Contemporary medical education emphasizes critical reasoning and knowledge application rather than rote memorization. Open-book formative assessments (OBFA) provide an authentic approach that fosters analysis, synthesis, and problem-solving. However, evidence on their role in enhancing higher-order thinking skills (HOTS) among Phase-1 MBBS students in India remains limited. This study explored student perceptions of OBFA in fostering HOTS and identified its perceived benefits and challenges.
A cross-sectional mixed-methods study using an explanatory sequential design was conducted among 137 Phase-1 MBBS students in Andhra Pradesh. Participants undertook both closed-book and open-book formative assessments in anatomy. Quantitative data from a validated questionnaire (Cronbach's alpha = 0.707) and qualitative data from ten focus-group discussions (7-8 students each) were analyzed using descriptive statistics, correlation, and Braun and Clarke's thematic framework.
Mean scores improved significantly from closed-book (12.95 ± 3.54) to open-book assessments (18.41 ± 2.07, p < 0.001). Students perceived OBFA as enhancing critical thinking (3.91), application of anatomical knowledge (3.99), and analytical integration (4.09). It reduced anxiety (3.82) and promoted self-directed learning (3.99). Perception of OBFA strongly correlated with analytical integration (r = 0.71, p < 0.001). Themes reflected a shift from memorization to conceptual learning, improved problem-solving, and reduced stress, though time constraints and resource management posed challenges.
OBFA fosters higher-order cognitive engagement, conceptual understanding, and independent learning among early-phase medical students. With appropriate orientation and faculty training, its integration with traditional methods can strengthen CBME-aligned assessment practices.
Medical education is shifting from factual recall toward developing critical reasoning, analytical thinking, and problem-solving skills essential for clinical competence. Traditional closed-book examinations primarily test memorization, which may not adequately prepare students for real-life medical decision-making that requires the application and synthesis of knowledge. In contrast, open-book assessments (OBAs) enable students to access reference materials during examinations, emphasising comprehension, integration, and evaluation rather than rote reproduction.
During the foundational Phase-1 MBBS curriculum, covering anatomy, physiology, and biochemistry, students must develop the capacity to connect concepts across disciplines. Formative assessments, which provide feedback and promote learning, are valuable in this phase. Incorporating open-book formative assessments (OBFAs) may encourage higher-order thinking skills (HOTS), such as analysis, application, and synthesis, consistent with Bloom's taxonomy [1]. These cognitive processes underpin critical reasoning, clinical judgment, and evidence-based decision-making in later stages of medical training.
However, research on the effectiveness of OBFA in early medical education remains limited, particularly within the Indian context. Few studies have explored students' perceptions of OBFA and its potential to foster critical thinking, problem-solving, and self-directed learning. Additionally, qualitative evidence examining learners' experiences, challenges, and the contextual feasibility of OBFAs in resource-based settings is sparse. Addressing these gaps, the present study investigates Phase-1 MBBS students' perceptions of open-book formative assessment in enhancing higher-order thinking skills, identifying its perceived benefits, limitations, and implications for integrating authentic, learner-centered assessment strategies in competency-based medical education (CBME).
A cross-sectional mixed-methods study employing an explanatory sequential design was conducted among Phase-1 MBBS students at a rural medical college in Andhra Pradesh, India. All 150 students were invited, and 137 participated, providing complete data.
Two formative assessments in anatomy were administered sequentially: one closed-book and one open-book formative assessment (OBFA). The closed-book assessment, conducted in May, comprised 10 multiple-choice and 3 short-answer questions (maximum score: 25) from the neuroanatomy module. The subsequent OBFA, held in June, followed the same structure but covered the abdominal region, with extended time (60 minutes) to accommodate resource consultation. Students were permitted to use standard anatomy textbooks and were briefed on examination procedures before implementation.
All assessment items underwent prevalidation by a panel of five subject and medical education experts. Each item was rated for relevance, clarity, and alignment with Bloom's taxonomy, yielding item-level content validity indices (I-CVI: 0.6-1.0) and scale-level CVIs (S-CVI: 0.8-0.86).
Quantitative data on student perceptions were collected using a prevalidated Likert-scale questionnaire (Cronbach's alpha = 0.707) containing items on critical thinking, problem-solving, and self-directed learning. Qualitative data were gathered through focus group discussions (FGDs) involving 7-8 students per group, stratified by performance level. Ten FGDs were conducted until data saturation, each lasting approximately 45 minutes, moderated by a trained facilitator unaffiliated with the assessments.
Quantitative data were analyzed using descriptive statistics, independent t-tests, and Mann-Whitney U tests to explore gender differences. Pearson's correlation coefficients were calculated to examine relationships among key perception domains. Qualitative data were analyzed manually using Braun and Clarke's six-step thematic analysis framework, including familiarization, coding, theme generation, and validation through member checking and peer debriefing [2].
Institutional Ethics Committee approval was obtained prior to data collection (Faculty/1285/25). Participation was voluntary, and confidentiality was maintained throughout the study.
A total of 137 students responded to the questionnaire and attempted both exams (13 students out of 150 were absent). The majority had no prior exposure to open-book assessment. The internal consistency of the questionnaire (Cronbach's alpha) was 0.707. Female students (92) outnumbered male students (45). The independent t-test (t = -0.33, p = 0.745) and Mann-Whitney U test (U = 2069.5, p = 1.0) showed no statistically significant difference between genders. Mean score increased significantly from 12.95 ± 3.54 in closed-book to 18.41 ± 2.07 in open-book assessment (paired t = -9.33, p < 0.001).
| Type Of Assessment | Maximum Score | Minimum Score | Mean score |
|---|---|---|---|
| Close book assessment | 20 | 3 | 12.95 ± 3.54 |
| Open-book assessment | 22 | 11 | 18.41 ± 2.07 |
| Item | Strongly agree (%) | Agree (%) | Neutral (%) | Disagree (%) | Strongly disagree (%) | Mean Score |
|---|---|---|---|---|---|---|
| Better Understanding of concepts OBE vs CBE | 10.9 | 48.2 | 32.1 | 8.0 | 0.8 | 3.61 ± 0.82 |
| Less anxious and stressful OBE vs CBE | 27.7 | 46.7 | 8.8 | 13.1 | 3.7 | 3.82 ± 1.09 |
| Understands topics better OBE vs CBE | 10.9 | 42.3 | 29.9 | 16.8 | 0.1 | 3.47 ± 0.90 |
| Actual learning happens with OBE vs CBE | 21.2 | 56.2 | 10.9 | 10.9 | 0.8 | 3.86 ± 0.90 |
| Item | Strongly agree (%) | Agree (%) | Neutral (%) | Disagree (%) | Strongly disagree (%) | Mean score |
|---|---|---|---|---|---|---|
| Enhances critical thinking | 20.4 | 56.9 | 16.8 | 5.9 | 0.0 | 3.91 ± 0.82 |
| Promotes application of anatomy knowledge | 21.2 | 60.6 | 14.6 | 3.6 | 0.0 | 3.99 ± 0.71 |
| Analyse and integrate information | 24.8 | 61.3 | 11.7 | 2.2 | 0.0 | 4.09 ± 0.67 |
| Promotes problem solving | 22.6 | 56.2 | 16.1 | 5.1 | 0.0 | 3.96 ± 0.77 |
| Item | Strongly agree (%) | Agree (%) | Neutral (%) | Disagree (%) | Strongly disagree (%) | Mean scores |
|---|---|---|---|---|---|---|
| Motivated and meaningful learning | 13.9 | 51.8 | 21.2 | 12.4 | 0.7 | 3.66 ± 0.89 |
| Time management issues | 5.1 | 27.0 | 24.8 | 38.0 | 5.1 | 2.87 ± 1.04 |
| Organising material was difficulty | 15.3 | 47.4 | 24.8 | 12.4 | 0.7 | 3.65 ± 0.91 |
| OBE promotes self-directed learning | 21.2 | 60.6 | 15.3 | 2.9 | 0.0 | 3.99 ± 0.72 |
| Subdomain | Perceptions | Critical thinking | Application | Analysis & integration | Motivation for SDL |
|---|---|---|---|---|---|
| Perceptions | 1.00 | 0.47 | 0.52 | 0.71 | 0.47 |
| Critical thinking | 0.47 | 1.00 | 0.54 | 0.50 | 0.49 |
| Application | 0.52 | 0.54 | 1.00 | 0.49 | 0.41 |
| Analysis & integration | 0.71 | 0.50 | 0.49 | 1.00 | 0.38 |
| Motivation for SDL | 0.47 | 0.49 | 0.41 | 0.38 | 1.00 |
| Themes | Sub-Themes | Quotations |
|---|---|---|
| Perceptions on open-book exam | Expectations and reality | "I thought it would be easy since the book was allowed, but actually, it requires practice." / "I expected that I would find answers and copy from textbook, but the questions have to be understood correctly." |
| Perceptions on open-book exam | Reduced Stress | "I felt less stressed compared to closed-book exams." / "OBFA reduced exam fear and helped me attempt with confidence." |
| Modified learning approaches | Shift from Rote to Conceptual Learning | "I focused more on concepts and understanding the topic" / "I was trying to find answers, understand what I was reading, and then answered the questions." |
| Modified learning approaches | Application of Knowledge | "Some questions were case scenarios, so I had to connect different parts of the topic." / "I thought just naming structures was enough in anatomy, but I had to apply that knowledge." |
| Benefits of OBE | Promote problem-solving and critical thinking | "I could remember the material better because I applied what I read for the exam." |
| Benefits of OBE | Promotes self-directed learning | "It is better not to memorise; open-book test is a good method for self-learning" |
| Challenges of OBE | Time Management | "Even though I had my textbook, I couldn't finish in time." |
| Challenges of OBE | Information processing | "It was hard to quickly find what I needed in the book." / "I was not sure how to use the textbook effectively during open book exam". |
| Preferences and suggestions | Balanced assessment | "OBFA is good for formative, but university exams should be closed book" / "I prefer both methods for learning a subject". |
| Preferences and suggestions | Need for training | "If I had practiced in OBFA, I would have performed better." / "More OBFA with more training, but both methods are good." |
This study examined Phase-1 MBBS students' perceptions of open-book formative assessment (OBFA) and its influence on higher-order thinking skills (HOTS) using a mixed method explanatory sequential design. The findings indicate that OBFA enhanced conceptual understanding, analytical reasoning, and integrative learning, while reducing examination-related anxiety. Students reported that open-book testing encouraged deeper engagement with study material and promoted reflective, self-directed learning. These results underscore OBFA's potential as an innovative assessment approach that aligns with competency-based medical education (CBME).
Quantitative analysis demonstrated a significant improvement in mean scores from closed-book to open-book assessments, suggesting that access to learning resources facilitated deeper understanding rather than superficial memorisation. The highest mean scores were recorded for statements related to comprehension and clinical application. Strong correlations between perception and analytical integration (r = 0.71, p < 0.001) and between critical thinking and application (r = 0.54, p < 0.001) support that positive attitudes toward OBFA are linked with enhanced cognitive performance.
The findings align with earlier work by Alghamdi et al. 2024 [3] and Mahmoudzadeh-Sagheb et al. 2015 [4], where students preferred open-book formats and noted reduced stress and promoted self-directed learning. Reduction in anxiety resonates with classic findings by Feldhusen et al. 1961 [7], Broyles et al. 2005 [8], and Dale et al. 2009 [9]. However, challenges such as time management and resource navigation emphasize the need for prior orientation and training in resource utilization [10,19-21].
This mixed-method study demonstrated that open-book formative assessment (OBFA) effectively enhances higher-order thinking skills (HOTS) among Phase-1 MBBS students within a competency-based medical education framework. Students performed significantly better in open-book tests, indicating improved understanding, analytical reasoning, and integrative learning. Perceptions and focus group insights revealed that OBFA fosters conceptual understanding, critical thinking, problem-solving, and self-directed learning while reducing examination anxiety. Its success depends on structured faculty training, student orientation, and periodic integration with traditional assessments.