Introduction

In the past few years, several studies have reported various e-learning teaching modes in the field of medical education. Each mode has its own advantages and drawbacks. In this changing trend, adapting to the newer methods and testing its effectiveness are crucial for implementation ( 1 , 2 ). Human anatomy is one of the subjects in medical curriculum which is important for clinical practice. The anatomy courses for undergraduate medical students are taught using traditional regional approach. Conventionally, gross anatomy is divided into region wise – upper/lower limbs, abdomen, thorax, head and neck, and neuroanatomy. Each region is spread over 6 weeks, and it is taught by didactic lectures followed by cadaver-based demonstrations. Apart from cadaveric demonstrations, alternative methods of practical demonstrations using videos, and virtual reality modes are also used ( 3 - 6 ) During the Covid-19 pandemic, practical demonstration was completely cut down. Owing to this situation, globally all educators moved to online mode of teaching and learning ( 7 ). One of the established e-learning modes for anatomy practical demonstration was dissection videos of cadavers recorded by anatomy faculties with specific learning needs and objectives ( 8 , 9 ). These videos were made available through learning management systems. This mode of teaching helped the students to learn the objectives similar to face-to -learning with cadaveric demonstrations. Studies have reported that using such multimedia e-learning resources is better than virtual reality videos ( 10 , 11 ). These newer methods enhance the knowledge in computer-based learning and self-directed learning skills.

Traditionally, anatomists believe that the decline in knowledge is attributed to modern methods of teaching and learning ( 12 ). However, medical educationists perceive modern approaches offer contextual knowledge and give similar results in assessment as compared to traditional teaching methods and assessments ( 1 , 2 ).

In implementing a newer method, three aspects have to be considered: i-when to teach, ii- how to teach, and iii-how to assess the knowledge ( 12 - 14 ). In regular face-to-face teaching, two types of assessment are done: region-wise formative assessment followed by summative assessment. Assessments include theory and practical examination. As a part of practical evaluation, spotter exam is conducted in dissection laboratory using prosected cadaveric specimens and bones. During the pandemic, since teaching and learning were conducted through the online mode, traditional practical examinations could not be conducted. Hence, only online spotter examination was conducted using prosected cadaveric images and colour atlas images. Since the online spotter exam is gaining popularity, especially after the pandemic, it is essential to further evaluate the process and validate its routine usage. In this scenario, the students’ performance and perception about both traditional spotter examination (TSE) and online spotter examination (OSE) are necessary for future planning and designing the assessment methods. Hence, the present study was conducted to 1) correlate the students’ performance in traditional spotter examination and online spotter examination and 2) analyze the students’ perception about both exam patterns.

Methods

This is a cross-sectional descriptive study which was approved by the Institute Research Ethics Committee (IRB/KMCH/ 011/2021) and written informed consent was obtained from all participants. A total of 120 students in the first medical professional year were selected for the study based on simple random sampling method. Selection was based on their convenience to attend the examination and answer the survey questions. The study was conducted in the department of anatomy over a period of six months (between January 2021 to June 2021).

Two modes of practical examination, i.e. traditional spotter and online spotter, were conducted for each of the following regions: the thorax, abdomen, head & neck, and neuroanatomy. Questions were designed by the authors according to Blooms Anatomy Tool ( 15 ). Levels one and two test the student’s ability to identify, recall, describe, or distinguish anatomical structures. The third and fourth level questions test their ability to interpreting and analysing. TSE was conducted in the dissection hall following steeplechase pattern using cadaveric specimens. A total of fifteen spotter stations were set up. Each spotter station contained two questions pertaining to identification, location, nerve supply, blood supply, actions, and clinical relevance. Responses were in the free answer format (FAF). Each spotter station was timed for one minute. After the traditional examination, OSE was conducted in the same study group using computers, smart phones, and other electronic devises. Spotter questions were designed using 2D cadaveric images of prosected cadaveric specimens and images from Colour Atlas of Anatomy ( 16 ). Similar to traditional exam, each spotter question had an image with arrows directed to point the structure. Each spotter station was not timed, but the overall time limit was set. The online questionnaire was created using Google form with timer settings and was sent to individual students by email. The entire online examination was monitored. At the end of the exam, the students submitted their Google forms, and the answers were recorded automatically. Students’ scores in both examinations were entered into Microsoft excel. The spotter question included multiple-choice questions (MCQs). After the exam, the students were instructed to voluntarily complete a questionnaire (Table-1) to evaluate their perceptions of OSE and TSE. Questions were prepared following international guidelines ( 17 , 18 ). Questions pertaining to the quality of specimens, image quality, time limit, answering format, time of results, and ease of examination were asked. A total of 15 questions were given. Questions were validated by subject experts and medical educationists.

Statistical Analysis

All data were analysed in SPSS statistical package, version 21 (IBM, Armonk, NY) and reported descriptively. The mean scores of OSE vs. TSE were compared using independent sample t-test. A p value ≤0.05 was considered significant. Regarding analysis of the questionnaire pertaining to online and traditional exam pattern, the students answered the questions on a Likert scale ranging from 1-3 with 1-Disagree, 2–Neutral, 3-Agree. The responses were expressed as percentages for each item on the questionnaire. Cronbach’s alpha for the items of the questionnaire was 0.82.

Ethical Consideration

This is a cross-sectional descriptive study which was approved by the Institute Research Ethics Committee (IRB/KMCH/ 011/2021) and written informed consent was obtained from all participants.

Results

A total of 120 students were enrolled in the study. All 120 students attended both examinations and then answered the questionnaire. Mean test score was higher for OSE about 8.7±1.1 compared to TSE test score of 6.2±1.3. Differences observed among the scores were statistically significant (𝑃 < 0.05, CI 95%).

Students’ perception about OSE

Each question was designed to know the students’ perception regarding the online and traditional exam patterns. With respect to online examinations, about 70% (n=84) of students agreed that OSE with images of prosected specimens and images from colour atlas was easy to identify, 25% (n=30) disagreed, and 5% (n=6) were neutral. The majority of the participants 65% (n=78) felt that SAQ and MCQ were easy to answer, but 15% (n=18) disagreed, and 20% (n=24) were neutral. Self-navigating the slide, convenience of moving back and forth to answer, and ability to spend more time for difficult spotters compared to easy spotters received positive response 60%; (n=72) from the participants. No bias in evaluation and declaration of results immediately at the end of OSE received positive response. Moreover, competitive entrance examination for postgraduate courses was conducted in similar lines with OSE. Hence, 90% (n=108) of the students felt that OSE would help them in future online exams. On the contrary, 80% (n=96) of the students agreed they were anxious about Internet connectivity, while 20% (n=24) disagreed (Table 1, Figure 1).

Figure 1. Students’ response to questions pertaining to Online Spotter Exam (OSE) on Likert scale

Students’ perception about TSE

About 50% (n=60) of the students agreed that TSE with cadaveric specimens did not affect their performance, while the remaining 40% (n=48) disagreed and 10% (n=12) were neutral. Moving in steeplechase pattern and its effect on the students’ performance received mixed responses with 50% (n=60) supporting it and 50% not. Only 40% (n=48) agreed that free answer format (FAF) of answering in TSE was easy and 50% (n=60) disagreed. Time limit set for each spotter and bias in evaluation was considered to be a disadvantage by 90% (n=108) (Table 1, Figure 2).

Figure 2. Students’ responses to questionnaire on Traditional Spotter Exam (TSE) on Likert scale

Discussion

Learning and assessment are inte-dependent. Assessment helps to design an effective teaching learning method. Gibbs describes choosing an appropriate assessment instrument is crucial to access the learning domains ( 17 ). For testing a particular domain, assessment has to link the objectives and learning outcomes. Earlier studies have reported that, in the subject of human anatomy, practical examination is the most recommended method of assessment and inclusion of newer pedagogical methods such as OSE is the need of the hour ( 18 , 19 ). A well-established practical method to test the cognitive domain is Spotter exam.

Students’ performance in the examinations

In the literature search, it was found that the scores in practical examination were the same in traditional and online spotter examinations conducted among students enrolled in medical and allied medical courses ( 20 , 21 ). However, the findings of the present study are not in the same line with earlier studies. We found that student’s performance was higher (8.7±1.1) in OSE. Performance in an exam is dependent on several factors such as high-stake or low-stake exam, teaching method, learning styles, pattern of the exam, question and answer format, time limit, and evaluation method ( 21 , 22 ).

In the present study, OSE was conducted as part of formative assessment to test the students’ knowledge at periodic intervals. Scores obtained in formative assessments have a cumulative/considerable percentage in summative exam score calculation. Hence, the student’s performance in formative assessment is significantly important for securing better scores in summative exams. With introduction of online teaching and assessment methodologies, student’s familiarity with online learning has dramatically improved by the virtue of its routine usage. This could be one of the reasons for better scores in the current study. Based on the teaching method, students adopt suitable learning styles. In traditional teaching, students learn with prosected specimens of cadavers and dry bones in dissection laboratory. This type of learning is a deep learning style, whereas in online teaching, learning is done with recorded videos of prosected specimens which is a strategic learning style ( 23 , 24 ). In this context, choosing an appropriate assessment complimenting the teaching methodology is important for better outcome. During the pandemic, online teaching was the only mode. Hence, the students were assessed online. Since the teaching and assessment modes were aligned with each other, students were able to perform better in OSE.

In traditional exam, the quality of specimen used is highly variable since it depends on dissection technique, preservation, storage, and display. However, in online exam, high resolution pre-validated images are used which provides consistency and reliability to the examination ( 21 , 22 ). The same has been agreed by 70% of the students in the current study.

Furthermore, during the steeplechase pattern, chances of mishandling the specimens by students is higher which can affect the outcome ( 23 ). Such default can be completely avoided in OSE. Considering the above drawbacks, OSE is superior without any interference by students during the exam.

Answering format depends upon the mode of exam. Short answer question (SAQ) and MCQ in OSE have an advantage over free answer format (FAF) in TSE since it requires less time to type the answer for each question ( 25 ). In traditional FAF, the answer sheets are manually corrected by the faculties. This might cause bias among the evaluators, which could be one of the reasons for low score/performance. Evaluation bias is absent in online assessment which reflects the true performance of the student. Hence, traditional exam has reduced validity and reliability compared to online exam. Similar findings are hypothesized in previous studies ( 21 , 23 ).

Students’ perception about the examinations

The majority of the students (70%) believed a single sitting in OSE exam allowed them to quickly scan the entire exam to know the gist of the contents before answering. This helps them to attempt lower order questions quickly and spend more time for higher order questions, thereby significantly reducing exam-related anxiety ( 21 ). However, in TSE, exams are conducted in batches following steeplechase pattern with multiple re-runs which invariably causes more anxiety, longer waiting time, and inability to scan all the questions before answering, leading to poor time management. Hence, it is important to find alternative methods/strategies to reduce the students’ anxiety levels and optimize performance ( 26 ). Since most high-stake competitive exams are conducted online, it is imperative to sensitise and train the students to online exam. Another advantage of online exam is that it can be conducted under various settings around the year, and use of resources for the performance of exam in terms of manpower and materials is minimal, as reported earlier ( 18 ). The majority (95%) of the participants agreed that online spotter exam was similar to other competitive exams, and it might help them gain familiarity for future postgraduate entrance exams. When asked about results, 90% of the students opined that online exam had an advantage with instant and non-bias results compared to traditional exam which has delays in reporting the results and bias in evaluation. Instant results help them to quicky self-evaluate and improvise contrast to delayed results in TSE. Reports of previous studies suggest that time of announcement of the results should not be considered while choosing an assessment tool.

Limitations of the study

Though online assessment is a newer trend, it comes with drawbacks. Students and faculties were concerned about Internet connectivity during the exam. The problems could also arise from hardware, software, or issues with power supply ( 27 ). 80% of the participants reported apprehension about Internet connectivity due to difference in location, network providers, and data plan of each participant. This may impact the student’s attention span and performance during the exam. This might indirectly reduce the reliability of the assessment method. In this fast-moving era, newer technologies have to be instilled to avoid such issues. Another drawback of online exam is remote proctoring of the exam. Proctoring an exam is important to validate the assessment. This could be addressed by video monitoring and shifting the testing environment to in-campus testing centres, where the exams can be proctored directly ( 28 ).

Conclusion

Online assessment will become the mainstream over the next few years. Given this fact and the future trend in medical education, OSE can be included as part of formative assessment to assess the students’ knowledge and learning outcomes. Better performance and students’ willingness suggests that OSE can be considered as a replacement to TSE in anatomy practical exam. Hence, it is recommended to standardise OSE in different settings to test its reliability and reproducibility for the benefits of students and faculties.

Acknowledgements

We thank the students and faculties of the department of anatomy for their cooperation and participation in the study.

Authors' contribution

S.A, N.K.S Concept design, data collection, analysis, drafting manuscript; S.J.P: Data collection, proof reading. All authors read and approved the final manuscript. All authors agreed to be accountable for all aspects of the work and ensured that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved.

Conflict of Interest

None Declared.

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