The Optimal Number of Choices in Multiple-Choice Tests: A Systematic Review


1 Pediatrician, Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

2 Psychiatrist, Department of Psychiatry, North Khorasan University of Medical Sciences, Bojnurd, Iran.

3 Pediatrics Endocrinology Department, Mashhad University of Medical Sciences, Mashhad, Iran.

4 MSc in Critical Care Nursing, Emergency Department of Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.

5 Department of Midwifery, Firoozabad Branch, Islamic Azad University, Firoozabad, Iran.

6 Assistant Professor of Intensive Care Medicine, Department of Anesthesiology, Mashhad University of Medical Sciences, Mashhad, Iran.

7 Mother and Child Welfare Research Center, Hormozgan University of Medical Sceinces, Badar Abas, Iran.



One of the long-term issues faced by test designers and educators is the appropriate number of choices in a multi-choice test. Currently, the usual number of options for multiple-choice questions in the medical field are three to five, and it is generally believed that more options are better. Numerous theoretical and empirical studies have provided evidence in favor of using three-choice questions. According to the findings of these studies, the psychometric properties of three-choice questions are similar to four- or five-choice questions and the validity and reliability of the test or the coefficients of difficulty and differentiation do not change significantly with decreasing the number of options. Therefore, reducing the number of questions can reduce the time needed to design tests and take exams, saving the time and energy of the faculty and students. Most studies have concluded that it is cost-effective to use a three-choice question if it does not change the psychometric properties of the test by reducing the number of options.