Lead-ins can be written to require the student to select more than one response or to order the responses in some way. Care must be taken to give explicit directions. A useful form of item stem is the clinical vignette, which describes a patient in a clinical situation. Carefully selected and crafted stems of this type can be used beginning in the first-year courses to draw relationships between basic and clinical sciences. Structure-function relationships are also excellent forms of item stems in the basic sciences.
Vignettes can range from complete patient descriptions to brief presentations.
Extended matching items can be written in a nonvignette format. However, care must be taken not to focus on recall of isolated facts or on simple associations. To minimize cuing, stems within a set should be of similar structure. The full range of higher order skills cannot be assessed without requiring some writing from the student. Neither extended matching nor multiple-choice questions are adequate for assessing the generative skills.