Start with a blueprint. Before writing a single question, decide what the exam must cover and how many marks each topic and learning outcome deserves. A blueprint stops the paper drifting towards whatever was easiest to write questions about, and shows students and colleagues that the exam is fair.
Match the question type to what you’re testing. Multiple-choice questions sample a lot of content quickly and mark reliably. Short answers check that students can recall and explain without prompting. Extended responses test argument, analysis and judgement. Scenario questions ask students to apply what they know to something that looks like practice. A good paper uses each for what it does best.
Put the marks where the learning is. Students read the marks as a signal of what matters. If your most important outcome is clinical reasoning, but most marks go on recall, the exam is telling students to memorise. Weight the paper towards the outcomes you care about most.
Write stems that stand on their own. A good multiple-choice stem asks a clear question that a well-prepared student could answer before reading the options. Avoid “all of the above”, “none of the above” and negatively worded stems (“which is NOT…”), which test reading skill more than knowledge. Make every distractor plausible, and keep the options similar in length.
Spread the correct answers. Students notice when “C” comes up again and again. Spread the correct answers evenly across the options, and keep numeric options in order, so position never gives the answer away.
Write the marking guide with the question. If you can’t say what a full-mark answer contains, the question isn’t ready. Listing the creditable points and how many marks each earns makes marking faster and more consistent, especially when several people mark the same paper.
Check the time. Work through the paper yourself, or ask a colleague to, and time it. As a rough guide, students need about a minute per mark plus reading time. A paper that’s too long tests speed, not understanding.
Check it before students sit it. The paper is written by AI. It’s a strong starting point, but check every question and answer, especially calculations, dosages, legal points and anything that depends on local guidelines, and have a colleague review it as you would any exam. The final paper is always yours.