MCQs, despite their reputation as simplistic or "lazy" tools, remain one of the most versatile and widely used formats for both formative and summative assessments. When designed using evidence-based principles, MCQs can effectively challenge students to apply, analyze, and synthesize knowledge. To achieve this, educators must go beyond surface-level question design, incorporating psychological and educational constructs such as constructive alignment and cognitive load theory, as well as practical principles like distractor writing, test blueprints, and validity testing. These steps are crucial in medical education, where accurate assessment of clinical reasoning and decision-making is paramount. For decades, Multiple Choice Questions (MCQs) have been integral to medical education, playing a significant role in assessing knowledge in undergraduate, postgraduate, and specialist training programs. The advent of Learning Management Systems (LMS) in the 1990s facilitated the transition from traditional paper-based MCQs to digital platforms, enabling automated features like instant marking, question shuffling, branching pathways, and feedback. By the early 2000s, e-learning authoring tools further transformed MCQ design, introducing interactive elements such as images, videos, animations, and complex question types like drag-and-drop tasks and hotspot identification. These innovations allowed educators to better engage learners and address diverse cognitive challenges. Developing effective MCQs involves integrating foundational educational theories such as Bloom's taxonomy, constructive alignment, and cognitive load theory. These frameworks inform the creation of questions that transcend rote memorization, promoting higher-order thinking and the practical application of knowledge. Well-designed MCQs, particularly those based on hypothetical or clinical scenarios, can assess analytical reasoning, decision-making, and problem-solving skills, thus fostering deep learning. However, effective implementation requires careful preparation of students, ensuring alignment between learning activities, assessment methods, and desired educational outcomes. This article explores the theoretical underpinnings and practical strategies for crafting MCQs in medical education, emphasizing their potential to enhance learning experiences. The discussion focuses on overcoming common challenges, such as ambiguity in question design and misconceptions about the limitations of MCQs. By adopting evidence-based practices, medical educators can use MCQs not just for assessment but as tools to stimulate critical thinking and engagement, creating a dynamic and supportive learning environment.