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A test blueprint describes the key elements of a test, including the content to be covered, the amount of emphasis allocated to each content area, and other important features. This article offers practical guidelines for developing test blueprints. We first discuss the role of learning outcomes and behavioral objectives in test blueprinting, and then describe a four-stage process for creating test blueprints. The steps include identifying the major knowledge and skill domains (i.e. competencies); delineating the specific assessment objectives; determining the method of assessment to address those objectives; and establishing the amount of emphasis to allocate to each knowledge or skill domain. The article refers to and provides examples of numerous test blueprints for a wide variety of knowledge and skill domains. We conclude by discussing the role of test blueprinting in test score validation, and by summarizing some of the other ways that test blueprints support instruction and assessment.

Research suggests that the three-option format is optimal for multiple choice questions (MCQs). This conclusion is supported by numerous studies showing that most distractors (i.e., incorrect answers) are selected by so few examinees that they are essentially nonfunctional. However, nearly all studies have defined a distractor as nonfunctional if it is selected by fewer than 5% of examinees. A limitation of this definition is that the proportion of examinees available to choose a distractor depends on overall item difficulty. This is especially problematic for mastery tests, which consist of items that most examinees are expected to answer correctly. Based on the traditional definition of nonfunctional, a five-option MCQ answered correctly by greater than 90% of examinees will be constrained to have only one functional distractor. The primary purpose of the present study was to evaluate an index of nonfunctional that is sensitive to item difficulty. A secondary purpose was to extend previous research by studying distractor functionality within the context of professionally-developed credentialing tests. Data were analyzed for 840 MCQs consisting of five options per item. Results based on the traditional definition of nonfunctional were consistent with previous research indicating that most MCQs had one or two functional distractors. In contrast, the newly proposed index indicated that nearly half (47.3%) of all items had three or four functional distractors. Implications for item and test development are discussed.

Purpose: In 2007, the United States Medical Licensing Examination embedded multimedia simulations of heart sounds into multiple-choice questions. This study investigated changes in item difficulty as determined by examinee performance over time. The data reflect outcomes obtained following initial use of multimedia items from 2007 through 2012, after which an interface change occurred., Method: A total of 233,157 examinees responded to 1,306 cardiology test items over the six-year period; 138 items included multimedia simulations of heart sounds, while 1,168 text-based items without multimedia served as controls. The authors compared changes in difficulty of multimedia items over time with changes in difficulty of text-based cardiology items over time. Further, they compared changes in item difficulty for both groups of items between graduates of Liaison Committee on Medical Education (LCME)-accredited and non-LCME-accredited (i.e., international) medical schools., Results: Examinee performance on cardiology test items with multimedia heart sounds improved by 12.4% over the six-year period, while performance on text-based cardiology items improved by approximately 1.4%. These results were similar for graduates of LCME-accredited and non-LCME-accredited medical schools., Conclusions: Examinees' ability to interpret auscultation findings in test items that include multimedia presentations increased from 2007 to 2012.

This study evaluated the extent to which medical students with limited English-language experience are differentially impacted by the additional reading load of test items consisting of long clinical vignettes. Participants included 25,012 examinees who completed Step 2 of the U.S. Medical Licensing Examination®. Test items were categorized into five levels based on the number of words per item, and examinee scores at each level were evaluated as a function of English-language experience (English as a second language [ESL] status and scores on a test of English-speaking proficiency). The longest items were more difficult than the shortest items across all examinee groups, and examinees with more English-language experience scored higher than those with less experience across all five levels of word count. The effect of primary interest-the interaction of word count with English-language experience-was statistically significant, indicating that score declines for longer items were larger for examinees with less English-language experience; however, the magnitude of this interaction effect was barely detectable (η 2 = .0004, p < .001). Additional analyses supported the conclusion that the differential effect for examinees with less English-language experience was small but worthy of continued monitoring.

Purpose: Previous studies on standardized patient (SP) exams reported score gains both across attempts when examinees failed and retook the exam and over multiple SP encounters within a single exam session. The authors analyzed the within-session score gains of examinees who repeated the United States Medical Licensing Examination Step 2 Clinical Skills to answer two questions: How much do scores increase within a session? Can the pattern of increasing first-attempt scores account for across-session score gains?, Method: Data included encounter-level scores for 2,165 U.S. and Canadian medical students and graduates who took Step 2 Clinical Skills twice between April 1, 2005 and December 31, 2010. The authors modeled examinees' score patterns using smoothing and regression techniques and applied statistical tests to determine whether the patterns were the same or different across attempts. In addition, they tested whether any across-session score gains could be explained by the first-attempt within-session score trajectory., Results: For the first and second attempts, the authors attributed examinees' within-session score gains to a pattern of score increases over the first three to six SP encounters followed by a leveling off. Model predictions revealed that the authors could not attribute the across-session score gains to the first-attempt within-session score gains., Conclusions: The within-session score gains over the first three to six SP encounters of both attempts indicate that there is a temporary "warm-up" effect on performance that "resets" between attempts. Across-session gains are not due to this warm-up effect and likely reflect true improvement in performance.

Examinees who initially fail and later repeat an SP-based clinical skills exam typically exhibit large score gains on their second attempt, suggesting the possibility that examinees were not well measured on one of those attempts. This study evaluates score precision for examinees who repeated an SP-based clinical skills test administered as part of the US Medical Licensing Examination sequence. Generalizability theory was used as the basis for computing conditional standard errors of measurement (SEM) for individual examinees. Conditional SEMs were computed for approximately 60,000 single-take examinees and 5,000 repeat examinees who completed the Step 2 Clinical Skills Examination(®) between 2007 and 2009. The study focused exclusively on ratings of communication and interpersonal skills. Conditional SEMs for single-take and repeat examinees were nearly indistinguishable across most of the score scale. US graduates and IMGs were measured with equal levels of precision at all score levels, as were examinees with differing levels of skill speaking English. There was no evidence that examinees with the largest score changes were measured poorly on either their first or second attempt. The large score increases for repeat examinees on this SP-based exam probably cannot be attributed to unexpectedly large errors of measurement.

Purpose: Prior studies report large score gains for examinees who fail and later repeat standardized patient (SP) assessments. Although research indicates that score gains on SP exams cannot be attributed to memorizing previous cases, no studies have investigated the empirical validity of scores for repeat examinees. This report compares single-take and repeat examinees in terms of both internal (construct) validity and external (criterion-related) validity., Method: Data consisted of test scores for examinees who took the United States Medical Licensing Examination Step 2 Clinical Skills (CS) exam between July 16, 2007, and September 12, 2009. The sample included 12,090 examinees who completed Step 2 CS on one occasion and another 4,030 examinees who completed the exam on two occasions. The internal measures included four separately scored performance domains of the Step 2 CS examination, whereas the external measures consisted of scores on three written assessments of medical knowledge (Step 1, Step 2 clinical knowledge, and Step 3). The authors subjected the four Step 2 CS domains to confirmatory factor analysis and evaluated correlations between Step 2 CS scores and the three written assessments for single-take and repeat examinees., Results: The factor structure for repeat examinees on their first attempt was markedly different from the factor structure for single-take examinees, but it became more similar to that for single-take examinees by their second attempt. Scores on the second attempt correlated more highly with all three external measures., Conclusions: The findings support the validity of scores for repeat examinees on their second attempt.

Years of research with high-stakes written tests indicates that although repeat examinees typically experience score gains between their first and subsequent attempts, their pass rates remain considerably lower than pass rates for first-time examinees. This outcome is consistent with expectations. Comparable studies of the performance of repeat examinees on oral examinations are lacking. The current research evaluated pass rates for more than 50,000 examinees on written and oral exams administered by six medical specialty boards for several recent years. Pass rates for first-time examinees were similar for both written and oral exams, averaging about 84% across all boards. Pass rates for repeat examinees on written exams were expectedly lower, ranging from 22% to 51%, with an average of 36%. However, pass rates for repeat examinees on oral exams were markedly higher than for written exams, ranging from 53% to 77%, with an average of 65%. Four explanations for the elevated repeat pass rates on oral exams are proposed, including an increase in examinee proficiency, construct-irrelevant variance, measurement error (score unreliability), and memorization of test content. Simulated data are used to demonstrate that roughly one third of the score increase can be explained by measurement error alone. The authors suggest that a substantial portion of the score increase can also likely be attributed to construct-irrelevant variance. Results are discussed in terms of their implications for making pass-fail decisions when retesting is allowed. The article concludes by identifying areas for future research.

Background: Previous research has shown that ratings of English proficiency on the United States Medical Licensing Examination Clinical Skills Examination are highly reliable. However, the score distributions for native and nonnative speakers of English are sufficiently different to suggest that reliability should be investigated separately for each group., Method: Generalizability theory was used to obtain reliability indices separately for native and nonnative speakers of English (N = 29,084). Conditional standard errors of measurement were also obtained for both groups to evaluate measurement precision for each group at specific score levels., Results: Overall indices of reliability (phi) exceeded 0.90 for both native and nonnative speakers, and both groups were measured with nearly equal precision throughout the score distribution. However, measurement precision decreased at lower levels of proficiency for all examinees., Conclusions: The results of this and future studies may be helpful in understanding and minimizing sources of measurement error at particular regions of the score distribution.

Purpose: To determine if graduates of different types of educational programs obtain similar scores on the Examination in Radiation Therapy administered by the American Registry of Radiologic Technologists. The results will help inform discussions regarding educational requirements for radiation therapists., Methods and Materials: Test scores were obtained for 531 candidates who had taken the examination for the first time in 1997, 1998, or 1999. Candidates were divided into the following three categories, based on the type of educational program attended: hospital-based certificate, associate's degree, or bachelor's degree. To determine if test scores were related to the type of educational preparation, analyses of variance were conducted separately to test for differences in total scores and section scores, and scores on test questions intended to measure critical thinking skills., Results: Candidates with an associate's degree scored slightly lower than candidates with a bachelor's degree on the total test (p < 0.10) and lower than candidates with either a certificate or bachelor's degree on Section B of the examination (Treatment Planning and Delivery, p < 0.10). Baccalaureate candidates did not obtain higher scores than those prepared in certificate programs. On critical thinking questions, candidates with certificates scored higher than those with associate's degrees (p < 0.10). Some evidence suggested that candidates with a certificate scored higher on critical thinking than those with a bachelor's degree (p < 0.10), and that candidates with a bachelor's degree scored higher than candidates with an associate's degree (p < 0.10)., Conclusions: Although some of the differences in the mean test scores among the three educational groups were statistically significant, all differences were small and do not support one type of educational preparation over another.

Although oral examinations are widely used for making decisions regarding an individual's level of competence, they are frequently of limited reliability. A significant part of the error in oral performance ratings is due to the tendency for some evaluators to be lenient and others to be stringent in their assignment of ratings. This article describes and evaluates a simple method to identify and correct for errors of leniency and stringency. The method, which is based on a regression model recommended by Wilson (1988), extends and simplifies the procedures recommended by Cason and Cason (1984, 1985). The method provides an estimate of each individual's performance that has been corrected for errors of leniency and stringency. In addition, it produces for each rater an index of leniency or stringency and several other statistics useful in evaluating the properties of rating data. The regression method is applied to performance ratings from three separate administrations of an oral examination in a medical specialty. The results indicate modest but significant levels of leniency and stringency error; correcting for such errors would change the pass/fail decisions for about 6% of the examinees. Limitations of the procedure, as well as the need for additional research, are discussed.