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By Dan Limmer

The NREMT announced in 2019 and reiterated their position at the recent NAEMSE virtual conference that the NREMT is switching from a “best answer” to a “one correct answer” format.

Before I take what might seem like a slightly contrary viewpoint, I want to be sure to state that I am and remain a fan of the NREMT. Their forward-facing attitude and approachability are positive. Their response to the pandemic has been appropriate and practical.

So what am I going to say that may appear to go against the NREMT? I just don’t think it will make a big difference in the questions on the exam. Consider these points:

The NREMT “best answer” format was often seen as a code word for trickery.

Conspiracy theorists are a dime a dozen today. The “NREMT is a money grab” mentality is sadly too pervasive. The change from the “best answer” to “one correct answer” gives these people one less thing about which to complain. That isn’t a bad thing and shows an awareness and positive messaging from the NREMT.

The NREMT exam still has well-constructed questions.

What makes a question challenging? A solidly written stem with one correct answer and three good distractors. This isn’t going to stop. The NREMT will still have plausible distractors. It would be a mistake to make the exam too easy.

NREMT questions will still be different than the ones on your exams.

Face it – it is tough to create questions like the NREMT. They have item writing panels with talented writers, psychometricians, and the ability to validate questions from a giant pool of candidates. You don’t. It is challenging and time-consuming to write questions like that. Students will still find the NREMT different and scary. This hasn’t changed at all.

Technology Enhanced Items (TEI) will raise the bar a bit.

The NREMT hasn’t taken a step back with the “one correct answer” announcement. Almost concurrently, they announced TEIs: a multiple response format plus questions with images and videos. This brings the NREMT into the new century. Intuitively, I believe the new question types will up the ante without the “best answer” baggage. But time will tell. Generally, I predict our students will need a more in-depth understanding to succeed at some of these questions. Pathophysiology, somewhat undervalued and not taught to full potential, will be king here. Depth is important, however, even in things like intro and operations.

TEIs are used on other major health profession certification examinations and seem like a natural extension of the EMS certification examination into the 21st century.

The Point?

The NREMT is our certification examination, and it isn’t going anywhere. It is the responsibility of students and educators to stay up-to-date on the most current science in their certification level and the pathophysiology, assessment, and management of patients they may encounter. That part will never change.

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Join the discussion 7 Comments

  • Lisa Migliori says:

    As an instructor, I love these updates.

  • Barry J Bruner says:

    I too am very pleased to see the direction the TEI’s will take the Certification Exam. I would like to think it gives a more balanced testing to all types of students as the exam addresses all types of learners by including pics and video. When I sat for My Fire safety Officer certification Exam in NJ over 10 years ago the exam including these types of questions. I have also utilized something similar in class sessions/quizzes since 2012.

  • Greg West says:

    It’s about time that this was addressed. If you want evidence of how terrible these “best answer” questions are, look at Dan Limmer explaining why an answer is “best”- not to a group of students, but to a group of EMS educators (https://www.youtube.com/watch?v=PIDKsKvlE0c&t=23s). If EMS instructors can’t get the answer to a question right, why would we ever expect students to?

    There’s yet another step that needs to be taken here- the questions that do get utilized have to be associated with objectives. Since NHTSA dropped their national objectives, every textbook has a different set of objectives that they establish for student learning. Currently, questions come from any number of sources and not all information is presented to students as part of their course. We need to once again adopt a single, objective-based curriculum that defines what every EMT succeeding in a program has been taught. Until then, the NREMT exam will continue to fail in evaluation since there is no standard to which we teach.

    • Dan Limmer says:

      Hi Greg. Thanks for the note. I can agree with some, but not all of what you say.

      I don’t think anyone is grieving over the demise of “best answer.” Although in my post I basically say that I am not sure how much this will be apparent in question difficulty as an exam item is made difficult by the quality of the distractors. Even with one correct answer, this won’t be a cakewalk–and there will still be NREMT naysayers. Ultimately the best thing educators can do is up their exam ante with more challenging questions.

      Where I disagree is the call for a national curriculum or objectives. The education standards serve this role for us. My case against this is that there is no national nursing curriculum, no national respiratory curriculum, etc. This moves us farther from the other health professions. The items developed by the government become outdated quickly and not updated regularly.

      I also think that even if there were set objectives, I could still interpret the depth of content and analysis of science differently than my friend Joe Mistovich does in his textbook or the other textbooks on the market. The NREMT’s practice analysis helps determine the test content–by seeing what providers actually do.

      In short, I think a lock step approach is bad for us in the long run both as a profession and for the ability to think critically. But I do think that you have given me an idea for a presentation on how to develop content–especially for EMT courses which aren’t affected by accreditation.

      • Greg West says:

        Hi Dan-

        I’d disagree with two points.

        First, if the test content is being determined by what providers do, not what is taught, why is there a difference? And remember, people taking the NREMT are not providers…yet. We all know that the EMT course provides a foundation to become an EMT- its end product is not a fully functioning EMT, nor should it be. Doctors and nurses don’t pass their exams and then go directly into practice- they have the equivalents of FTOs that guide them through the application and enhancement of their knowledge and skills before they are deemed ready to be “on their own”. If there’s a difference between what the graduate of an EMT course and an experienced provider knows (and there certainly is), that difference needs to be recognized on the exam. The video link that I provided in my post speaks volumes- the “students” that you were interacting with were all instructors (and likely experienced providers)- how do you explain their inability to answer the question “correctly”? And if these are the instructors, how will their students fare on the exam?

        Secondly, well-written objectives can define the scope, or depth, of knowledge expected of students. All courses blend the data presented in the textbook with the instructor’s own sense of what needs to be taught. If there is no national standard objective list, then NREMT questions need to be based on the objectives common to all textbooks. That’s very easy to do- there are only three major texts and it would be very easy to verify that information required to answer a question is presented in all three. I’ve taken the NREMT exam and been amazed at the random questions that are never addressed in the book. Example- who has the right of way at an intersection- EMS, police, fire or postal truck? The answer, postal truck, is not in any of the textbooks and is quite questionable as a valid question to ask when you have 70-120 questions to ascertain whether someone should be providing emergency health care. So if we can’t have standardized objectives, we can certainly settle on the NREMT taking the time and putting in the effort to assure that all textbooks carry the information that has been presented to the students by the authors.

        I don’t mean to be negative or confrontational, but the NREMT has been a disaster for years- I actually spoke to you about it about a decade ago when you dropped by to chat with me and my instructors in MA. I’ve had brilliant students who’ve said it best: “I don’t mind a hard exam, but I hate a bad exam.” The NREMT has produced a bad exam for years- it can’t claim to measure knowledge without being able to reference what knowledge is required of the student in the first place- that’s what objectives ascertain. Your announcement is most welcome- no more “best answers”. But it needs to be followed up with the NREMT committing to assuring the the textbooks we utilize (and I utilize yours) contain the information required to know what they need to know.

        • Dan Limmer says:

          Hi Greg–I’m sorry I didn’t match the name with you. I remember that trip well. A great place you have there.

          I think we can disagree on this amicably–and even take it up when we can finally all get together at a conference again! I do see that you are very passionate about this and I always respect that.

          My personal approach to this is to teach greater depth–especially in my EMT courses. I also value thinking and have frequent exercises to stimulate that. I don’t have an adversity to the NREMT–and I find them very open to change these days. It is a psychometrically sound and valid exam that should be challenging to do what they claim–measure entry-level competence.

          As for the experienced providers (and educators), some may not have been taught well. I teach AEMT classes where I usually have to reteach basic pathophysiology. I also have to deprogram students from thinking they have to give oxygen to everyone after returning from clinical time–and for the bad advice they have received about passing the NREMT.

          I remain unconvinced about the role of objectives in standardizing content. Mistovich and I have great respect for each other but we write different books. And even if he and I did some synchronizing, we can’t control other publishers. Would something in 2 out of 3 books classify for the exam? I think the bar is the exam, based on the standards.

          Right now about 70% of the EMTs who take the exam pass on the first try and usually a slightly higher percentage of paramedics. Perhaps it is the involvement in writing the book or teaching for a long (long, long) time, but I don’t think my students will get 100% on the NREMT–and if they get a freak question they need to answer it as best they can and hope it is a pilot question. I haven’t heard about the mail truck one but lore is full of emotional support donkey questions and others that I just can’t worry about–nor will I put them in my book.

          It has been a great conversation. I hope we can take it up in person when all this @#$%*& clears. I hear MA is getting hit hard again. Stay safe and healthy!

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