Introduction Writing and answering multiple choice questions (MCQs) is a learning activity that potentially engages deep learning. We conducted three year-long case studies of MCQ writing and answering in PeerWise to engage students in learning Pathology. Methods Overall, an instrumental case-study design with the structure of sequential multiple case studies was used. Across three years fourth year medical students were required to write and answer MCQs. In 2016 students were provided with advice for writing questions and were encouraged to adhere to Bloom's taxonomy. In 2017, to reduce cognitive load, students were provided with a MCQ template and allocated topics. In 2018, to encourage engagement, students were informed that the top forty MCQs would be in the final exam. Results An evaluation survey was used to measure each student's perception of the MCQ exercise. In 2016 most students had a negative opinion of the MCQ exercise. Students found writing MCQs too time consuming and demanding. In 2017 student's attitudes to the MCQ exercise were more positive. In 2018 there were insufficient responses to the survey but informal student feedback suggested the MCQ exercise was considered an inefficient use of student study time. There were minimal changes in student's activity levels from 2016 to 2017. However, in 2018 when students were informed that the top forty MCQs generated would be included in their final exam they answered a greater number of MCQs than in previous years. Conclusions

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Based on the reviewers comments, we added a few extra sentences to clarify the distribution and timing of the survey and added an additional legend to clarity Figure 3A.