11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyg.2020.00164\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2020.00164\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArtino ARJ, Zafar Iqbal M, Crandall SJ (2023) Debunking the Learning-Styles Hypothesis in Medical Education. Acad Med 98:289. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/acm.0000000000004738\u003c/span\u003e\u003cspan address=\"10.1097/acm.0000000000004738\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePashler H, McDaniel M, Rohrer D et al (2008) Learning styles: Concepts and evidence. Psychological science in the public interest. 9:105\u0026ndash;119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1539-6053.2009.01038.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1539-6053.2009.01038.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayer RE (2014) The Cambridge Handbook of Multimedia Learning. Cambridge University Press; ISBN: 978-1-107-61031-6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayer RE (2020) Designing multimedia instruction in anatomy: An evidence-based approach. Clin Anat 33:2\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ca.23265\u003c/span\u003e\u003cspan address=\"10.1002/ca.23265\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunt DR (1978) Illustrated multiple choice examinations. Med Educ 12:417\u0026ndash;420. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1365-2923.1978.tb01420.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2923.1978.tb01420.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuzzard A, Bajsdaranayake R, Harvey C (1987) How to Produce Visual Material for Multiple Choice Examinations. Med Teach 9:451\u0026ndash;456. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3109/01421598709008341\u003c/span\u003e\u003cspan address=\"10.3109/01421598709008341\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDwyer F, De Melo H (1984) A systematic assessment of the effect of visual testing of visualized instruction: A Justification for Instructional Congruency. J Vis Verbal Lang 4:53\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/23796529.1984.11674379\u003c/span\u003e\u003cspan address=\"10.1080/23796529.1984.11674379\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips AW, Smith SG, Straus CM (2013) Driving Deeper Learning by Assessment: An Adaptation of the Revised Bloom's Taxonomy for Medical Imaging in Gross Anatomy. Acad Radiol 20:784\u0026ndash;789. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.acra.2013.02.001\u003c/span\u003e\u003cspan address=\"10.1016/j.acra.2013.02.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVorstenbosch MA, Klaassen TP, Kooloos JG et al (2013) Do images influence assessment in anatomy? Exploring the effect of images on item difficulty and item discrimination. Anat Sci Educ 6:29\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1290\u003c/span\u003e\u003cspan address=\"10.1002/ase.1290\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCase SM, Swanson DB (2002) Constructing written test questions for the basic and clinical sciences. National Board of Medical Examiners Philadelphia, PA\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan der Vleuten CP, Schuwirth LW (2005) Assessing professional competence: from methods to programmes. Med Educ 39:309\u0026ndash;317. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1365-2929.2005.02094.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2929.2005.02094.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolland J, Stevens N (2020) Guidelines for the development of multiple choice items \u0026amp; assessments. Dublin, Ireland: RCSI University of Medicine and Health Sciences; ISBN: 978-1-9996983-0-0. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://repository.rcsi.com/articles/book/Guidelines_for_the_development_of_multiple_choice_items_assessments_/13947164\u003c/span\u003e\u003cspan address=\"https://repository.rcsi.com/articles/book/Guidelines_for_the_development_of_multiple_choice_items_assessments_/13947164\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDowning SM (2002) Construct-irrelevant Variance and Flawed Test Questions: Do Multiple‐choice Item‐writing Principles Make Any. Difference? Acad Med 77:S103\u0026ndash;S104\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaladyna TM, Downing SM (2004) Construct-Irrelevant Variance in High-Stakes Testing. Educ Meas Issues Pract 23:17\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1745-3992.2004.tb00149.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1745-3992.2004.tb00149.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbedi J (2006) Language issues in item development. In: Haladyna TM, Downing SM, editors. Handbook of test development: Routledge; pp 377\u0026ndash;398. ISBN: 9780203874776\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas M, Ettarh R, Lowrie D et al (2019) A guide to competencies, educational goals, and learning objectives for teaching medical histology in an undergraduate medical education setting. Med Sci Educ 29:523\u0026ndash;534. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s40670-018-00688-9\u003c/span\u003e\u003cspan address=\"10.1007/s40670-018-00688-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiggs J (2003) Aligning teaching and assessing to course objectives. Teach Learn High Educ 2:13\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEitel A, Scheiter K (2015) Picture or Text First? Explaining Sequence Effects when Learning with Pictures and Text. Educ Psychol Rev 27:153\u0026ndash;180. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10648-014-9264-4\u003c/span\u003e\u003cspan address=\"10.1007/s10648-014-9264-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVorstenbosch MA, Bouter ST, Hurk MM et al (2014) Exploring the validity of assessment in anatomy: Do images influence cognitive processes used in answering extended matching questions? Anat Sci Educ 7:107\u0026ndash;116. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1382\u003c/span\u003e\u003cspan address=\"10.1002/ase.1382\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolland J, O\u0026rsquo;Sullivan R, Arnett R (2015) Is a picture worth a thousand words: an analysis of the difficulty and discrimination parameters of illustrated vs. text-alone vignettes in histology multiple choice questions. BMC Med Educ 15:184. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12909-015-0452-9\u003c/span\u003e\u003cspan address=\"10.1186/s12909-015-0452-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrisp V, Sweiry E (2006) Can a picture ruin a thousand words? The effects of visual resources in exam questions. Educ Res (Windsor) 48:139\u0026ndash;154. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/00131880600732249\u003c/span\u003e\u003cspan address=\"10.1080/00131880600732249\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerends IE, van Lieshout EC (2009) The effect of illustrations in arithmetic problem-solving: Effects of increased cognitive load. Learn Instr 19:345\u0026ndash;353. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.learninstruc.2008.06.012\u003c/span\u003e\u003cspan address=\"10.1016/j.learninstruc.2008.06.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolland J, Clarke E, Glynn M (2016) Out of sight, out of mind: Do repeating students overlook online course components? Anat Sci Educ 9:555\u0026ndash;564. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1613\u003c/span\u003e\u003cspan address=\"10.1002/ase.1613\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Winter JC, Dodou D (2010) Five-point Likert items: t test versus Mann-Whitney-Wilcoxon. Pract Assess Res Eval 15:1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7275/BJ1P-TS64\u003c/span\u003e\u003cspan address=\"10.7275/BJ1P-TS64\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarifio J, Perla RJ (2007) Ten common misunderstandings, misconceptions, persistent myths and urban legends about Likert scales and Likert response formats and their antidotes. J Soc Sci 3:106\u0026ndash;116. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3844/jssp.2007.106.116\u003c/span\u003e\u003cspan address=\"10.3844/jssp.2007.106.116\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConroy RM (2012) What hypotheses do nonparametric two-group tests actually test? Stata J 12:182. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1536867X1201200202\u003c/span\u003e\u003cspan address=\"10.1177/1536867X1201200202\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorman G (2010) Likert scales, levels of measurement and the laws of statistics. Adv Health Sci Educ 15:625\u0026ndash;632. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10459-010-9222-y\u003c/span\u003e\u003cspan address=\"10.1007/s10459-010-9222-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSullivan GM, Artino AR (2013) JGME 5:541\u0026ndash;542. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4300/JGME-5-4-18\u003c/span\u003e\u003cspan address=\"10.4300/JGME-5-4-18\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Analyzing and Interpreting Data From Likert-Type Scales\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3:77\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1191/1478088706qp063oa\u003c/span\u003e\u003cspan address=\"10.1191/1478088706qp063oa\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClarke V, Braun V, Hayfield N (2015) Thematic analysis. In: Smith JA, editor. Qualitative psychology: A practical guide to research methods. Vol. 3: SAGE Publications Ltd; pp 222\u0026ndash;248. ISBN: 978-1-4462-9846-6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoderre S, Mandin H, Harasym PH et al (2003) Diagnostic reasoning strategies and diagnostic success. Med Educ 37:695\u0026ndash;703. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1046/j.1365-2923.2003.01577.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1365-2923.2003.01577.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeemskerk L, Norman G, Chou S et al (2008) The effect of question format and task difficulty on reasoning strategies and diagnostic performance in internal medicine residents. Adv Health Sci Educ 13:453\u0026ndash;462. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10459-006-9057-8\u003c/span\u003e\u003cspan address=\"10.1007/s10459-006-9057-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeist BS, Gonzalo JD, Durning S et al (2014) Exploring clinical reasoning strategies and test-taking behaviors during clinical vignette style multiple-choice examinations: a mixed methods study. JGME 6:709\u0026ndash;714. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4300/JGME-D-14-00176.1\u003c/span\u003e\u003cspan address=\"10.4300/JGME-D-14-00176.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKiger ME, Varpio L (2020) Thematic analysis of qualitative data: AMEE Guide 131. Med Teach 42:846\u0026ndash;854. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/0142159X.2020.1755030\u003c/span\u003e\u003cspan address=\"10.1080/0142159X.2020.1755030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoderre S, Harasym P, Mandin H et al (2004) The impact of two multiple-choice question formats on the problem-solving strategies used by novices and experts. BMC Med Educ 4:23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1472-6920-4-23\u003c/span\u003e\u003cspan address=\"10.1186/1472-6920-4-23\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGorard S (2013) Research design: Creating robust approaches for the social sciences. Sage; ISBN: 1446290859\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurning SJ, Dong T, Artino AR et al (2015) Dual processing theory and expertsʼ reasoning: exploring thinking on national multiple-choice questions. Perspect Med Educ 4:168\u0026ndash;175. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s40037-015-0196-6\u003c/span\u003e\u003cspan address=\"10.1007/s40037-015-0196-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurning SJ, Artino AR, Beckman TJ et al (2013) Does the think-aloud protocol reflect thinking? Exploring functional neuroimaging differences with thinking (answering multiple choice questions) versus thinking aloud. Med Teach 35:720\u0026ndash;726. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/doi:10.3109/0142159X.2013.801938\u003c/span\u003e\u003cspan address=\"doi:10.3109/0142159X.2013.801938\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEricsson KA, Simon HA (1998) How to study thinking in everyday life: Contrasting think-aloud protocols with descriptions and explanations of thinking. Mind Cult Act 5:178\u0026ndash;186. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1207/s15327884mca0503_3\u003c/span\u003e\u003cspan address=\"10.1207/s15327884mca0503_3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAczel B, Lukacs B, Komlos J et al (2011) Unconscious intuition or conscious analysis? Critical questions for the Deliberation-Without-Attention paradigm. Judgm Decis Mak 6:351\u0026ndash;358. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S1930297500001960\u003c/span\u003e\u003cspan address=\"10.1017/S1930297500001960\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRey A, Goldstein RM, Perruchet P (2009) Does unconscious thought improve complex decision making? Psychol Res PRPF 73:372\u0026ndash;379. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00426-008-0156-4\u003c/span\u003e\u003cspan address=\"10.1007/s00426-008-0156-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGigerenzer G, Brighton H (2009) Homo heuristicus: Why biased minds make better inferences. Top Cogn Sci 1:107\u0026ndash;143. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1756-8765.2008.01006.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1756-8765.2008.01006.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelsey JM (2016) Inner experience and self-ratings of inner speaking. University of Nevada, Las Vegas: University of Nevada, Las Vegas; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://digitalscholarship.unlv.edu/thesesdissertations/2691\u003c/span\u003e\u003cspan address=\"https://digitalscholarship.unlv.edu/thesesdissertations/2691\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurning SJ, Ten Cate OTJ (2007) Peer teaching in medical education. Med Teach 29:523\u0026ndash;524. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/01421590701683160\u003c/span\u003e\u003cspan address=\"10.1080/01421590701683160\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSam AH, Field SM, Collares CF et al (2018) Very-short‐answer questions: reliability, discrimination and acceptability. Med Educ 52:447\u0026ndash;455. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/medu.13504\u003c/span\u003e\u003cspan address=\"10.1111/medu.13504\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHołda MK, Stefura T, Koziej M et al (2019) Alarming decline in recognition of anatomical structures amongst medical students and physicians. Ann Anat 221:48\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.aanat.2018.09.004\u003c/span\u003e\u003cspan address=\"10.1016/j.aanat.2018.09.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLanglois J, Bellemare C, Toulouse J et al (2016) Spatial abilities and anatomy knowledge assessment: A systematic review. Anat Sci Educ. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1655\u003c/span\u003e\u003cspan address=\"10.1002/ase.1655\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. n/a-n/a\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuursema J-M, Vorstenbosch M, Kooloos J, Stereopsis (2017) Visuospatial Ability, and Virtual Reality in Anatomy Learning. Anatomy research international. ; 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2017/1493135\u003c/span\u003e\u003cspan address=\"10.1155/2017/1493135\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Brien KE, Cannarozzi ML, Torre DM et al (2008) Training and Assessment of CXR/Basic Radiology Interpretation Skills: Results From the 2005 CDIM Survey. Teach Learn Med 20:157\u0026ndash;162. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10401330801991840\u003c/span\u003e\u003cspan address=\"10.1080/10401330801991840\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips AW, Smith SG, Straus CM (2013) The role of radiology in preclinical anatomy: a critical review of the past, present, and future. Acad Radiol 20:297\u0026ndash;304e1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.acra.2012.10.005\u003c/span\u003e\u003cspan address=\"10.1016/j.acra.2012.10.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRathan R, Hamdy H, Kassab SE et al (2022) Implications of introducing case based radiological images in anatomy on teaching, learning and assessment of medical students: a mixed-methods study. BMC Med Educ 22:723. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12909-022-03784-y\u003c/span\u003e\u003cspan address=\"10.1186/s12909-022-03784-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMagi M, Jayagandhi S, Dinesh Kumar V et al (2022) Analysing the Effect of Incorporating Images While Framing MCQs For Online Clinical Anatomy Assessment Among First Year Medical Students. Int J Anat Res 10:8482\u0026ndash;8488. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.16965/ijar.2022.225\u003c/span\u003e\u003cspan address=\"10.16965/ijar.2022.225\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNotebaert AJ (2016) The effect of images on item statistics in multiple choice anatomy examinations. Anat Sci Educ 68\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1637\u003c/span\u003e\u003cspan address=\"10.1002/ase.1637\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSagoo MG, Smith CF, Gosden E (2016) Assessment of anatomical knowledge by practical examinations: The effect of question design on student performance. Anat Sci Educ 9:446\u0026ndash;452. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1597\u003c/span\u003e\u003cspan address=\"10.1002/ase.1597\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahlmann O (2018) Illustrated versus non-illustrated anatomical test items in anatomy course tests and German Medical Licensing examinations (M1). GMS J Med Educ 35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3205/zma001172\u003c/span\u003e\u003cspan address=\"10.3205/zma001172\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRutgers DR, van Raamt F, van der Gijp A et al (2018) Determinants of Difficulty and Discriminating Power of Image-based Test Items in Postgraduate Radiological Examinations. Acad Radiol 25:665\u0026ndash;672. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.acra.2017.10.014\u003c/span\u003e\u003cspan address=\"10.1016/j.acra.2017.10.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeppink J, van den Heuvel A (2015) The evolution of cognitive load theory and its application to medical education. Perspect Med Educ 4:119\u0026ndash;127. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s40037-015-0192-x\u003c/span\u003e\u003cspan address=\"10.1007/s40037-015-0192-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSweller J (2016) Story of a research program. Educ Rev 23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.14507/er.v23.2025\u003c/span\u003e\u003cspan address=\"10.14507/er.v23.2025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoyle M, Boyle B, Holland J et al (2022) The trainee experience: a candidate feedback from the pilot European exam in medical microbiology. Poster presented at: 11c -Medical education for CM/ID. ECCMID. ; Lisbon, Portugal 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBen Awadh A, Clark J, Clowry G et al (2022) Multimodal Three-Dimensional Visualization Enhances Novice Learner Interpretation of Basic Cross‐Sectional Anatomy. Anat Sci Educ 15:127\u0026ndash;142. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.2045\u003c/span\u003e\u003cspan address=\"10.1002/ase.2045\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStringer JK, Santen SA, Lee E et al (2021) Examining Bloom\u0026rsquo;s Taxonomy in Multiple Choice Questions: Students\u0026rsquo; Approach to Questions. Med Sci Educ 31:1311\u0026ndash;1317. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s40670-021-01305-y\u003c/span\u003e\u003cspan address=\"10.1007/s40670-021-01305-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiemeier AM, Stacy ZA, Burke JM (2011) Using multiple choice questions written at various Bloom's Taxonomy levels to evaluate student performance across a therapeutics sequence. INNOVATIONS Pharm 2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.24926/iip.v2i2.224\u003c/span\u003e\u003cspan address=\"10.24926/iip.v2i2.224\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaidi NB, Hwang C, Scott S et al (2017) Climbing Bloom's taxonomy pyramid: Lessons from a graduate histology course. Anat Sci Educ 10:456\u0026ndash;464. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ase.1685\u003c/span\u003e\u003cspan address=\"10.1002/ase.1685\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePettersson AF, Karlgren K, Al-Saadi J et al (2023) How students discern anatomical structures using digital three-dimensional visualizations in anatomy education. Anat Sci Educ 00:1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1002/ase.2255\u003c/span\u003e\u003cspan address=\"10.1002/ase.2255\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCook MP (2006) Visual representations in science education: The influence of prior knowledge and cognitive load theory on instructional design principles. Sci Educ 90:1073\u0026ndash;1091. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/sce.20164\u003c/span\u003e\u003cspan address=\"10.1002/sce.20164\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchuwirth L, Vleuten Cvd, Donkers H (1996) A closer look at cueing effects in multiple-choice questions. Med Educ 30:44\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1365-2923.1996.tb00716.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2923.1996.tb00716.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErolin C (2023) Preference for realism in 3D anatomical scans. J Vis Commun Med 46:85\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/17453054.2023.2226690\u003c/span\u003e\u003cspan address=\"10.1080/17453054.2023.2226690\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Irish Network of Healthcare Educators","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Assessment, histology, images, multiple-choice questions, cognitive load","lastPublishedDoi":"10.21203/rs.3.rs-4200329/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4200329/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eInterpretation of images and spatial relationships is essential in medicine, but the evidence-base on how to assess these skills is sparse. Thirty medical students were randomized into two groups (A and B), and invited to \u0026ldquo;think aloud\u0026rdquo; while completing 14 histology MCQs. All students answered six identical MCQs, three with only text and three requiring image interpretation. Students then answered eight \u0026ldquo;matched\u0026rdquo; questions, where a text-only MCQ on Version A was \u0026ldquo;matched\u0026rdquo; with an image-based MCQ on Paper B, or \u003cem\u003evice versa\u003c/em\u003e. Students\u0026rsquo; verbalizations were coded with a realist, inductive approach and emerging codes were identified and integrated within overarching themes. High-performing students were more likely to self-generate an answer as compared to middle and lower-performing students, who verbalized more option elimination. Images had no consistent influence on item statistics, and students\u0026rsquo; self-identified visual-verbal preference (\u0026ldquo;learning style\u0026rdquo;) had no consistent influence on their results for text or image-based questions. Students\u0026rsquo; verbalizations regarding images depended on whether interpretation of the adjacent image was necessary to answer the question or not. Specific comments about the image were present in 95% of student-item verbalizations (142 of 150) if interpreting the image was essential to answering the question, whereas few students referred to images if they were an unnecessary addition to the vignette. In conclusion, while assessing image interpretation is necessary for authenticity and constructive alignment, MCQs should be constructed to only include information and images relevant to answering the question, and avoid adding unnecessary information or images that may increase extraneous cognitive load.\u003c/p\u003e","manuscriptTitle":"A qualitative exploration of student cognition when answering text-only or image-based histology multiple-choice questions.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-02 05:30:04","doi":"10.21203/rs.3.rs-4200329/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9ae56472-417e-4744-abe6-7d493f59cc17","owner":[],"postedDate":"April 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":30117529,"name":"Educational Psychology"}],"tags":[],"updatedAt":"2024-04-02T05:30:04+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-02 05:30:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4200329","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4200329","identity":"rs-4200329","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}