Thinking differently - Students' cognitive processes when answering two different formats of written question.

Background: Single-best answer questions (SBAQs) are common but are susceptible to cueing. Very short answer questions (VSAQs) could be an alternative, and we sought to determine if students' cognitive processes varied across question types and whether students with different performance levels used different methods for answering questions.

Methods: We undertook a 'think aloud' study, interviewing 21 final year medical students at five UK medical schools. Each student described their thought processes and methods used for eight questions of each type. Responses were coded and quantified to determine the relative frequency with which each method was used, denominated on the number of times a method could have been used.

Results: Students were more likely to use analytical reasoning methods (specifically identifying key features) when answering VSAQs. The use of test-taking behaviours was more common for SBAQs; students frequently used the answer options to help them reach an answer. Students acknowledged uncertainty more frequently when answering VSAQs. Analytical reasoning was more commonly used by high-performing students compared with low-performing students.

Conclusions: Our results suggest that VSAQs encourage more authentic clinical reasoning strategies. Differences in cognitive approaches used highlight the need for focused approaches to teaching clinical reasoning and dealing with uncertainty.