Table 1

Key components of an image challenge question

PurposeWhat to includeWhat to avoid
VignetteIntroduce the clinical scenario.
  • Up to 200 words with only the amount of information required to answer the question.

  • Approximate age to protect patient privacy, for example, ‘A man in his 60s’.

  • Patient characteristics such as race, disability or socioeconomic status unless critical for the correct diagnosis.

  • Extraneous details in the history or physical examination.

  • Red herrings, or intentionally misleading information.

FigureShow the relevant finding.
  • High-quality, still single image or multipanel figure, ideally coloured.

  • Accompanying video for online version.

  • Very brief legend (eg, ‘Transthoracic echocardiogram in the parasternal-long axis orientation’ or ’12-lead ECG’).

  • Identifying patient information (names, medical record numbers).

  • Interpretation of the image in the legend.

Lead-inAsk the question.
  • A single clear question which allows the test-taker to answer even before looking at the options.

  • Negatively phrased lead-ins.

  • Questions which ask the reader to choose more than one correct answer.

  • True/false questions (which sometimes masquerade as ‘which of the following statements are true’).

Answer optionsProvide a set of plausible answers to the lead-in.
  • Four or five short homogenous options.

  • Plausible distractors which need to be less correct than the right answer.

  • Explanations of ‘why’ in the answer options.

  • Long or complicated answer choices.

  • Ambiguous terms such as usually, often or useful.

  • Brand-name drugs or devices.

ExplanationProvide the correct answer and teach.
  • Up to 200 words.

  • Reasons why one option is the most correct and the others are less correct.

  • Interpretation of the image.

  • Supplementary figures or videos.

  • Brief clinical pearls which expound on the teaching point.

  • Up to five references, ideally contemporary.

  • Clinical information which was needed to answer the question correctly.

  • Personal or institutional opinion which deviates from standards of practice.