A Quasi-Experimental Study on the Impact of Blended Assessment on Performance and Anxiety Levels of Otorhinolaryngology Clinical Interns

Introduction

In China’s 5-year clinical medical education system, students dedicate the first 3 years to acquiring foundational medical knowledge and theoretical understanding before commencing clinical internships in their fourth year. During these internships, students primarily engage in observational learning activities, such as observing surgeries and attending lectures, without direct involvement in surgical procedures or hands-on clinical interventions. Particularly in otorhinolaryngology clinical training, the conventional pedagogy tends to over-rely on didactic knowledge transmission. Given the specialty’s unique challenges—including intricate anatomical relationships and confined surgical fields—trainees frequently experience conceptual difficulties, demonstrate insufficient learning engagement, and ultimately achieve suboptimal training outcomes.

According to Bloom’s taxonomy, the learning process advances through hierarchical cognitive levels: Memory and Understanding, followed by Application, Analysis, Synthesis/Integration, and Evaluation—each stage fostering progressively higher-order cognitive abilities. ¹ Recent studies have shown that open-book examinations (OBE) can effectively assess students’ higher-order cognitive abilities, such as knowledge application, problem analysis, and clinical decision-making.^2,3 Particularly in highly practical disciplines like otorhinolaryngology, rote theoretical memorization proves inadequate for clinical demands. It is imperative to implement effective assessment methods that guide students in developing both clinical reasoning for disease management and essential procedural skills.

Traditionally, closed-book examinations (CBE) have served as the predominant method for assessing students’ knowledge at the Memory and Understanding levels, largely due to their perceived fairness and objectivity.^4,5 However, the diagnosis and treatment of otorhino-laryngologic diseases often require multidisciplinary knowledge integration (eg, radiology, pathology) for comprehensive clinical decision-making. The current CBE model fails to adequately evaluate students’ ability to synthesize and apply such knowledge to solve real-world clinical problems. However, as students transition into clinical practice, the educational emphasis shifts toward cultivating higher-order cognitive skills, including Application, Analysis, Synthesis/Integration, and Evaluation. Current CBE formats, which often prioritize textbook-based responses, tend to encourage rote memorization while limiting opportunities for in-depth analysis and the development of clinical reasoning skills. ⁶

Building upon previous research,^7,8 this study innovatively proposes a blended assessment (BA) model that strategically integrates the OBE and CBE. This approach, validated by Hong et al ⁸ in dental education, has demonstrated significant improvements in students’ self-directed learning capabilities while maintaining appropriate academic engagement levels. To address the unique challenges in otorhinolaryngology training, we have modified the traditional CBE by incorporating OBE elements: the first segment assesses foundational knowledge retention through CBE, while the second segment evaluates clinical problem-solving skills via OBE. Through comparative analysis with conventional CBE, this study aims to assess the impact of this innovative approach on both academic performance and pre-examination anxiety levels among otorhinolaryngology trainees. ⁹ The findings are expected to establish a novel assessment paradigm for enhancing clinical education quality in this specialty.

Materials and Methods

Results

General Characteristics and Performance Differences Between CBE and BA Groups

The study included 240 participants (123 males and 117 females). General characteristics and academic performance were analyzed. Age and gender distributions were assessed for normality and compared using the chi-square test. Exam grades, which followed a normal distribution, were compared using independent samples t-tests. Preparation time and anxiety scores, which were non-normally distributed, were compared using the Mann-Whitney U test (see Table 1).

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Table 1.

General Characteristics and Differences in Performance Between Closed-Book and Blended Assessment Students.

ParametersGroups	Age (22 years, %)	Gender (male, %)	Grades (points)	Preparation time (min)	Anxiety score (points)
2019	86 (74.8%)	59 (51.3%)	83.17 ± 6.51	48 (24, 48)	42 (34, 46)
2020	97 (77.6%)	64 (51.2%)	83.27 ± 6.37	48 (24, 48)	40 (34, 45)
χ2/t/Z	0.263	0.000	0.118	−2.215 a	−0.823 a
P	.608	.987	.906	.027*	.411

a

Z value for non-normally distributed metric data.

*

Indicates statistically significant difference with a P-value <.05.

Analysis of Factors Influencing Pre-Examination Anxiety

The Pearson correlation coefficient was used to examine potential relationships between RTA scores and other variables. No significant correlations were found between RTA scores and exam grades (see Figure 1) or preparation time (see Figure 2). In addition, the Mann-Whitney U test was employed to analyze the relationship between anxiety scores and gender, revealing no significant correlation (z = −0.814, P = .416; see Table 2). The mean RTA scores were 40.6 for females and 39.6 for males.

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Figure 1.

Correlation between anxiety scores and grades.

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Figure 2.

Correlation between anxiety scores and preparation time.

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Table 2.

Differences in Anxiety Scores by Gender.

Variable	Male	Female	Z	P
Anxiety score (points)	39 (34, 46)	42 (34, 46)	−0.814 a	.416

A P-value <.05 indicates a statistically significant difference.

a

Z value for non-normally distributed metric data.

Student Preferences for Examination Formats

This segment of the study analyzed examination format preferences among 125 students from the 2020 cohort who participated in both CBE and OBE. Of these students, 24 (19.2%) preferred CBE, with females comprising 70.8% of this group. By contrast, the majority of students (80.2%) favored OBE, with females representing 43.6% of this preference group. For a detailed distribution of preference levels, see Figure 3.

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Figure 3.

Student preferences for examination formats.

Discussion

Examinations are a critical component of the educational process, serving as essential tools for evaluating teaching efficacy and student learning outcomes. In otorhinolaryngology clinical education, particularly within the internship phase of China’s 5-year medical training program, teaching practices have traditionally emphasized theoretical knowledge retention over clinical reasoning and practical skills development. This mismatch often limits students’ ability to manage the specialty’s complex clinical scenarios, which frequently involve intricate anatomical regions, narrow surgical spaces, and multidisciplinary diagnostic considerations.

With the ongoing evolution of medical education reform, especially under the internship system, there is a growing need to shift from rote memorization toward fostering students’ higher-order cognitive abilities—such as knowledge application, clinical analysis, and decision-making. In this context, understanding the advantages and limitations of OBE and CBE is particularly relevant for educators in highly practical specialties like otorhinolaryngology.

OBE, which permits the use of textbooks, notes, and other reference materials during exams, has been implemented in various educational settings for many years.^11-13 However, to our knowledge, there are no reported instances of its application as a final assessment tool in otorhinolaryngology clinical internships. Existing literature suggests that OBE may reduce anxiety levels compared to CBE, potentially leading to improved academic performance.^14-16 Unlike studies advocating for the wholesale replacement of CBE with OBE, this study introduces a BA model that strategically integrates the 2 formats and compares its outcomes to those of traditional CBE. Interestingly, our findings indicate that students undergoing BAs did not exhibit significantly different anxiety levels compared to those assessed using traditional CBE. This may be attributed to the novelty of the format, which could introduce additional cognitive demands and emotional stress. Prior research has shown that test anxiety is closely linked to poor performance, as it may impair focus and provoke negative emotions during high-stakes assessments. ¹⁷ Nevertheless, our results revealed no significant correlation between pre-examination anxiety levels and academic performance, preparation time, or gender. It is worth noting that female students reported slightly higher average anxiety scores (M = 40.6) than their male counterparts (M = 39.6), suggesting that female medical students may experience greater stress during high-stakes clinical assessments. In otorhinolaryngology training, where students must not only memorize theoretical concepts but also apply them flexibly in diverse clinical contexts, this gender difference underscores the need for targeted psychological support and exam preparation guidance.

Prior studies have highlighted that OBE fosters deeper understanding by encouraging students to apply and synthesize knowledge in real-world contexts, thereby enhancing clinical reasoning skills.^7,18,19 By contrast, traditional CBE often places excessive emphasis on rote memorization and test-taking strategies, ¹ which may be inadequate in disciplines such as otorhinolaryngology, where foundational knowledge is necessary but not sufficient for managing complex patient cases. Some research suggests that the lower stress associated with OBE may lead to complacency and reduced preparation. ¹⁸ For instance, Heijne-Penninga et al ¹⁷ observed that students tend to spend less time preparing for OBE, perceiving them as less demanding than CBE due to the availability of reference materials. However, studies by Myyry and Joutsenvirta, ²⁰ and Theophilides and Koutselini ²¹ found no significant differences in study time between the 2 formats. In our study, although no significant differences in academic performance were observed between the BA and traditional CBE groups, students in the BA group reported longer preparation times. This suggests that the inclusion of OBE components may have enhanced students’ motivation to learn without compromising academic rigor. Such an approach may be particularly advantageous in otorhinolaryngology, where students must integrate anatomical, pathological, radiological, and procedural knowledge to make accurate diagnostic and therapeutic decisions.

In the survey on assessment preferences, over 80% of students favored the OBE component over CBE. Interestingly, the majority of CBE supporters were female (over 70%), possibly reflecting greater concerns about unfamiliar assessment formats. Student feedback indicated that although OBE questions were more challenging and did not alleviate anxiety, they promoted active learning and encouraged more thorough preparation and review. This is particularly meaningful in otorhinolaryngology, where active engagement with clinical cases—rather than passive absorption of textbook content—is essential for developing diagnostic and procedural competence. In addition, the blended model helped reduce the burden of memorizing exhaustive details, allowing students to focus more on developing clinical reasoning skills. Conversely, students who preferred CBE felt overwhelmed by the unpredictable nature of OBE questions, expressing difficulty in identifying effective study strategies. This highlights the importance of clearly communicating the expectations and structure of OBE assessments in otorhinolaryngology training and providing representative sample questions or practice exams to help students adjust their study approaches accordingly.

Despite these promising findings, several limitations must be acknowledged. First, students were asked to retrospectively report their preparation time, which may have introduced recall bias. Second, in the OBE segment, which aimed to assess higher-order cognitive abilities, students provided answers based on their levels of understanding, resulting in a wide range of responses. Although the evaluation criteria for open-book questions were established through faculty discussions, the objectivity, scientific validity, and measurability of these criteria require further verification. Future studies should address these limitations by incorporating real-time tracking of preparation time and refining the assessment rubrics for OBE to ensure consistency and reliability.

Conclusions

This study introduces an innovative BA model by incorporating an OBE component into the traditional CBE framework used in 5-year clinical internship teaching. Unlike conventional CBE or pure OBE approaches, this blended model retains a segment dedicated to evaluating foundational knowledge while integrating a component designed to assess the application of knowledge and problem-solving abilities in clinical contexts. This dual approach not only enables a comprehensive evaluation of students’ capacity to address real-world clinical challenges but also supports the transition from foundational knowledge acquisition to the development of advanced clinical reasoning skills. The findings demonstrate that this blended assessment model is a feasible and effective examination strategy for internship teaching, offering a balanced approach to assessing both theoretical understanding and practical competencies.