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SIMPLE Exam Development

The SIMPLE key features exam was developed based on feedback from schools using SIMPLE. The goal was to develop an innovative assessment tool that focused on clinical decision-making. In doing so, we looked beyond our borders to find the key features approach.

Key features are critical steps in the identification and resolution of a clinical problem and focus on areas where examinees are most likely to have difficulty.Key feature problems consist of a case scenario followed by one or more questions which ask students to prioritize a differential diagnosis, select which historical, physical exam, or testing data are necessary to diagnose the problem, or identify the most appropriate management of the problem. They are distillations of longer clinical cases to their core elements.  In the key features format, students may choose multiple correct options, if doing so would be correct in an authentic clinical situation (e.g. ordering IV fluids and antibiotics simultaneously for a septic patient).  They may receive partial credit for each option.

Key features examinations are used for the Medical Council of Canada’s national Qualifying Examination (taken at the end of medical school),2 the Royal Australian College of General Practitioners certification examination for fellowship,3 and the American Society of Colon and Rectal Surgeons’ Colon and Rectal Surgery Educational Program Self-Assessment Examination.4 Key features examinations have also been developed for medical students in Canada and Germany.5,6

The SIMPLE key features exam was developed by a group of experienced medical educators under the guidance of Dr. Georges Bordage, an expert in the key features approach.  It underwent piloting and a multi-institutional validation study at medical schools around the U.S.


  1. Page G, Bordage G, Allen T. Developing key-feature problems and examinations to assess clinical decision-making skills. Academic medicine : Journal of the Association of American Medical Colleges 1995;70:194-201.

  2. Page G, Bordage G. The Medical Council of Canada's key features project: a more valid written examination of clinical decision-making skills. Academic Medicine 1995;70:104-10.

  3. Farmer EA, Hinchy J. Assessing general practice clinical decision making skills: the key features approach. Australian Family Physician 2005;34:1059-61.

  4. Trudel JL, Bordage G, Downing SM. Reliability and validity of key feature cases for the self-assessment of colon and rectal surgeons. Annals of Surgery 2008;248:252-8.

  5. Amini M, Moghadami M, Kojuri J, et al. An innovative method to assess clinical reasoning skills: Clinical reasoning tests in the second national medical science Olympiad in Iran. BMC research notes 2011;4:418.

  6. Fischer MR, Kopp V, Holzer M, Ruderich F, Jünger J. A modified electronic key feature examination for undergraduate medical students: validation threats and opportunities. Medical Teacher 2005;27:450-5.


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