Proceedings of the Fourth International Natural Language Generation Conference, pages 111–113,
Sydney, July 2006. c©2006 Association for Computational Linguistics
Generating Multiple-Choice Test Items from Medical Text:
A Pilot Study
Nikiforos Karamanis
Computer Laboratory
University of Cambridge
CB3 0FD, UK
nk304@cam.ac.uk
Le An Ha and Ruslan Mitkov
Computational Linguistics Research Group
University of Wolverhampton
WV1 1SB, UK
{L.A.Ha, R.Mitkov}@wlv.ac.uk
Abstract
We report the results of a pilot study on generating
Multiple-Choice Test Items from medical text and
discuss the main tasks involved in this process and
how our system was evaluated by domain experts.
1 Introduction
AlthoughMultiple-ChoiceTestItems(MCTIs)are
used daily for assessment, authoring them is a
laborious task. This gave rise to a relatively new
research area within the emerging field of Text-
to-Text Generation (TTG) called Multiple-Choice
Test Item Generation (MCTIG).1
Mitkov et al. (2006) developed a system
which detects the important concepts in a
text automatically and produces MCTIs testing
explicitly conveyed factual knowledge.2 This
differs from most related work in MCTIG such as
Brown et al. (2005) and the papers in BEAUNLP-
II (2005) which deploy various NLP techniques to
produce MCTIs for vocabulary assessment, often
using preselected words as the input (see Mitkov
et al. for more extensive comparisons).
TheapproachofMitkovetal. issemi-automatic
since the MCTIs have to be reviewed by domain
experts to assess their usability. They report that
semi-automatic MCTIG can be more than 3 times
quicker than authoring of MCTIs without the aid
of their system.
1TTG, in which surface text is used as the input to
algorithms for text production, contrasts with Concept-
to-Text Generation (better known as Natural Language
Generation) which is concerned with the automatic
production of text from some underlying non-linguistic
representation of information (Reiter and Dale, 2000).
2Mitkov et al. used an online textbook on Linguistics as
their source text. Clearly, their approach is not concerned
with concepts or facts derived through inferencing. Neither
does it address the problem of compiling a balanced test from
the generated MCTIs.
Moreover, analysis of MCTIs produced semi-
automatically and used in the classroom reveals
that their educational value is not compromised in
exchange for time and labour savings. In fact, the
semi-automatically produced MCTIs turn out to
fare better than MCTIs produced without the aid
of the system in certain aspects of item quality.
This paper reports the results of a pilot study on
generating MCTIs from medical text which builds
on the work of Mitkov et al.
2 Multiple-Choice Test Item Generation
A MCTI such as the one in example (1) typically
consists of a question or stem, the correct answer
or anchor (in our example, “chronic hepatitis”)
and a list of distractors (options b to d):
(1) Which disease or syndrome may progress to cirrhosis
if it is left untreated?
a) chronic hepatitis
b) hepatic failure
c) hepatic encephalopathy
d) hypersplenism
The MCTI in (1) is based on the following clause
from the source text (called the source clause; see
section 2.3 below):
(2) Chronic hepatitis may progress to cirrhosis if it is left
untreated.
We aim to automatically generate (1) from (2)
using our simple Rapid Item Generation (RIG)
system that combines several components
available off-the-shelf. Based on Mitkov et al., we
saw MCTIG as consisting of at least the following
tasks: a) Parsing b) Key-Term Identification c)
Source Clause Selection d) Transformation to
Stem e) Distractor Selection. These are discussed
in the following sections.
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2.1 Sentence Parsing
Sentence Parsing is crucial for MCTIG since the
other tasks rely greatly on this information. RIG
employs Charniak’s (1997) parser which appeared
to be quite robust in the medical domain.
2.2 Key-Term Identification
One of our main premises is that an appropriate
MCTI should have a key-term as its anchor
rather than irrelevant concepts. For instance, the
concepts “chronic hepatitis” and “cirrhosis” are
quite prominent in the source text that example (2)
comes from, which in turn means that MCTIs
containing these terms should be generated using
appropriate sentences from that text.
RIG uses the UMLS thesaurus3 as a domain
specific resource to compute an initial set of
potential key terms such as “hepatitis” from the
source text. Similarly to Mitkov et al., the initial
set is enlarged with NPs featuring potential key
terms as their heads and satisfying certain regular
expressions. This step adds terms such as “acute
hepatitis” (which was not included in the version
of UMLS utilised by our system) to the set.
The tf.idf method (that Mitkov et al. did
not find particularly effective) is used to promote
the 30 most prominent potential key terms within
the source text for subsequent processing, ruling
out generic terms such as “patient” or “therapy”
which are very frequent within a larger collection
of medical texts (our reference corpus).
2.3 Source Clause Selection
Mitkov et al. treat a clause in the source text
as eligible for MCTIG if it contains at least one
key term and is finite as well as of the SV(O)
structure. They acknowledge, however, that this
strategy gives rise to a lot of inappropriate source
clauses, which was the case in our domain too.
To address this problem, we implemented a
module which filters out inappropriate structures
for MCTIG (see Table 1 for examples). This
explains why the number of key terms and MCTIs
varies among texts (Table 2).
A finite main clause which contains an NP
headed by a key term and functioning as a
subject or object with all the subordinate clauses
which depend on it is a source clause eligible
for MCTIG provided that it satisfies our filters.
Example (2) is such an eligible source clause.
3http://www.nlm.nih.gov/research/umls/
Structure Example (key term in italics)
Subordinate clause Although asthma is a lung disease, ...
Negated clause Autoimmune hepatitis should not
be treated with interferon.
Coordinated NP Excessive salt intake causes
hypertension and hypokalemia.
Initial pronoun It associates with hypertension instead.
Table 1: Inappropriate structures for MCTIG.
Experimentation during development showed that
our module improves source clause selection by
around 30% compared to the baseline approach of
Mitkov et al.
2.4 Transformation to Stem
Once an appropriate source clause is identified,
it has to be turned to the stem of a MCTI. This
involves getting rid of discourse cues such as
“however” and substituting the NP headed by the
key term such as “chronic hepatitis” in (1) with a
wh-phrase such as “which disease or syndrome”.
The wh-phrase is headed by the semantic type of
the key-term derived from UMLS.
RIG utilises a simple transformational
component which produces a stem via minimal
changes in the ordering of the source clause. The
filtering module discussed in the previous section
disregards the clauses in which the key term
functions as a modifier or adjunct. Additionally,
most of the key terms in the eligible source clauses
appear in subject position which in turn means
that wh-fronting and inversion is performed in just
a handful of cases. The following example, again
based on the source clause in (2), is one such case:
(3) To which disease or syndrome may chronic hepatitis
progress if it is left untreated?
2.5 Selection of Appropriate Distractors
MCTIs aim to test the ability of the student
to identify the correct answer among several
distractors. An appropriate distractor is a concept
semantically close to the anchor which, however,
cannot serve as the right answer itself.
RIG computes a set of potential distractors
for a key term using the terms with the same
semantic type in UMLS (rather than WordNet
coordinates employed by Mitkov et al.). Then, we
apply a simple measure of distributional similarity
derived from our reference corpus to select the
best scoring distractors. This strategy means that
MCTIs with the same answer feature very similar
distractors.
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# of # of Usable Usable Items w/out Replaced distractors Total Average Time
Chapter Words Key-terms Items Items post-edited stems per term Time per Item
Asthma 8,843 9 66 42 (64%) 18 (27%) 2.0 140 mins 3 mins 20 secs
Hepatitis 10,259 17 92 49 (53%) 19 (21%) 0.9 150 mins 3 mins 04 secs
Hypertension 12,941 22 121 59 (49%) 15 (12%) 0.8 200 mins 3 mins 23 secs
Total 32,043 40 279 150 (54%) 52 (19%) − 490 mins 3 mins 16 secs
Table 2: Usability and efficiency of Multiple-Choice Test Item Generation from medical text.
3 Evaluation
RIG is a simple system which often avoids
tough problems such as dealing with key-terms in
syntactic positions that might puzzle the parser or
might be too difficult to question upon. So how
does it actually perform?
Three experts in producing MCTIs for medical
assessment jointly reviewed 279 MCTIs (each
featuring four distractors) generated by the
system. Three chapters from a medical textbook
served as the source texts while a much larger
collection of MEDLINE texts was used as the
reference corpus.
The domain experts regarded a MCTI as
unusableifitcouldnotbeusedinatestorrequired
too much revision to do so. The remaining items
were considered to be usable and could be post-
edited by the experts to improve their content and
readability or replace inappropriate distractors.
As Table 2 shows, more than half of the items in
total were judged to be usable. Additionally, about
one fifth of the usable items did not require any
editing. The Table also shows the total number of
key-terms identified in each chapter as well as the
average number of distractors replaced per term.
The last column of Table 2 reports on the
efficiency of MCTIG in our domain. This variable
is calculated by dividing the total time it took
the experts to review all MCTIs by the amount
of usable items which represent the actual end-
product. This is a bit longer than 3 minutes
per usable item across all chapters. Anecdotal
evidence and the experts’ own estimations suggest
that it normally takes them at least 10 minutes to
produce an MCTI manually.
Given the distinct domains in which our system
and the one of Mitkov et al. were deployed (as
well as the differences between them), a direct
comparison between them could be misleading.
We note, however, that our usability scores are
always higher than their worst score (30%) and
quite close to their best score (57%). The amount
of directly usable items in Mitkov et al. was
between just 3.5% and 5%, much lower than
what we achieved. They also report an almost
3-fold improvement in efficiency for computer-
aided MCTIG, which is very similar to our
estimate. These results indicate what our work has
contributed to the state of the art in MCTIG.
In our future work, we aim to address the
following issues: (a) As in Mitkov et al., the
anchor of a MCTI produced by RIG always
corresponds to a key-term. However, the domain
experts pointed out several cases in which it is
better for the key-term to stay in the stem and
for another less prominent concept to serve as the
answer. (b) Students who simply memorise the
input chapter might be able to answer the MCTI if
its surface form is too close to the source clause so
another interesting suggestion was to paraphrase
the stem during MCTIG. (c) We also intend to
introduce greater variability in our process for
distractor selection by investigating several other
measures of semantic similarity.
Acknowledgments
We are grateful to Tony LaDuca, Manfred Straehle and
Robert Galbraith from the National Board of Medical
Examiners (NBME) for their expert-based feedback and to
three anonymous reviewers for their comments.

References
BEAUNLP-II. 2005. Papers on MCTIG by Hoshino and
Nakagawa, Liu et al., and Sumita et al. In Proceedings of
the 2nd Workshop on Building Educational Applications
Using NLP.
Jonathan Brown, Gwen Frishkoff, and Maxine Eskenazi.
2005. Automatic question generation for vocabulary
assessment. In Proceedings of HLT-EMNLP 2005, pages
249–254.
Eugene Charniak. 1997. Statistical parsing with a context-
free grammar and word statistics. In Proceedings of AAAI
1997, pages 598–603.
Ruslan Mitkov, Le An Ha, and Nikiforos Karamanis. 2006.
A computer-aided environment for generating multiple-
choice test items. Natural Language Engineering,
12(2):177–194.
Ehud Reiter and Robert Dale. 2000. Building Natural
Language Generation Systems. Cambridge University
Press.
