Collaborative Assessment in the Gross Anatomy Lab

Abstract

Purpose

In 2018, the Michigan State University College of Human Medicine incorporated two-stage examinations into the gross anatomy curriculum. Multiple studies have investigated two-stage examinations and have largely reported positive findings. Here, we used a mixed-methods approach to further investigate the feasibility and student perceptions of the two-stage examination in the context of a medical school curriculum that emphasizes longitudinal group-based learning and formative assessments.

Methods

Three student cohorts were assessed with a formative two-stage examination at the end of their first-year anatomy experience. Data for the quantitative analysis included examination scores from the individual and group portions of the two-stage examination. For the qualitative stage of this project, we utilized a constructivist grounded theory methodology in which data, including both post-examination survey results and one-on-one semi-structured student interviews, were transcribed (interviews), coded, inductively and iteratively reviewed, and thematically interpreted.

Results

Survey and interview results revealed an overwhelmingly positive perception of the collaborative assessment experience. Student comments demonstrated educational value in the immediate feedback provided by this examination format and suggested that collaboration during the examination transformed the assessment into a learning experience.

Conclusions

While two-stage examinations have the potential to positively transform an assessment into a learning experience, we also identified complex relationships between content knowledge and anxiety that may affect student perceptions. In addition, examination logistics (e.g., curricular timing) have the potential to negatively affect student perceptions, indicating that faculty should consider these factors when implementing collaborative assessments into their curriculum.

Introduction

The principles of teamwork, collaboration, and cooperation are essential to the development of the future physician. However, medical education has historically been an individual and competitive endeavor. Rotellar and Cain [1] state, “the ever-evolving landscape of healthcare requires a curriculum that enables students to think through problem situations and enter the workforce confident in their ability to provide high-quality patient-centered care.” In 2016, the Michigan State University College of Human Medicine (MSU CHM) underwent a complete curriculum redesign and now trains students using the “Shared Discovery Curriculum” (SDC). The core principles of the SDC include longitudinal learning groups, flipped classrooms, and formative assessments.

The 190 students at MSU CHM who matriculate each year are divided evenly among two campuses: East Lansing (EL) and Grand Rapids (GR). Within each campus, students are divided into 4 learning societies. The students are then organized into scholar groups of seven to eight students, Learning Society Scholar Groups (LSSG). The LSSGs are strategically organized to include students with diverse demographics, educational backgrounds, and life experiences. Scholar groups are further divided into lab groups of three or four students; purposefully grouping students with similar prior anatomy experience (Fig. 1). Historically, gross anatomy laboratories have served as the first formal exposure to collaborative learning in undergraduate medical schools [2], as it has been a long-standing practice to assign multiple students to work on a single cadaver. Over the last 50 years, the importance of small groups in anatomy has been increasingly recognized, both from a psychosocial perspective [3] and from an educational perspective [4]. Research shows that the ideal anatomy lab group size varies with the nature of the class, with group sizes ranging from two to sixteen [5–7] but typically between three and six [8–10]. From a pedagogical point of view, small groups are likely to motivate students to prepare for the class and engage more actively in discussions [10].

Fig. 1.

Overview of organization of MSU CHM students

The gross anatomy laboratory is prosection-based at MSU CHM, with students working collaboratively within their assigned laboratory groups for the entirety of the academic year (although working in assigned laboratory groups is not enforced in any formal manner). Each laboratory session has two components for students: a flipped classroom component consisting of preparatory study material completed prior to the session and a laboratory component which utilizes a laboratory guide to direct the student small groups through a series of self-guided cadaveric exercises. The students are additionally provided lists of anatomical structures in order to prepare for the formative laboratory practical examinations.

Within the scope of this study, the understanding of formative assessments is crucial. The Liaison Committee on Medical Education defines formative testing as “information communicated to a medical student in a timely manner that is intended to modify the student’s thinking or behavior in order to improve subsequent learning and performance in the medical curriculum [11].” Formative testing models have been shown to provide separate testing benefits from the traditional summative testing models [12, 13]. While the traditional summative testing models offer more immediate short-term reward in the form of a grade, they tend to promote the “binge and forget” method of learning, in which students spend short bursts of effort to learn content but rapidly release that fund of knowledge immediately after the exam (i.e., receiving maximum benefit at minimal cost). Formative testing, especially through progress-suite exams, encourages learning by providing feedback that enables students to identify areas of content weakness and adjust their study habits. This approach, however, can be perceived as extraneous work on the side of the student as they are putting in a large amount of effort without seeing any immediate reward (i.e., grade). Therefore, formative testing has the potential to lead to a larger percentage of “non-serious” test takers. This effect can be reduced, but not eliminated, by the exclusion of competitive summative exams from the curriculum, thereby allowing students to put their time and focus towards preparing for these formative progress style exams [14]. Additional benefits of formative assessments have been found as long as the assessments are seen to have some sort of value to the student, such as shifting the emphasis from short term to continuous learning and encouraging students to view assessments as a learning experience.

The SDC is a fully-integrated, competency-based curriculum which has eliminated routine summative exams [15]. Grade recommendations are made by the Student Competence Committee based on each student’s academic portfolio. Progress-suite exams are used twice a semester to monitor student growth and include a progress clinical skills examinations (PCSE) and a comprehensive necessary science examinations (CNSE). Progress-suite exams are given slightly different weight each semester but generally account for more than 75% of the portfolio. Multisource feedback from preceptors, peers, interprofessional team members, and self-assessments also contributes to the portfolio. Assessments tied to educational activities, such as labs, have a negligible impact on semester grade. For example, a gross anatomy lab practical is typically worth less than 0.7% (0.007) of the points available in a given semester. Therefore, assessments tied to specific educational experiences are largely formative. Due to this formative nature, students who perform poorly on exams, including the anatomy practicals, are still able to progress in the curriculum without major repercussions and have the opportunity to learn from their performance.

In the SDC curriculum where subject exams are formative, many students have anecdotally reported that they spent minimal time studying prior to the anatomy assessment. In addition to opting to “go in cold,” which may be a valid self-assessment approach, some students did not feel that completion of the formative anatomy practical was beneficial to their learning. In the first 2 years of this new curriculum (2016–2018), more than 10% of students opted to not complete the week 24 anatomy capstone, forcing the anatomy faculty to evaluate the department’s assessment practices. In 2018, the gross anatomy faculty transitioned their assessment approach to include two formative two-stage laboratory exams, one held at the end of week 3 and the other at the end of week 24, with the goal of increasing the value of the formative anatomy assessment for students.

Two-stage examinations are composed of an individual assessment, immediately followed by a collaborative assessment. At MSU CHM, the gross anatomy department utilized the longitudinal small laboratory student group assignments for the collaborative portion of the assessment. Two-stage examinations create an opportunity for students to deliberate their examination answers and rationale among their small groups. Ideally, this deliberation results in peer teaching and a deeper understanding of the content. Previous studies have demonstrated related positive and negative themes across multiple educational settings including community colleges, undergraduate courses, nursing school, pharmacy school, and medical school, across the classroom and laboratory settings. Positive themes included increased discussion [16–22], immediate feedback [16–19, 23, 24], positive student experience [22, 25], and having to “think more deeply” [16–19, 21, 22, 26, 27]. Common negative themes included not all group members contributing equally (“social loafing”) [16, 21, 23, 27–29] and not enough time allowed for adequate discussion [16, 23, 27, 28]. Additional themes such as inconsistent groups [28] and undesirable physical environment for group discussion [27] also appeared as negative themes. Interestingly, current literature shows a mixed response from students regarding their anxiety during this testing process [18, 30].

Despite the contributions of the aforementioned studies, there is little literature regarding the student perception of the two-stage examination in an environment where assessments are formative and testing groups are longitudinal. Within the broader context of the MSU CHM curriculum, this study contributes to the current body of knowledge by exploring student perceptions of the two-stage examination within an academic environment where small groups of students have formed strong bonds while working closely together during all academic activities for the entirety of the academic year and are accustomed to formative, low-stake assessments. We hypothesized that this unique academic environment would have a positive effect on student perception and performance on the two-stage examination in the gross anatomy laboratory.

Materials and Methods

Participants

First-year medical students at MSU CHM from matriculation years 2018, 2019, and 2021 participated in this study. The students from matriculation year 2020 were not included in this study as the COVID-19 pandemic prevented them from participating in this in-person two-stage assessment. Students from all three cohorts participated in the two-stage examination during their spring semester and were offered the opportunity to complete an optional, online post-examination survey. A random sampling of students of the matriculation year 2021 was additionally offered the opportunity to participate in one-on-one interviews. Table 1 demonstrates student participation totals across all three cohorts.

Table 1.

Summary of student participation across cohorts

Matriculation year	Cohort sizea	Individual examb	Group examc	Post-exam surveyd	Interviewe
2018	191	160	159	63	0
2019	188	188	188	52	0
2021	190	187	179	65	16
Total	569	535	526	180	16

^aTotal number of students enrolled in cohort

^bNumber of students who completed the individual portion of the exam (first stage)

^cNumber of students who completed the group portion of the exam (second stage)

^dNumber of students who completed the post-examination survey

^eNumber of students who completed the semi-structured interviews

Methodology

This study utilized a mixed-methods approach with multiple data sources to explore student performance, perception, and experience of the two-stage examination in the gross anatomy laboratory. The study design included both quantitative and qualitative analyses. This study was deemed exempt by the institutional review board of Michigan State University. Portions of this work were previously presented as a poster at the Grand Rapids Citywide Research Day on April 13, 2022, in Grand Rapids, Michigan, and the International Association of Medical Science Educators (IAMSE) Annual Meeting on June 5, 2022, in Denver, Colorado.

Quantitative Analysis: the Two-Stage Examination

The two-stage examination began with an individual assessment, immediately followed by the identical assessment completed collaboratively by longitudinal groups. Results of the individual examination had a very minimal impact on the final grade for students—less than 3.5% of the overall grade for the semester. Results from the collaborative examination did not factor into the final grade for students; this was a formative learning experience. During the individual portion of the examination, students rotated through examination stations independently, without any collaboration or communication with peers. The assessment included a variety of question types, such as short answers for identification of structures, as well as second-order questions, tagged across cadaver, bone, organ, and radiograph-based questions. Students were allowed 60 s at each station to answer the question. Every 60 s, students advanced from station to station in a predetermined and systematic manner and were not permitted to re-visit any station. Upon completion of the individual assessment portion, students submitted their answer sheets and assembled into the pre-assigned longitudinal anatomy groups to complete the group assessment portion.

During the group portion of the examination, each group of students re-visited all stations and collaboratively answered the questions on one answer sheet. Students were permitted to communicate within their own group, but intergroup communication was prohibited. Unlike the individual portion of the assessment, groups could answer questions in any preferred order, they could re-visit examination stations, and there was no time limit per question. Groups were given 45 min to complete this portion of the assessment and submitted their group answer sheet when finished.

Quantitative analysis was conducted through collection and analysis of examination scores from both the individual and group portions of the assessment for all three cohorts. Averages and standard deviations were calculated for each cohort utilizing Microsoft Excel software. Hypothesis testing, including t-tests and ANOVA, were performed using the online statistics program DATAtab.

Qualitative Analysis: Post-examination Survey Likert Scale Analysis

An optional, anonymous survey was offered to students of the three cohorts to collect information about student perceptions and experiences during the two-stage examination. Students were invited to complete an online Qualtrics survey after they completed both the individual and group assessments. Students received this email invitation prior to receiving their scores, but the survey was open for 1 month; the majority of students responded after receiving their score. Students were asked to provide consent for their responses to be aggregated and utilized in this research project. Incentive for participation was provided only to the students of the matriculation year 2021; participants from this cohort were entered into a raffle for a single $40 gift card.

The survey consisted of twenty questions aimed at gathering information about examination preparedness and experience (Table 2). Fifteen questions contained a 7-point Likert scale utilizing strongly disagree, disagree, somewhat disagree, neither agree nor disagree, somewhat agree, agree, and strongly agree. Two questions were open-ended questions, with a fill-in-the-blank answer field. Three questions were multiple-choice questions. The survey took an average of 5 min to complete.

Table 2.

Post-examination survey questions

1. Preparation for two-stage exam: multiple-choice or fill-in-the-blank
How often did you utilize open laboratory hours to study for the laboratory exam?
Please indicate how you prepared for the laboratory exams during open laboratory time
If you used a different resource of technique to prepare for the laboratory exams, please describe
Please rate how prepared you felt for the lab exams (prior to taking the exam)

2. Two-stage examination experience: 7-point Likert scale
I felt the laboratory exams fairly represented the material I learned in ANTR 355
One minute was sufficient to answer each question on the individual lab exam
We had appropriate time to complete all questions on the group lab exam
Our group refrained from discussion with other groups during the exam
Every group member “pulled their weight” (contributed to the learning process)
The level of discussion during group testing was high
My level of involvement during the discussions was high
When I was confident in an answer, it was difficult to convince my group that it was correct
When I disagreed with group members, I was receptive to their opinions
Unanimity was reached on all questions
The group testing format created tension within the group
I appreciated the immediate feedback afforded by group testing
The group testing format transformed the capstone from an assessment to a learning experience
The group testing experience demonstrated the value of working in a team
I would recommend this process for other content areas

3. Two-stage examination experience: fill in the blank
Describe your experience with the two-stage examination

Numerical values were assigned to Likert scale responses to allow for calculation of averages with standard deviations. Thirteen of the Likert scale responses were coded as follows: strongly disagree = 1, disagree = 2, somewhat disagree = 3, neither agree nor disagree = 4, somewhat agree = 5, agree = 6, and strongly agree = 7. The two “negative” Likert scale questions (“When I was confident in an answer, it was difficult to convince my group that it was correct” and “The group testing format created tension within the group”) were coded strongly disagree = 7, disagree = 6, somewhat disagree = 5, neither agree nor disagree = 4, somewhat agree = 3, agree = 2, and strongly agree = 1. This coding allowed all responses that related to a positive experience to be scored higher than negative experiences.

Qualitative Analysis: Grounded Theory Methodology

We utilized a constructivist grounded theory methodology to analyze data collected from the two open-ended questions included on the post-examination survey (Table 2) and the one-on-one semi-structured student interviews. According to this methodology, data (interviews) were transcribed, coded, inductively and iteratively reviewed, and thematically interpreted [31–33]. We chose a constructivist grounded theory approach in order to explore and conceptualize our students’ experiences with the goal of developing a theoretical understanding we can use to enhance our assessment practices. Grounded theory is well established in medical education research as a useful methodology from which to draw conclusions to improve curricular practices [34–42].

First, analysis of the open-ended survey data was conducted utilizing a constructivist grounded theory methodology to explore the range of student experiences with the group exam. The open-ended survey answers were read in their entirety. The text was then split into meaningful phrases, which were coded by a single faculty researcher (RT). Through inductive and iterative review, as well as thematic interpretation, a pattern of similarities appeared and themes emerged. Following the analysis, we decided that further investigation of the results would be best accomplished through conduction of student interviews.

An interview protocol was constructed to further investigate the recurring themes and questions that arose from the post-examination survey data analysis. Three weeks following the completion of the two-stage examination, a recruitment email was sent to a random sample of students who completed the optional post-examination survey from the cohort matriculation year 2021. The email provided information about the goals of the research project and invited students to participate in one-on-one interviews conducted via Zoom by either student or researcher (NR or FW). An incentive of a $10 gift card was provided for participation in the interviews. Each interview lasted approximately 15 min, and interview transcripts were collected utilizing an automatic transcription feature via Zoom. All participants provided consent for recording, transcription, and aggregation of responses to be utilized in this research project. Table 3 displays the interview protocol.

Table 3.

Student interview protocol

1. Anatomy education background
What was your major at your undergraduate institution?
If you took anatomy, was it in high school, a community college, or a 4-year university?
What is your comfort level in the cadaver laboratory?

2. MSU CHM gross anatomy laboratory experience
Please share your experience working in your assigned laboratory groups
How did you work with your laboratory group during the scheduled laboratory time?
How did you work with your laboratory group outside of the scheduled laboratory time?
Did you experience any increased or decreased anxiety with the two-stage examination format?

3. Experience of the two-stage examination
What did you find challenging about the laboratory practical format during the individual assessment portion?
Do you feel that having group examinations made you more likely to make sure the students in your group understood the information?
What barriers did you find with discussion during the group assessment stage of the examination?
Do you feel that there would be improved or worsened discussion if you were able to choose your laboratory groups rather than having them assigned?
How do you feel group size impacted discussion during the group assessment portion of the examination?
Do you think larger/smaller groups would change the amount of discussion during the group assessment portion of the examination?
How would you feel about having points associated with the group assessment portion of the examination?

4. Feedback
What recommendations do you have for the anatomy faculty?
How can we improve our assessments?

A single faculty researcher (RT) reviewed the transcripts in conjunction with the recordings for accuracy and to familiarize herself with the full dataset and confirmed that data saturation had been reached. The researcher then coded the transcripts using an iterative and inductive approach in which codes were reviewed and modified as necessary to accurately represent the interview data. The process of analyzing, comparing, and combining codes resulted in the identification of three primary themes with subthemes. Throughout this process, the research team engaged in discussions which resulted in consensus being reached on both the codes and themes.

Results

Two-Stage Examination Performance

Individual examination scores as well as group examination scores were analyzed for all three cohorts of students (Fig. 2). The general trend revealed that the group score was higher than the individual assessment scores of each member of that group. Across all three cohorts, the average group score was 88.98% (SD = 4.84), and the average individual score was 66.24% (SD = 5.69). The average increase from an individual assessment score to a group score was 22.68% (SD = 22.96). A two-tailed t-test for independent samples showed that the increase between individual assessment score and group score was statistically significant at the 95th confidence interval (p =  < 0.001).

Fig. 2.

Examination results by matriculation year

The individual examination score was higher than the group examination score for 13 out of 521 (2.5%) students. The average decrease in the group examination score compared to the individual examination score was 2.64% (SD = 1.55) in these 13 instances.

Likert Scale Survey Results

The post-examination optional survey contained fifteen 7-point Likert scale questions to assess student perceptions of the two-stage laboratory examination (Fig. 3). The data set included survey results from 180 students who completed the survey in its entirety across the three cohorts. Following the numerical coding method described in the “Methods” section, the response data demonstrated acceptable internal consistency (Cronbach’s alpha reliability score = 0.82). Likewise, removing the two “unfavorable” questions also resulted in the data demonstrating acceptable internal consistency (Cronbach’s alpha reliability score = 0.81).

Fig. 3.

Likert scale survey results

Most interesting to the contributions of this study, students who completed the survey reported that the group testing format transformed the capstone from an assessment to a learning experience with a mean response of 5.67, representing agreement (SD = 1.48). Students reported that every group member “pulled their weight” (i.e., contributed to the learning process) with a mean response of 5.82, representing agreement (SD = 1.60). The survey also revealed that the group testing experience demonstrated the value of working in a team as students reported a mean response of 5.89, representing agreement (SD = 1.19). Lastly, students reported that they would recommend this process for other content areas with a mean response of 5.76, representing agreement (SD = 1.44).

Grounded Theory Analysis

Thematic analysis within a constructivist grounded theory methodology was applied to open-ended survey responses and interview transcripts (Fig. 4). This analysis yielded three major themes with subthemes. The three major themes included the two-stage examination as more than an assessment, the impact of individual performance and anxiety, and the negative impact of examination logistics.

Fig. 4.

Grounded theory analysis

The theme, “the two-stage examination as more than an assessment” contained subthemes which demonstrated that the students found this format to be both a learning opportunity and a teaching opportunity. Students expressed value in the opportunity for immediate feedback as well. When asked questions regarding their opinions of the two-stage examination, an interview participant explained:

I’m not generally a person who leaves and goes to look up answers. I don’t really want to know what I got wrong, but I think it was nice to do it in the group setting because then we could actually talk about, ‘Why did I think it was this?’

The theme, “the impact of individual performance and anxiety,” led to subthemes which revealed the complex interconnections of student’s perceived self-performance and anxiety levels on the overall examination experience. Interviewed students who self-reported a favorable examination performance and/or a low level of test-taking anxiety reported an overall positive perception of the two-stage examination. In contrast, the interviewed students who self-reported a poor examination performance and/or higher levels of anxiety at the time of testing overall reported a more negative perception of the two-stage examination. Additional subthemes suggested that cohesive group dynamics were related to a more positive student experience, and lack of confidence in regard to examination content worsened anxiety. During the interview, a participant reflected on their individual anxiety level, as well as what they observed in their group members, and stated:

There were definitely times during it when people were like, ‘I know I got this wrong, and I don’t even want to think about it.’

The theme, “the negative impact of examination logistics” did highlight some areas of improvement for the anatomy department at this institution. However, it did not necessarily reveal pertinent information related to the structure or format of the two-stage examination. Subthemes revealed negative student opinions regarding the timing of the examination within the year, as multiple other departments were also conducting examinations and the spring vacation was immediately following the two-stage examination. In addition, the discussion volume during the group stage of the examination was distracting to some participants. Finally, the formative nature of the group stage of the examination negatively impacted student experience, as students did not perceive a strong need to perform at a high level during the collaborative portion of the examination. An interview participant reflected on the formative nature of the group stage of the examination and explained:

I think, because it didn’t count for anything and because we couldn’t change our individual answers, it was just kind of like, you know, let’s get through it.

Discussion

The two-stage examination model is a widely accepted method for assessment, supported by an abundance of quantitative research that has demonstrated overwhelming positive results in regard to student performance [16–18, 21, 22, 25–27, 29, 43, 44]. Our study contributes to the current body of knowledge by investigating student perspectives of the two-stage examination in the gross anatomy laboratory within a unique medical school curriculum with a primary focus on longitudinal, team-based learning and formative assessment. Our quantitative results complement previously published research, as group examination scores were significantly higher than individual student scores. Our qualitative analysis demonstrates the value of two-stage examinations when used as formative assessments and highlights the importance of group dynamics on the student experience. Overall, students responded favorably to the experience of the two-stage examination. We strongly recommend the incorporation of this assessment method into gross anatomy medical school courses.

Two-Stage Examination as More Than an Assessment

Surveys and interviews revealed the positive student perceptions of the two-stage examination. This finding is consistent with previous studies [16–20, 22, 25–27, 30, 44], with the exception of one by Parsell [28], who found a negative perception among community college students, but a positive perception among students at a research institution. Students agreed that the group testing format transformed the capstone from an assessment to a learning experience, with many students recommending this examination method for other content areas. Students appreciated the immediate feedback offered by this examination format and the opportunity to discuss their decision-making process with their peers and participate in peer teaching. These findings are also in agreement with previous studies demonstrating appreciation of immediate feedback [16–18, 21, 22, 24, 26], increased student discussion [16, 18, 20, 21, 27, 44], and increased participation in peer teaching [16, 21, 22, 24, 26]. Interestingly, contributions from Green [29] demonstrated conflicting results that did not show increased peer teaching or increased discussion.

Invaluable to the development of a future physician is the ability to work as a team to think critically and find solutions to complex problems. Our study revealed that students believe this examination experience demonstrated the value of working in a team. Students agreed that the level of discussion during group testing was high, their personal involvement was significant to the group, and that every group member contributed to the learning process. The benefits of strong communication skills were reinforced by this examination format, evidenced by students reporting that when they were confident in their answer, they did not find it difficult to communicate their thought process to convince their group of the correct answer. Equally important, students reported that when they disagreed with a group member, they were receptive to their opinions and had productive discussions (Fig. 3).

Examination Logistics

Student experience and perceptions of the two-stage examination were most negatively impacted by examination logistics at our institution. Most prevalent was the timing of the examination within the academic year. The examination was held on the last day of the “early clinical experience” (ECE) which spans from late August to the first week in March. For the majority of students, this examination was the last scheduled activity of the ECE, which was directly followed by a week-long spring break. Some students reported that the additional time to take the assessment as a group “unnecessarily” cut into their spring break time.

It is also important to note that during the week of the two-stage examination, there were several other ECE capstone experiences within the curriculum. After a week of assessments, students’ fatigue level was high. The formative nature of this gross anatomy assessment in the context of fatigued students with only one final assessment to complete before they began their spring break complicated the student experience of this examination.

Finally, some students noted the negative impact of the loud and crowded environment of the gross anatomy laboratory during the group examination. The level of discussion during the group portion of the examination was high as students worked through examination stations without any specified order or required organization. This negative theme is consistent with previous studies [16, 18, 26].

The examination logistics explained above are institutional specific factors that can be altered to reduce the negative impact on the examination experience. In fact, the two faculty researchers have already addressed the timing of the examination within the academic year for future classes. We recommend to all faculty who are designing a two-stage examination to mindfully minimize the negative impact of examination logistics at their specific institution.

Content Knowledge, Anxiety, and Group Dynamics

This study identified complex interconnections between content knowledge, test anxiety, and group dynamics that influenced the student experience and perception of the two-stage examination. This interaction is best viewed through the lens of self-determination theory.

Self-determination theory explains motivation as reliant on three core psychological needs: autonomy, competence, and relatedness [40, 42, 45–47]. Students who shared in their interview that they felt confident during the examination, supported by their laboratory group members with a strong sense of group cohesiveness, and reported a higher level of comfort in the anatomy lab can be categorized as having a higher self-determination level. These higher levels were associated with a positive experience and perception of the two-stage examination. However, students who lacked one or more of the core psychological needs experienced this assessment method in a less favorable manner. Students who perceived the two-stage examination negatively demonstrated either lower competence, evidenced by lower quartile individual examination scores, and/or self-reported high levels of test-taking anxiety, and/or those that lacked a sense of belonging within their longitudinal laboratory group partners.

The curriculum at MSU CHM supports the development of positive group dynamics by assigning students to longitudinal small groups and aims to decrease student test-taking anxiety through the elimination of high-stakes summative examinations and a strong emphasis on formative learning experiences. These unique elements of the curriculum at MSU CHM cultivate an environment that is conducive to students having a positive perception of the two-stage examination by increasing their sense of autonomy, competence, and relatedness. This positive influence of the curriculum structure on motivation likely explains the favorable student experience and perceptions of the two-stage examination, with only 5.0% of MSU CHM students (n = 180) who disagreed or strongly disagreed with the statement “I would recommend (two-stage testing) for other content areas.” Our findings offer a framework to interpret the conclusions of previous studies that demonstrated a lower student satisfaction rate of the two-stage examination, as students in these studies worked in short-term, small groups for the examination experience [16, 20, 22, 25, 27, 28]. In other words, it can be hypothesized that participants in the aforementioned studies experienced less relatedness during the group portion of the examination as compared to students at MSU CHM who demonstrated a more favorable experience.

Limitations and Future Research

This study was performed within a single subject (gross anatomy) at a single medical school with a unique curriculum based primarily upon team-based learning within longitudinal groups and formative assessments, which may limit the transferability of the findings. Our results are also limited in scope given that the interview population was drawn from a single cohort. Finally, participation in the study was optional and may not reflect the totality of the student experience.

Analysis did reveal key differences in the student experience between the two campuses where the two-stage examination was administered that were not known prior to this research. In particular, the students from the GR campus strictly adhered to their assigned longitudinal groups of four students for the entirety of the anatomy labs and two-stage examination. However, students from the EL campus did not strictly adhere to their assigned group of four students throughout the curriculum nor during the two-stage examination. Students from the EL campus even worked in groups as large as eight students for the two-stage examination. Interestingly, within the cohort of students with the matriculation year of 2021 from the EL campus, a group of eight students chose to complete only the individual portion of the two-stage examination and did not participate in the group portion of the examination.

Insight from interviews with students from the EL campus suggests that the utilization of a formative two-stage examination does not provide enough incentive alone to develop a strong group dynamic. More positive perceptions of group dynamics and cohesiveness were reported during interviews with students from the GR campus which suggests that the dedication to longitudinal learning groups has a beneficial effect on the student learning experience in the context of the two-stage examination. However, the intercampus differences regarding group dynamics revealed in our interviews were not reflected in the exam scores. Two-tailed t-tests for independent samples revealed no significant differences in either individual or group exam performance between campuses. Further exploration of these differences between campuses was beyond the scope of this study, but future research will explore factors that promote group cohesion in the gross anatomy laboratory.

Additional future goals for research include further investigation of the impact of the group dynamic on student experience in the setting of the casual and formative nature of the two-stage examination at MSU CHM. Factors related to examination logistics currently under consideration at our institution include the timing of the examination within the broader curriculum, the impact of student performance on the individual and group portions of the examination to their overall grade, the best ways to accommodate students who necessitate extended examination time, and ways to reduce distractions during the group portion of the examination.

Conclusions

Our study findings are consistent with recent research that supports the use of two-stage examinations to enhance the learning experience and deepen student understanding of complex material. Our study adds to the current body of knowledge by sharing student perceptions from a medical school curriculum that relies heavily on formative assessments to foster a strong collaborative learning environment within longitudinal student groups. Our research revealed three main themes: the two-stage examination is a valuable education tool and more than an assessment; there is a positive relationship between individual performance on the examination and self-determination levels; and the negative impact of examination logistics related to the timing of the examination within the academic year at MSU CHM.

It is important to note that implementation of a two-stage examination would require nearly double the amount of time required of both students and faculty to complete the examination and a large burden for faculty to prepare and plan for the examination. The format of the two-stage examination poses challenges for students who receive testing accommodations as well. Despite these challenges, we strongly suggest the addition of two-stage examinations to medical school anatomy laboratory curriculum. Two-stage examinations will transform a standard assessment into a valuable learning experience where students will participate in active learning through peer teaching and cultivate the skills that are vital to the development of the future physician—the ability to critically think and work as a team.

Author Contribution

All authors contributed to this project. R.M.T. and A.H.-B. contributed to the study conception and design. Survey collection was performed by R.M.T. Interviews were performed by F.W. and N.R. Data analysis was performed by R.M.T. and reviewed by A.H.-B., N.R., and F.W. Drafts of the manuscript were written, in order of contribution, by F.W., N.R., and R.M.T., and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

The research incentives were provided by MSU’s Department of Radiology faculty development funds. Internal Professional Development Funds.

Data Availability

Data is available on request.

Declarations

Ethics Approval

This study was deemed exempt by the institutional review board of Michigan State University.

Consent for Publication

All authors consent to the publication of this manuscript. Participants who consented to this project were informed that anonymized data would be utilized in a formal publication. Portions of this work were previously presented as a poster at the Grand Rapids Citywide Research Day on April 13, 2022, in Grand Rapids, Michigan, and the International Association of Medical Science Educators (IAMSE) Annual Meeting on June 5, 2022, in Denver, Colorado.

Competing Interests

The authors declare no competing interests.