This retrospective study compared the performance of preclinical medical students in the multiple-choice question (MCQ) and long essay question components of a comprehensive physiology final examination. During the 3 yr analyzed, 307 students had an average score of 47% (SD 9.9) in the long essay questions and 64% (SD 9.9) in the MCQs. Regression analysis showed a significant correlation (r = 0.62, P less than 0.01) between MCQs and long essay questions. When student performance was grouped by final course grade, a statistically significant correlation between MCQ and long essay scores existed only for the 210 students who received a passing grade (r = 0.20, P less than 0.01). The MCQ and long essay question scores were not correlated for the 57 students who failed (r = 0.25, P = 0.06) or for the 40 students who achieved honors and distinctions (r = -0.27, P = 0.11). MCQ scores were significantly higher (P less than 0.01) than essay scores for each of the groups when analyzed by two-way ANOVA. The results of this study suggest that for most students, the strong correlation between scores on MCQs and essay questions indicates that student performance was independent of testing format. For students at either end on the performance spectrum, the lack of correlation suggests that the performance in one of the testing formats had a strong influence on the final course grade. In addition, those students who failed the course were likely to be weak in both testing modalities, whereas students in all grade groups were more likely to perform better in the MCQs than in the long essay questions.