This paper offers an in-depth review of the latest advancements in the automatic generation of medical case-based multiple-choice questions (MCQs). The automatic creation of educational materials, particularly MCQs, is pivotal in enhancing teaching effectiveness and student engagement in medical education. In this review, we explore various algorithms and techniques that have been developed for generating MCQs from medical case studies. Recent innovations in natural language processing (NLP) and machine learning (ML) for automatic language generation have garnered considerable attention. Our analysis evaluates and categorizes the leading approaches, highlighting their generation capabilities and practical applications. Additionally, this paper synthesizes the existing evidence, detailing the strengths, limitations, and gaps in current practices. By contributing to the broader conversation on how technology can support medical education, this review not only assesses the present state but also suggests future directions for improvement. We advocate for the development of more advanced and adaptable mechanisms to enhance the automatic generation of MCQs, thereby supporting more effective learning experiences in medical education.

This narrative review is a detailed look at how we make multiple-choice questions (MCQs) based on medical cases in today’s medical teaching. Moving from old-style MCQs to ones that are more related to real clinical situations is really important. It helps in growing critical thinking and practical use, especially since MCQs are still the primary method for testing knowledge in medicine. We look at the history, design ideas, and both manual and computer-based methods that have helped create MCQs. Technologies like Artificial Intelligence (AI) and Natural Language Processing (NLP) are receiving a lot of focus for their ability to automate the creation of question. We also talk about the challenges of using real patient cases, like the need for exact clinical information, reducing unclear information, and thinking about ethical issues. We also investigate the measures of validity and reliability that are crucial to maintaining the honesty of case-based MCQs. Finally, we look ahead, speculating on where medical education is headed as new technologies are incorporated and the value of case-based evaluations continues to rise.

The use of large language models (LLMs) to automate the generation of medical case-based multiple-choice questions (MCQs) is increasing, but their accuracy, reliability, and educational validity are still not well understood. This study in a comparative framework examined nine LLMs with four different prompting methods to evaluate LLM-produced MCQs for clinical coherence and readiness for assessment. A uniform evaluation pipeline was constructed to examine automatic text-similarity measures using automated metrics (BLEU, ROUGE, and METEOR), structural and parsability measures, and operational effectiveness (latency, cost, quality-efficiency ratios). Human validation was performed on the best-performing model and prompt combination (OpenBioLLM-70B with Chain-of-Thought) focusing on the model prompt that demonstrated the best linguistic fidelity and clinically aligned reasoning. Two clinical experts independently reviewed 88 items using a five-domain rubric covering appropriateness, clarity, relevance, distractor quality, and cognitive level. Results indicated significant variation across models and prompting strategies, with Chain-of-Thought yielding the best overall performance in comparison to other strategies. The OpenBioLLM-70B model demonstrated the best overall balance of quality, parsability, and efficiency, achieving a prompt template quality score of 90.4, a consistency score of 88.8, and a response time of 3.28 s, with a quality-per-dollar value of 134.11. The expert rating confirmed clinical alignment, but there was consensus that distractor quality needed further improvements. These results provide evidence that LLMs under optimal prompting conditions can reliably support MCQ generation and provide large-scale, cost-effective support for medical assessment production.