formative assessment examples in medical education

• Open access
• Published: 02 March 2023

Reflection on the teaching of student-centred formative assessment in medical curricula: an investigation from the perspective of medical students

• Tianjiao Ma 1 , 4 ,
• Hua Yuan 1 ,
• Feng Li 1 ,
• Shujuan Yang 2 ,
• Yongzhi Zhan 2 ,
• Jiannan Yao 1 &
• Dongmei Mu 3  

BMC Medical Education volume  23 , Article number:  141 ( 2023 ) Cite this article

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Formative assessment (FA) is becoming increasingly common in higher education, although the teaching practice of student-centred FA in medical curricula is still very limited. In addition, there is a lack of theoretical and pedagogical practice studies observing FA from medical students’ perspectives. The aim of this study is to explore and understand ways to improve student-centred FA, and to provide a practical framework for the future construction of an FA index system in medical curricula.

This study used questionnaire data from undergraduate students in clinical medicine, preventive medicine, radiology, and nursing at a comprehensive university in China. The feelings of medical students upon receiving student-centred FA, assessment of faculty feedback, and satisfaction were analysed descriptively.

Of the 924 medical students surveyed, 37.1% had a general understanding of FA, 94.2% believed that the subject of teaching assessment was the teacher, 59% believed that teacher feedback on learning tasks was effective, and 36.3% received teacher feedback on learning tasks within one week. In addition, student satisfaction results show that students’ satisfaction with teacher feedback was 1.71 ± 0.747 points, and their satisfaction with learning tasks was 1.83 ± 0.826 points.

Students as participants and collaborators in FA provide valid feedback for improving student-centred FA in terms of student cognition, empowered participation, and humanism. In addition, we suggest that medical educators avoid taking student satisfaction as a single indicator for measuring student-centred FA and to try to build an assessment index system of FA, to highlight the advantages of FA in medical curricula.

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During the COVID-19 pandemic, teaching models, assessments and feedback mechanisms in medical curricula were forced to adapt and make changes to minimize the negative impact of the epidemic on medical education [ 1 , 2 ]. Although online curricula during the epidemic led to a greater diversity of content [ 3 , 4 , 5 ], medical curricula have strong professional characteristics. They not only spread medical knowledge, but also cultivate the logical thinking ability of medical students to find, analyse and solve problems. This makes the teaching assessment face many challenges [ 6 , 7 ], a reduction in effective communication between students and faculty [ 8 ], a lack of depth and breadth in teaching models [ 9 , 10 ], and a repetition of assessment components such as attendance, group reporting, and answering questions during face-to-face instruction [ 11 ]. Therefore, a new issue in the development of modern medical education is that medical educators focus on students, pay attention to their real feelings and feedback, encourage their participation in teaching assessment, and continuously improve teaching models and assessment methods [ 12 , 13 ].

Student-centred includes a conceptual framework of three dimensions, namely cognitive (focus on student learning progress), agency (focus on student empowerment), and humanist (knowing students as individuals) [ 14 , 15 ], which guided the design of this study. In student-centred teaching assessment design, cognition was reflected in the educator’s focus on student learning performance [ 16 ]; agency required the educator to consider how to enhance student engagement through power sharing [ 17 ]; and humanism is integrated throughout the teaching and learning process [ 17 , 18 ], with the educator taking the initiative to understand students’ interests, desires, and needs. In other words, student-centred “power sharing” and “responsiveness to needs” are not separate, and teachers do not change their dominant position, but rather emphasize student agency, focusing on students’ learning experiences and meeting needs [ 14 ]. A recent student-centred study shows less attention to power sharing in East Asia than in other parts of the world [ 19 ], reminding us that student-centred teaching assessment needs to be validated in practice in a broader cultural educational context.

Formative assessment (FA) refers to the assessment in teachers and students systematically obtain evidence of students’ learning in the teaching process, promote students’ understanding of learning objectives, and support students to become learners and achieve learning objectives [ 20 , 21 , 22 , 23 ]. Teachers help students to establish a sense of ownership, continuously improve their own learning through teaching assessment, realize the value [ 24 ], and achieve assessment for learning. Modern medical education reform advocates for educators and researchers to support the realization of medical education goals, understanding and improving teaching assessment design [ 25 , 26 ]. Although the assessment of medical curricula is mainly summative [ 27 ], focusing on students’ memory of knowledge, the purpose of FA is to focus on students, not only focusing on students’ scores, but also personal feedback and skills [ 28 ], especially the mastery of knowledge and skills. The assessment itself is used for learning and application to learning. FA is widely used in medical teaching practice and research, but not all assessments are effective. Effective FA feedback needs to consider how students participate and how teachers help students make effective feedback [ 29 , 30 ].

Student satisfaction refers to the “subjective experience” of students in education and the perceived value of the learning experience [ 31 , 32 ]. Guided by the concept of student-centred humanism, educators are particularly concerned about student satisfaction, and student satisfaction has been recognized as a valid indicator of instructional assessment in both theoretical and practical studies of teaching and learning [ 32 ]. Some studies have shown that improvement of teaching activities by teachers directly affects on student satisfaction [ 33 ]. However, well-designed teaching assessments may not obtain higher student satisfaction [ 34 , 35 ]. This suggests a need for student-centred formative assessment and a deeper understanding of the value and role of student satisfaction, which has become a concern in medical education reform. We expect to understand medical students’ satisfaction after receiving student-centred FA and target the areas where FA needs to be changed. The quality of FA can be improved through scientific, appropriate, valid, and reliable methods [ 35 ]. At the same time, medical educators can benefit from feedback on students’ satisfaction and provide more appropriate teaching programs for independent learning [ 36 ].

Hence, this study selects medical students from a comprehensive university in China that has carried out medical curricula reform to observe and reflect on the content, methods, and feedback of teaching and learning assessments in medical curriculum through student-centred FA teaching practices. Based on the feedback regarding student satisfaction, we will also explore the shortcomings of FA as an indicator of student satisfaction and provide the best theoretical and practical framework for the design and implementation of FA in medicine or other disciplines.

Formative assessment design of medical curricula

The FA of medical curricula in a comprehensive university in China follows the principle of “teaching-assessment-feedback”. Starting from the feedback on teaching objectives, it investigates students’ views on the implementation of FA, matches with knowledge objectives, ability objectives and emotional value objectives, analyses whether the teaching objectives have been achieved, and teachers immediately give feedback their opinions to students. FA methods include topic discussion, classroom questions, and answers, classroom tests, reflection logs, mind maps, etc., focusing on quantification. Each assessment module has a different emphasis on the training of medical students’ knowledge and ability. Evaluators’ assessment methods include: mutual assessment between teachers and students, mutual assessment between students and students, and self-assessment by students and teacher assessment. The total score of each medical course is generally composed of the weighted and cumulative scores of each module of formative assessment, plus the final exam scores. Based on clinical medicine, FA has been extended horizontally to nursing, public health and preventive medicine and other specialties. It extends vertically from undergraduate education to postgraduate education.

In addition, the medical curriculum reform of this comprehensive university is student-centered, exploring the construction of a scientific and feasible FA index system, effectively evaluating teaching evaluation practices, and guiding teachers to cultivate students’ ability to reflect and learn independently. Therefore, from the perspective of students’ understanding, attitude and satisfaction to FA, enriching FA index system is worth discussing extensively.

Participants

The study was designed as an investigative study. This comprehensive university in China have School of Clinical Medicine, School of Public Health, and School of Nursing. The undergraduate majors include clinical medicine, preventive medicine, radiology, and nursing. According to the research purpose, the research team has set the inclusion criteria for research objects, as follows: (1) undergraduate students receiving medical education, (2) undergraduate students who understand the research purpose; (3) undergraduate students who were voluntary to participate. Undergraduate students who did not receive medical course education, as well as undergraduate students who are conducting clinical practice, are excluded. The research team learned about the curriculum plan for the autumn semester of the academic year 2021–2022 in advance, and selected undergraduates majoring in clinical medicine, preventive medicine, radiology, and nursing from October 2021 to December 2021 in a comprehensive university in China for investigation.

The research team contacted instructors of medical curricula who distributed questionnaires in class through an online questionnaire platform (Questionnaire Star), and members of the research team answered the questions raised by the students when filling in the questionnaire. The completion of the questionnaire was voluntary for the students and informed consent was obtained from all participants. The study was approved by the ethics committee of the college where the research team leading member was based (Ethics Committee Approval Number: 2020092104).

Questionnaire

The compilation of the questionnaire takes the student-centred conceptual framework of three dimensions as the theoretical basis of the research. In combination with the implementation background of FA in China’s medical education [ 15 , 37 ], the questions designed are mainly divided into four parts: the basic demographic information of the respondents (gender, grade and major), medical students’ cognition of FA (degree of understanding, assessment scoring rules, main persons who completed the assessment, etc.), feedback (the effectiveness and timeliness of teachers’ feedback), satisfaction (FA method, content, tools informationization, scoring criteria, teacher feedback, and learning tasks). Among them, the satisfaction survey was scored with Likert’s five point scale, 1 to 5 was: very satisfied, satisfied, fair, dissatisfied or very dissatisfied. For the questionnaire in this study, Cronbach’s α = 0.976, KMO = 0.982, significance level P  < 0.001, indicating the reliability and validity of the questionnaire are good. The questionnaire is listed in the Supporting materials 1.

Statistical analysis

Statistical analysis was performed using SPSS 26.0, and all statistical tests were two-sided, with P < 0.05 considered statistically significant. Data descriptions of medical students’ demographic information, medical students’ cognition of FA, feedback were expressed as frequencies and percentages. The results of student satisfaction were analysed and expressed as Mean ± Standard Deviation. For the word frequency in the answer text of the open question, Excel was used to make a word cloud to analysis.

Participant characteristics

In our study, there were 984 questionnaires distributed, 924 valid questionnaires were collected, and the efficiency was 93.9%. Of the 924 participants, 290 were male (31.4%), 634 were female (68.6%), fresh man was 302 (32.7%), sophomore was 295 (31.9%), junior was 210 (22.7%) and senior was 117 (12.7%). Clinical medicine 238 (25.8%), preventive medicine 240 (26.0%), radiation medicine 200 (21.6%) and nursing 246 (26.6%).

Medical students’ cognition of formative assessment

Students’ understanding of FA may help them participate in FA design, implementation and feedback. Before in-depth investigation, it is necessary to know the medical students’ understanding of FA. We through the question “How much do you know about formative assessment?”, preliminary understanding of medical students’ understanding of FA. Among the surveyed students, there were 143 (15.5%) very familiar, 205 (22.2%) understood, 343 (37.1%) general understood, 189 (20.5%) not very familiar, and 44 (4.8%) no familiar. (Fig.  1 and Supplemental Table  1 ).

The degree of understanding of formative assessment by students

Students’ understanding of the scoring method of formative assessment

The content of FA is diverse, and the scoring method and weight of each method are different. In the survey of students, the question was “Do you know how to calculate the scores of each module of formative assessment?” They said they knew the calculation method of scores and the scores of each part, accounting for only 45.2% (Fig.  2 and Supplemental Table  2 ).

Medical students’ assessment of formative assessment teachers’ feedback

The effective feedback of FA considers the participation of students and how teachers can help students provide effective feedback. When students receive teacher assessment tasks, they undertake these tasks to achieve learning. The timing of teacher feedback is essential for students to acquire knowledge, which is helpful in improving the efficiency of FA. In our research, the feedback survey of medical students on FA of teachers shows that 59.0% think “I get effective feedback”. From the timeliness of feedback, the number of medical students who received feedback from teachers was 335 (36.3%) within one week, 275 (29.8%) immediately, 112 (12.1%) at the end of the course, 98 (10.6%) the second day, 52 (5.6%) within one month and 52 (5.6%) no feedback (Table  1 ).

The subjects of FA are usually teachers and students, the objects of assessment may be teachers, students’ learning process, teachers’ teaching quality and students’ learning quality. In the multiple choice question “Who do you think is the subject of FA?“, the options we set include teacher, student, peer and group. According to the survey results, 94.2% (870/924) thought it was the teacher, 45.1% (417/924) thought it was the student, 34.4% (318/924) thought it was peer, and 30.0% (277/924) thought it was a group (Fig.  3 and Supplemental Table  3 ).

Students’ views on the main implementers of formative assessment

Modules that medical students hope to add to the formative assessment of medical curricula

Open question “What formative assessment modules do you want to add in the future courses?“, The answer text is made into a word cloud, showing that the FA modules added by medical students in the future mainly include: peer assessment, presentation, questioning, take attendance, MOOC, etc. (Fig.  4 and Supplemental Table  4 ).

Formative assessment method preferred by medical students

Note: The font size indicates the module frequency that medical students want to increase in formative assessment, the higher the frequency, the larger the font.

Satisfaction of medical students with the formative assessment of medical curricula

The results of medical students’ satisfaction with various items of FA can reflect students’ acceptance of FA. The higher the satisfaction of medical students, they may have better learning effect. When they have better learning effect, they will also have higher degree of satisfaction, so as to achieve the purpose of FA implementation. The satisfaction of medical students reflects the implementation effect of FA in terms of FA method, content, tools informationization, scoring criteria, teacher feedback, and learning tasks. In the investigation, we found that more than 40% of the students think they are very satisfied with the method, content, tools informationization, scoring criteria, teacher feedback, and learning tasks in medical curricula FA, the results of student satisfaction show that students’ satisfaction with teacher feedback was 1.71 ± 0.747 points. Their satisfaction with learning tasks was 1.83 ± 0.826 points (Table  2 ; Fig.  5 ).

Satisfaction of medical students with formative assessment of medical courses

To the best of our knowledge, this study was the first to survey undergraduate students covering clinical medicine, preventive medicine, public health, and nursing at a comprehensive Chinese university to analyse their perceptions, feedback, and satisfaction with implementation of student-centred FA in the medical curriculum. The results of this study indicate the necessity of medical students as subjects of FA, highlighting the concept of student-centred in three aspects: student cognition, empowered participation, and humanism. Of note is the value of student satisfaction as a measure of FA indicators.

Medical students have lower degree of understanding of FA, which hinders the efficiency and effectiveness of FA feedback. The survey results showed that 37.1% had a general understanding of FA, even though the instructor introduced students to the scoring of each task in the FA design during the first session of each course. In addition, only 45.2% of medical students clearly understood how each section of the FA was scored. This differs from the results of the FA methodology survey conducted with teachers, who were very clear about the methodology and purpose of FA [ 21 , 23 ], while students were not. Possible reasons for this are that medical students are vague about the pedagogical goals of each FA task, are not yet clear about the attitudes, emotions, and values of FA, and are only passively working with teachers and completing assigned tasks. Future medical educators can pay attention to medical students’ cognitive development of teaching assessment and guide them to self-reflect and adjust their learning activities independently [ 38 , 39 , 40 , 41 ]. Suppose students lack the motivation to learn independently. In that case, the advantages of student-centred FA may be reduced, and teachers ask students ground to complete large, simple, and more repetitive tasks without thinking about what they are doing or learning, and without enjoying the authentic sense of accomplishment and satisfaction that comes from learning or completing tasks.

The power-sharing of student-centred FA, with teachers playing the roles of organizers, managers, and collaborators, attempts to encourage students to shift from passive acceptance of assessment to active participation in assessment and to guide students to become the subjects of FA [ 38 , 42 ]. In our study, the scoring of FA, consisting of three components: student self-assessment, student mutual assessment, and teacher-student mutual assessment, consciously fostered the role of medical students as subjects in FA [ 43 ]. However, 94.2% of the medical students who participated in the survey perceived teaching and learning assessment as teacher-led, while 30% chose student-led. In contrast to the results of previous studies, traditional instructional assessment in medical curricula, which is dominated by instructor-led summative assessment, means that there is relatively little flexibility or opportunity to allow students to make decisions about their learning, thereby affecting their opportunities and motivation to participate in the assessment [ 24 , 44 ]. Although medical student-centred FA received high levels of student satisfaction, medical students have a more ambiguous sense of themselves as assessment subjects. They remain stuck in an outdated notion that the teacher is the assessment in traditional teaching assessments [ 27 , 41 ]. In addition, medical students reported in the open topic, their preference for using FA methods in the medical curriculum, and their preference for FA methods with an element of teacher-student interaction, reflecting their preference for classroom activities with immediate feedback. This differs from previous research findings in that traditional educational practices focus on teacher-led strategy implementation. In contrast, student-centred FA leaves decision-making about course activities to students, who are actively engaged by having a good experience in the interaction. Perhaps instructional assessment power-sharing with students is not the right way to assess student-centred instruction, but it represents a potentially effective way to do so.

Within the framework of student-centred theory, humanism focuses on understanding students’ aspirations, interests, and personalities and responding to them. The results of medical students’ satisfaction with each entry of FA in the survey showed that the mean score of the number of learning tasks reflected a low level of satisfaction, which is consistent with the results of previous FA satisfaction surveys [ 40 , 45 ]. It is possible that students perceive that participating and completing the learning tasks of FA, with more time and effort, is still in a sense the same as traditional teaching assessment, passively completing the learning tasks assigned by teachers. Although student satisfaction is regarded as an important indicator to test teaching assessment, it does not mean that educators should cater to student satisfaction and reduce the amount and number of learning tasks [ 46 ]. At the same time, humanism advocates that the advantage of student satisfaction is to improve formative assessment by including students’ learning efficiency or teaching behavior, to promote students’ in-depth learning in FA. It is worth noting that some teachers may damage or reduce the FA standard to meet the students’ satisfaction, which affects the effectiveness of teaching evaluation. Avoid biased teaching evaluation results due to the limitations of student satisfaction [ 47 ], which may require the FA evaluation index system indicators to be diversified and complete, consider the dimensions of educators’ teaching behavior [ 48 ], students’ feedback and satisfaction with teaching evaluation [ 49 ], improve the single and one-sided defect of FA evaluation index system, and expand the positive impact of student satisfaction on student centered FA, promote teachers’ teaching and students’ learning.

Our study has several limitations that we recommend that future studies consider and address. First, we analyse medical students’ perspectives on the implementing of FA in the medical course, but this does not represent the perspectives of students in other disciplines. The medical course has the educational goal of developing medical personnel with professional, clinical competence and a strong sense of empathy, which is somewhat different from the educational goals of other disciplines, and future replication in other fields is needed to be able to generalize these findings. Second, the survey was completed voluntarily by students. Although the 93.9% response rate was reasonable, the lack of effective participation by some medical students did introduce a selection bias that should be considered a potential limitation. Finally, this study was cross-sectional, conducted during an epidemic, lacking in-depth follow-up, and lacking consideration of whether students’ perspectives have changed as the FA progressed, focusing on medical students’ overall competency over a more extended time and their updated recommendations for the FA.

With the wide application of FA, students’ views and attitudes towards this kind of teaching assessment are becoming increasingly important. We identified the important value of students as participants and collaborators in FA. In addition, combined with student satisfaction, we suggest that medical educators avoid using student satisfaction as a single indicator to measure the teaching effectiveness of student-centred FA. In the future, they might also incorporate diverse assessment indicators to construct an assessment index system for FA to highlight the advantages of FA in medical curricula.

Data Availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Acknowledgements

The author thanks the participating students for their help and kindness in sharing their experiences and opinions. Special thanks to Professor Yang Ning for her suggestions and support for the research.

This work was supported by the funds of Teacher teaching development research project of Jilin University[The construction of formative evaluation system based on the whole process of medical curriculum]; Higher Education Scientific Research Project of Jilin Association for Higher Education [JGJX2021C3, JGJX2022B7]; Fundamental Research Funds for the Central Universities[415010300093]; Jilin Province Health Science and Technology Capacity Improvement Project[2021GL005]; Jilin Provincial Science and Technology Development Plan Project[20220508065RC];Jilin University Education Reform and Research Support Project[2022JGY027]; Jilin University Graduate Ideological and Political Education Research Project[ysz202230]; Jilin Province Higher Education Teaching Reform Research Project[2021XZD054].

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Contributions

Tianjiao Ma and Yin Li made contributions to the study conception and design. Hua Yuan, Feng Li, Shujuan Yang, Jiannan Yao and Yongzhi Zhan made contributions to data collection. Tianjiao Ma and Yin Li contributed to data analysis and interpretation. Dongmei Mu contributed to the draft and critical revision of the manuscript. All authors approved the final manuscript for publication.

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The study was carried out in accordance with the Declaration of Helsinki. The ethical approval of this study was approved by the human research and ethics committee of the School of Nursing, Jilin University (2020092104) before starting this study. The study strictly followed the procedures of informed consent, non-harm, and confidentiality of participants.

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Ma, T., Li, Y., Yuan, H. et al. Reflection on the teaching of student-centred formative assessment in medical curricula: an investigation from the perspective of medical students. BMC Med Educ 23 , 141 (2023). https://doi.org/10.1186/s12909-023-04110-w

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DOI : https://doi.org/10.1186/s12909-023-04110-w

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41 Formative assessment

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Assessment is a complex process, serving a wide range of differing functions. Formative assessment is a powerful driver for learning, involving a dynamic interaction between students and their teachers to drive up the quality of the educational process. Grounded in social constructivist theories of education, effective formative assessment, or assessment for learning, utilizes constructive feedback as the tool by which students gain confidence and skills in self-regulation and reflection as well as the autonomy required for lifelong learning. In a programme of formative assessment, students are aware of the learning outcomes of the curriculum and the requirements for success. They are encouraged to examine their learning needs in order achieve their goals and also to engage in assessment of their own work and that of their peers, thereby developing a deeper understanding of their subject. Within an educational institution, assessment procedures should be explicitly aligned with the intended learning outcomes so that both formative and summative assessments directly facilitate learning and are embedded in curriculum design and review. By placing assessment at the heart of learning, a well developed programme of formative assessment can be an effective way of influencing institutional culture, ensuring that data gathered from all forms of assessment are analysed and used in a programme of continuous educational improvement. Formative assessment is employed in all educational sectors and has particular relevance to medical education in which observed practice and experiential learning are central to the educational process. The valuable skills for lifelong learning which are fostered by effective formative assessment are a feature of medical education and a key requirement for good medical practice.

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Assessment Methods in Undergraduate Medical Education

Nadia m al-wardy.

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Received 2010 Jan 19; Revision requested 2010 Mar 30; Revised 2010 Apr 18; Accepted 2010 Apr 21; Issue date 2010 Aug; Collection date 2010.

Various assessment methods are available to assess clinical competence according to the model proposed by Miller. The choice of assessment method will depend on the purpose of its use: whether it is for summative purposes (promotion and certification), formative purposes (diagnosis, feedback and improvement) or both. Different characteristics of assessment tools are identified: validity, reliability, educational impact, feasibility and cost. Whatever the purpose, one assessment method will not assess all domains of competency, as each has its advantages and disadvantages; therefore a variety of assessment methods is required so that the shortcomings of one can be overcome by the advantages of another.

Keywords: Medical Education, Undergraduate, Assessment, Educational

In 1990, Miller proposed a hierarchical model for the assessment of clinical competence. 1 This model starts with the assessment of cognition and ends with the assessment of behaviour in practice [ Figure 1 ]. Professional authenticity increases as we move up the hierarchy and as assessment tasks resemble real practice. The assessment of cognition deals with knowledge and its application (knows, knows how) and this could span the levels of Bloom’s taxonomy of educational objectives from the level of comprehension to the level of evaluation. 2 The assessment of behaviour deals with assessment of competence under controlled conditions (shows how) and the assessment of competence in practice or the assessment of performance (does). Different assessment tools are available which are appropriate for the different levels of the hierarchy. Van der Vleuten proposed a conceptual model for defining the utility of an assessment tool. 3 This is derived by conceptually multiplying several weighted criteria on which assessment tools can be judged. These criteria were validity (does it measure what it is supposed to be measuring?); reliability (does it consistently measure what it is supposed to be measuring?); educational impact (what are the effects on teaching and learning?); acceptability (is it acceptable to staff, students and other stakeholders?), and cost. The weighting of the criteria depended on the purpose for which the tool was used. For summative purposes, such as selection, promotion or certification, more weight was given to reliability while for formative purposes, such as diagnosis, feedback and improvement, more weight was given to educational impact. 4 Whatever the purpose of the assessment it is unlikely that one method will assess all domains of competency. A variety of assessment methods are, therefore, required. Since each assessment method has its own advantages and disadvantages, by employing a variety of assessment methods the shortcomings of one can be overcome by the advantages of another.

Miller’s hierarchical model for the assessment of clinical competence 1

This paper will not be an exhaustive review of all assessment methods reported in the literature, but only those with clear conclusions about their validity and reliability in the context of undergraduate medical education although many of them are also used in postgraduate medical education also. Some new trends, although still requiring further validation, will also be considered.

Assessment of Knowledge and its Application

The most common method for the assessment of knowledge is the written method (which can also be delivered online). Several written assessment formats are available to choose from. It should be noted, however, that in choosing any format, the question that is asked is more important than the format in which it is to be answered. In other words, it is the content of the question that determines what the question tests. 5 For example, sometimes, it is incorrectly assumed that multiple choice questions (MCQ) are unsuitable for testing problem solving ability because they require students to merely recognise the correct answer, while in open ended questions they have to generate the answer spontaneously. Multiple choice questions can test problem solving ability if constructed properly. 5 , 6 , 7 This does not exclude the fact that certain question formats are more suitable than others for asking certain types questions. For example, when an explanation is required, an essay question will, obviously, be more suitable than an MCQ.

Every question format has its own advantages and disadvantages which must be carefully weighed when a particular question type is chosen. It is not possible that one type of question will serve the purpose of testing all the aspects of a topic. Therefore, a variety of formats are needed to counter the possible bias associated with individual formats and they should be consistent with the stated objectives of the course or programme.

MULTIPLE CHOICE QUESTIONS (A-TYPE: ONE BEST ANSWER)

These are the most commonly used question type. They require examinees to select the single best response from 3 or more options. They are relatively easy to construct and enjoy high reliability per hour of testing since they can be used to sample a broad content domain. MCQs are often misconstrued as tests of simple facts, but, if constructed well, they can test the application of knowledge and problem solving skills. If questions are context-free, they almost exclusively test factual knowledge and the thought process involved is simple. 6 Contextualising the questions by including clinical or laboratory scenarios not only conveys authenticity and validity, but, also, is more likely to focus on important information rather than trivia. The thought process involved is also more complex with candidates weighing different units of information against each other when making a decision. 6 Examples of well constructed one best answer questions and guidelines about writing such questions can be found in Case and Swanson. 7

MULTIPLE CHOICE QUESTIONS (R-TYPE: EXTENDED MATCHING ITEMS)

One approach to context-rich questions is extended matching questions or extended matching items (EMQs or EMIs). 8 EMIs are organised into sets of short clinical vignettes or scenarios that use one list of options that are aimed at one aspect (e.g. all diagnoses, all laboratory investigations, etc). These options can range from 5 to 26 (although 8 options have been advocated to make more efficient use of testing time). 9 Some options may apply to more than one vignette while others may not apply at all. A well-constructed extended matching set includes four components: theme, options list, lead-in statement, and at least two item stems. An example and guidelines for writing such questions are shown in Case and Swanson. 7

KEY FEATURES QUESTIONS

Key features questions are short clinical cases or scenarios which are followed by questions aimed at key features or essential decisions of the case. 10 These questions can either be multiple choice or open ended questions. More than one correct answer can be provided. Key feature questions have been advocated to test clinical decision-making skills with demonstrated validity and reliability when constructed according to certain guidelines. 11 Although these questions are used in some “high-stakes” examinations in places such as Canada and Australia, 11 they are less well known than the other types and their construction is time consuming, especially if teachers are inexperienced question writers. 12

SHORT ANSWER QUESTIONS (SAQS)

These are open-ended questions that require students to generate an answer of no more than one or two words, rather than to select from a fixed number of options. Since they require some time to answer, not many SAQs can be asked in an hour of testing time. This leads to less reliable tests because of limited sampling. Also, their requirement to be marked by a content expert makes them more costly and time consuming; therefore, they should only be used when closed formats are excluded. It is important that the questions are phrased unambiguously and a well defined answer key is written before marking the question. 13 If multiple examiners are available, double marking is preferred. For efficiency, however, each marker should correct the same question for all candidates. This leads to more reliable scores than if each marker corrects all the questions of one group of candidates while another marker corrects all questions for another group. 5

ESSAY QUESTIONS

Essay questions are used when candidates are required to process, summarise, evaluate, supply or apply information to new situations. They require much more time to answer than short answer or multiple choice questions and, therefore, not quite as many questions can be used per hour of testing; hence, their lower reliability. Structuring (but not overstructuring) the marking process and using a correction scheme similar to the one used for short answer questions can improve reliability. The guidelines for writing short answer questions apply also to essay questions. 13

MODIFIED ESSAY QUESTIONS (MEQS)

This is a special type of essay question that consists of a case followed by a series of questions that relate to the case and that must be answered in the sequence asked. This leads to question interdependency and a student answering the first question incorrectly is likely to answer the subsequent questions incorrectly too. Therefore, no review or possibility of correcting previous answers is allowed and the case is reformulated as the reporting process progresses. A well-written MEQ assesses the approach of students to solving a problem, their reasoning skills, and their understanding of concepts, rather than recall of factual knowledge. 14 Due to psychometric problems associated with question interdependency, MEQs are being replaced by the key feature questions. 13 An example of an MEQ can be found in Knox. 14

SCRIPT CONCORDANCE TEST (SCT)

A new format that is slowly gaining acceptance in health professions education is the script concordance test (SCT). This format is designed to test clinical reasoning in uncertain situations 15 and is, as the author puts it, based on “the principle that the multiple judgments made in these clinical reasoning processes can be probed and their concordance with those of a panel of reference experts can be measured.” 16 The test has gained face validity since its content resembles the tasks that clinicians do every day. SCTs are based on short case scenarios followed by related questions that are presented in three parts: the first part (“if you were thinking of”) contains a relevant diagnostic or management option; the second part (“and then you were to find”) presents a new clinical finding, and the third part (“this option would become”) is a fivepoint Likert scale that captures examinees’ decisions as to what effect the new finding has on the status of the option. An example of an SCT question and guidelines for their construction can be found in Demeester and Charlin. 17

Assessment of Performance

Assessment of performance can be divided into two categories; assessment of performance in vitro, i.e. in simulated or standardised conditions, and assessment of performance in vivo , i.e. in real conditions. Both categories involve demonstration of a skill or behaviour continuously or at a fixed point in time by a student and observation and marking of that demonstration by the examiner. Several tools such as checklists, rating scales, structured and unstructured reports can be used to record observations and to assist in the marking or assessment of such demonstrations. Checklists and rating scales are used as scoring methods in various forms of assessments, including Objective Structured Clinical or Practical Examinations (OSCE, OSPE), Direct Observation of Procedural Skills (DOPS), peer assessment, self assessment, and patient surveys. 18

The assessment of actual performance, i.e. what the doctor does in practice, is the ultimate goal for a valid assessment of clinical competence. However, despite the face validity of this “in-training” assessment, problems of inadequate reliability due to lack of standardisation, limited observations and limited sampling of skills are cause of concern and limits their use as summative “high-stakes” or qualifying examinations. To mimic real conditions, assessments in simulated settings have been designed to assess performance such as OSCE/ OSPE.

Checklists are useful for assessing any competence or competency component that can be broken down into specific behaviours or actions that can be either done or not done. It is recommended that over-detailed checklists should be avoided as they trivialise the task and threaten validity. 4 Global ratings (a rating scale which is used in a single encounter, for example in an OSCE, in addition to or instead of a checklist, to provide an overall or “global” rating of performance across a number of tasks) provide a better reflection of expertise than detailed checklists. 19

Checklist development requires consensus by several experts on the essential behaviours, actions, and criteria for evaluating performance. This is important to ensure validity of content and scoring rules. Also, in order to obtain consistent scores and satisfactory reliability, evaluators who are trained in the use of checklists should be used. An example of a checklist can be found in Marks and Humphrey-Murto. 20

RATING SCALES

Rating scales are widely used to assess behaviour or performance. They are particularly useful for assessing personal and professional attributes, generic competencies and attitudes. The essential feature of a rating scale is that the observer is required to make a judgement along a scale that may be continuous or intermittent. An unavoidable problem of rating scales is the subjectivity and low reliability of the judgements. To be fair to the student, however, multiple independent ratings of the same student undertaking the same activity are necessary. It is also important to train the observers to use the rating forms. Guidelines on improving the quality of rating scales can be found in Davis and Ponnamperuma. 21

OBJECTIVE STRUCTURED CLINICAL EXAMINATION (OSCE)

The OSCE is primarily used to assess basic clinical skills. 22 Students are assessed at a number of “stations” on discrete focused activities that simulate different aspects of clinical competence. At each station standardised patients (SPs), real patients or simulators may be used, 23 and demonstration of specific skills can be observed and measured. OSCE stations may also incorporate the assessment of interpretation, non-patient skills and technical skills. Each student is exposed to the same stations and assessment. OSCE stations may be short or long (5–30 minutes) depending on the complexity of the task. The number of stations may vary from as few as eight to more than 20 although an OSCE with 14–18 stations is recommended to obtain a reliable measure of performance. 18 Reliability is a function of sampling and, therefore, of the number of stations and competences tested. 24 Scoring is done with a task specific checklist or a combination of a checklist and a rating scale. Global ratings produce equivalent results as compared to checklists. 19 , 25 , 26 The scoring of the students or trainees may be done by observers (faculty members, patients, or standardised patients).

Tips on organising OSCE examinations can be found in Marks and Humphrey-Murto. 20

SHORT CASES

Short cases assessment is commonly used in several places 27 , 28 to assess clinical competence. 29 In this type of assessment, students are asked to perform a supervised focused physical examination of a real patient, and are then assessed on the examination technique, the ability to elicit physical signs and interpret these findings correctly. Several cases are used in any one assessment to increase the sample size. Studies on the validity and reliability of short case assessment, however, are scarce and, as Epstein 30 advocates, their empirical validation must be done before promoting their use.

The long case has traditionally been used to assess clinical competence. In the long case, students interview and examine a real patient and then summarise their findings to one or two examiners who question the students by an unstructured oral examination on the patient problem and other relevant topics. The student’s interaction with the patient is usually unobserved. The long case has face validity and authenticity since the task undertaken resembles what the doctor does in real practice; however, the use of long case assessment in “high-stakes” summative examinations is not recommended, 31 and, in fact, it has been discontinued in North America, due to its low reliability. 32 On the other hand, its use in formative examinations is encouraged because of its perceived educational impact. 33 To increase the validity and reliability of long cases, several modifications have been introduced, for example: observing the candidates while they interact with the patient 34 , 35 (although observing the candidate is not a major contributor to reliability); 36 training the examiners to a structured examination process, 37 and increasing the number of cases. 36 , 38

360° evaluation

360° evaluation is a multi-source feedback assessment system that evaluates an individual’s competence from multiple perspectives within their sphere of influence. Feedback is objectively and systematically collected via a survey or rating scale that assesses how frequently a behaviour is performed. Multiple evaluators, who may include superiors, peers, students, administrative staff, patients and families, rate trainee performance in addition to the trainee doing a self-assessment. The rating scales vary with the assessment context.

360° evaluations have been used to assess a range of competencies, including professional behaviours, at undergraduate 39 and postgraduate levels. 40 However, the use of 360° evaluations in summative assessment is not advocated until further studies are conducted to establish their reliability and validity. 40 Their use in formative evaluations might be more appropriate since evaluators provide more balanced and honest feedback when the evaluation is formative and used for developmental purposes rather than for pass/fail decisions. 41 Nonetheless, it should be borne in mind that this type of evaluation can be time consuming and administratively demanding. 42 An example of a 360° evaluation form used in a study can be found in Wood et al . 43

MINI CLINICAL EVALUATION EXERCISES (MINI-CEX)

Mini-CEX 44 are based on tutor observations of routine interactions that supervising clinicians and trainees have on a daily basis. These trainee-patient encounters occur on multiple occasions with different evaluators and in different settings. They are relatively short observations (15–20 minutes) in which performance is recorded on a 4 point scale where 1 is unacceptable, 2 is below expectation, 3 is met expectations, and 4 is exceeded expectations. There is an opportunity for noting that a particular behaviour was unobserved and additional space to record details about the context of the encounter. The mini-CEX incorporates an opportunity for feedback from the evaluator and is mostly used for formative assessment. 39 Evaluators consist mostly of tutors whose primary role is to teach clerkship students. 39

Several competencies are evaluated by the mini-CEX: history taking, physical examination, clinical judgement, counselling, professionalism and other generic qualities. An example of a mini-CEX tool can be found in Norcini. 44

A portfolio is a collection of student work which provides evidence that learning has taken place. It includes documentation of learning and progression, but most importantly a reflection on these learning experiences. 45

Portfolios documentation may include case reports; record of practical procedures undertaken; videotapes of consultations; project reports; samples of performance evaluations; learning plans, and written reflection about the evidence provided. Scoring methods include checklists and rating scales developed for a specific learning and assessment context and are usually carried out by several examiners who probe students regarding portfolio contents and decide whether the student has reached the required standard. 45

Portfolio assessment is considered a valid way of assessing outcomes; however, it has low to moderate reliability due to the wide variability in the way portfolios are structured and assessed. Also, this form of assessment is not considered very practical due to the time and effort involved in its compilation and evaluation 46 and, perhaps for these reasons, portfolios are commonly used for formative assessment and less commonly for summative purposes. 47 , 48 However, at present, the strength and extent of the evidence base for the educational effects of portfolios in the undergraduate setting is limited. 49 Guidelines for portfolio compilation can be found in Friedman et al., 46 Snadden and Thomas, 50 and Thistlethwaite. 51

Various assessment methods that test a range of competencies are available for examiners. The choice should be dictated by fitness for purpose and a number of utility criteria. The importance and weighting of these criteria depends on the purpose of the assessment method, i.e. either summative, formative or both.

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