CLINICAL & BASIC RESEARCH

SQU Med J, August 2011, Vol. 11, Iss. 3, pp. 383-390, Epub. 15th Aug 11
Submitted 24th Apr 11
Revision ReQ. 24th May 11 Revision recd. 1st Jun 11
Accepted 8th Jun 11

Department of Human & Clinical Anatomy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman.
*Corresponding Author email: ibrahim1@squ.edu.om

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aBstract: Objectives: Traditionally, summative practical examination in anatomy takes the form of ‘spotters’ 
consisting of a stream of prosections, radiological images and dissections with pins indicating specific structures. 
Recently, we have started to administer similar examinations online using the quiz facility in Moodle™ (a free, 
open-source web application for producing modular internet-based courses) in addition to the traditional format. 
This paper reports on an investigation into students’ perceptions of each assessment environment. Methods: Over 
a 3-year period, practical assessment in anatomy was conducted either in traditional format or online via learning 
management software called Moodle™. All students exposed to the two examination formats at the College of 
Medicine & Health Sciences, Sultan Qaboos University, Oman, were divided into two categories: junior (Year 3) 
and senior (Year 4). An evaluation of their perception of both examination formats was conducted using a self-
administered questionnaire consisting of restricted and free response items. Results: More than half of all students 
expressed a clear preference for the online environment and believed it was more exam-friendly. This preference 
was higher amongst senior students. Compared to females, male students preferred the online environment. Senior 
students were less likely to study on cadavers when the examination was conducted online. Specimen quality, ability 
to manage time, and seating arrangements were major advantages identified by students who preferred the online 
format. Conclusion: Computer-based practical examinations in anatomy appeared to be generally popular with our 
students. The students adopted a different approach to study when the exam was conducted online as compared to 
the traditional ‘steeplechase’ format.

Keywords: Anatomy; Attitude to computers; Medical education

Perceptions and Attitudes of Medical Students 
towards Two Methods of Assessing Practical 

Anatomy Knowledge
*Ibrahim M Inuwa, Varna Taranikanti, Maimouna Al-Rawahy, Omar Habbal

CLINICAL & BASIC RESEARCH

Advances in Knowledge
1. This study reports on an online method of organising anatomy “spotter” examinations.
2. It provides insight into student perceptions of assessment methods in medical education.
3. Over 44% of the students surveyed preferred the online examination method.



Perceptions and Attitudes of Medical Students towards Two Methods of Assessing Practical Anatomy Knowledge

384 | SQU Medical Journal, August 2011, Volume 11, Issue 3

During the last 20 to 25 years, digital technology has emerged rapidly from a novelty to being ubiquitous in medical 
education.1 The advances in computer technology 
and software available for medical education 
purposes have concurrently brought technological 
and software advances for the development and 
administration of computer-based examinations for 
medical students.2

Several advantages of computer-based 
examination over traditional methods have 
been suggested. These include an increase in the 
efficiency and reliability of the assessment process,3 
immediate scoring and feedback for the student and 
the instructor,4 the opportunity for item banking 
and the collection of item statistics, and the ability 
to incorporate multimedia into examinations, as 
well as a wide range of new items and new testing 
formats.1

Concurrent with studies reporting advantages, 
others attempted to examine student attitudes 
toward computer-based testing and its impact on 
students' study habits. One such previous study 
found that paediatric residents' attitudes were 
strongly positive toward the process and that the 
majority of residents preferred computer-based 
test administration over written examinations.5 

Later, Rattan et al.6 also reported that medical 
students preferred a computer test over a paper and 
pencil test. Miller et al.7 in a study on computer-
based examination in anatomic pathology similarly 
reported that medical students valued such a 
method and supported its use.

In addition to the many practical advantages 
alluded to, computer-based testing could also 
facilitate the development of more valid assessment 
strategies. This is because one of the most 
important goals of a good examination design 
is to minimise influences that interfere with the 
unambiguous expression of an examinee’s ability. 
Examinations should therefore be designed so that 
all examinees have an opportunity to perform their 
best in relation to the constructs being measured. 
The medium through which such examination is 
administered (on paper or online) should not act as 
a hindrance to the students’ performance and not 
just reflect their ability to adapt to a technology or 
to an examination format.1

The medical curriculum at Sultan Qaboos 
University extends over seven academic years. The 

first phase lasts for four years following which the 
degree of B.Sc. Health Sciences is awarded whilst 
the remaining three years comprise a clinical 
programme leading to the MD degree. An academic 
year consists of two semesters, each of 15 weeks 
duration.

Anatomy teaching is provided mainly during 
the B.Sc. Health Sciences programme, first as an 
introductory course and later integrated with other 
disciplines in organ-system courses.8 The teaching 
approach involves didactic tutor-led sessions, 
student-centered tutorials, based on patient 
scenarios that illustrate relevant anatomy, and 
practical classes in the dissection room. The anatomy 
practical uses prosected cadavers, plastinated 
organs, plastic models and radiological images. 
Although students learn on cadavers, these are 
mainly tutor-led demonstrations in small groups on 
already dissected specimens. For cultural reasons, 
there is no established body donation programme 
in the country; therefore, all cadavers have to be 
imported from abroad. Over the last decade it had 
become increasingly difficult to obtain cadavers due 
to restrictions placed on export by the countries of 
origin; this is partly because such countries do not 
seem to have enough cadavers to satisfy the need of 
their own medical schools.9 

Assessment in anatomy is conducted in the form 
of written examinations such as multiple choice 
or short answer questions. In addition, students’ 
ability to identify anatomical structures or correlate 
morphology with function is traditionally assessed 
through practical examinations. These consist of a 
circular stream of prosections, radiological images 
and dissections with pins pointing to specific 
structures (popularly referred to as ‘spotters’). 
Specific questions are then asked about where the 
pin is placed so as to identify a structure, its source 
of blood supply or function. With the increasing 
difficulty in obtaining a constant supply of cadaveric 
material, the wear and tear of the existing ones 
became a real problem to the extent that the normal 
anatomy has become increasingly unrecognisable. 
In such a situation, innovation is needed both in 
teaching and assessment so as to use the available 
cadaveric material optimally. This led to the idea 
of developing an online summative assessment 
system using digitised images of the same material 
used in teaching. Our goal has been to create digital 
resources for conducting examinations similar 



Ibrahim M Inuwa, Varna Taranikanti, Maimouna Al-Rawahy, Omar Habbal

Clinical and Basic Research | 385

to the traditional anatomy practical examination 
(spotter). 

Computer-based assessment is not just an 
alternative method of delivering examinations, 
it represents an important qualitative shift from 
traditional methods such as paper based tests.10 

Consequently, when examinations migrate from 
paper-and-pencil format to computer delivery, 
a wide range of issues could arise such as test 
fairness, students’ preparation habits and their 
perception of the examination format. In this 
study, we investigated our students’ perceptions of 
both online and traditional methods of practical 
assessment in anatomy. In particular, we were 
interested in investigating whether students 
adopt similar or different learning and test-taking 
strategies depending on the examination method.

Methods
Ethical approval for this project was obtained from 
the Research and Ethics Committee of the College 
of Medicine & Health Sciences at Sultan Qaboos 
University. Data collection was carried out during 
the six fall and spring semesters from 2007 to 
2009 (inclusive) when organ-system courses were 
delivered. Teaching of anatomy in a 7-year medical 
curriculum is delivered over three academic years 
(years 2 to 4) within integrated organ-system 
courses. Practical examinations are administered 
at the end of each course. Typically, the number of 
questions ranges from 40–50 items for each organ-
system course.

The practical examination in the online 
environment utilised digitised ‘assessment objects’ 
from materials used for teaching. These included 

 
Figure 1: Two examples of online spotter questions. 



Perceptions and Attitudes of Medical Students towards Two Methods of Assessing Practical Anatomy Knowledge

386 | SQU Medical Journal, August 2011, Volume 11, Issue 3

dissected cadavers, surface anatomy and radiological 
images and microscopic slides [Figure 1]. In 
addition, short video clips of 30 seconds duration 
demonstrating muscle action were also used. These 
‘objects’ were optimised for online viewing and then 
uploaded onto the learning management software, 
Moodle™ (a free, open-source web application 
for producing modular internet-based courses).11 
This software has been used for online learning 
experiences in a variety of courses for the health 
professions.12-16 Using the quiz tool in the software, 
a bank of questions was created and linked to the 
assessment objects. Access to the software and the 
questions is through the password-protected secure 
University server.

With regards to the examination in the 
traditional format, the actual specimens were laid 
out in a circular stream in the dissecting room. 
Lettered tags were then attached with pins to 
specific spots on the specimens and questions were 
asked regarding those tagged spots. The number 
of questions was similar to that of the online 
environment.  The questions were reviewed by a 
team of two faculty members to ensure accuracy 
and concordance with course objectives before the 
start of the examination. The perception of medical 
students towards anatomy practical examination 
was studied among those in years 3 and 4 
(comprising about 120 students in each cohort) 
for three consecutive years, and anatomy practical 
examinations in organ-system courses were 
conducted both in traditional and online formats 
for all students. Students are informed by the course 

director about the format of practical examination 
at the beginning of each course. Our policy specifies 
that only course directors familiar with Moodle 
are permitted to administer online examinations. 
Others not yet trained, or not favourably inclined 
towards virtual learning philosophy, administer 
the practical examinations in the usual traditional 
format within the dissecting room. Immediately 
after each examination, and before results were 
announced, a paper-based or electronic student 
survey was carried out requesting voluntary 
feedback on their experience. Students had the 
right to decline taking part in the survey and were 
informed that the data would be published. The 
responses were categorised into those from senior 
students (year 4) and junior students (year 3). A chi-
square test for independence between gender and 
seniority was computed using GraphPad Prism, 
version 5.00 for Windows (GraphPad Software, 
San Diego, California, USA, www.graphpad.com).  
A P value of 0.05 or lower was considered significant.

Results
A total of 515 completed responses were returned 
(71.5 % response rate). This comprised 165 (32%) 
senior and 350 (68%) junior students. There was 
an equal gender distribution amongst both junior 
and senior respondents (male: female = 1: 1.01). The 
actual distribution of students that preferred one 
of the examination formats, or had no preference, 
is presented in Table 1a. Overall, 229 (44.5%) of 
all respondents preferred the online environment 
whilst 190 (36.9%) preferred the traditional format 
and 96 (18.6%) had no particular preference [Table 
1a]. A significant proportion (82%) of students 
who preferred the traditional format were junior 
students (P <0.001). Similarly, there was a slight 
but significant gender difference with females and 
junior students expressing more preference for 

Table 1a: Distribution of students that preferred either examination format or had no preference

Gender

Seniority Online examination                      Traditional format                 No Preference Totals

Male Female Male Female Male Female

Junior 60 45 70 87 40 48 350

Senior 70 54 8 25 2 6 165

Total 130 99 78 112 42 54 515

Table 1b: Chi-Square statistics on preference of 
examination format by medical students

Gender Seniority

Chi-Square 5.9 245.2

Degree of freedom (df ) 1 1

Significance <0.05 <0.001



Ibrahim M Inuwa, Varna Taranikanti, Maimouna Al-Rawahy, Omar Habbal

Clinical and Basic Research | 387

traditional examination format (P <0.05) [Table 
1b]. Interestingly, amongst those respondents 
expressing no preference, 91% were junior students 
with no significant gender difference [Table 1a].

Amongst all students who responded, the major 
reasons given for prefering the online examination 
format (n = 229) included better specimen quality 
(151), ability to manage the total time for the 
examination rather than being forced to spend an 
equal time on each question (160), and not having 
to keep moving throughout the examination, but 
remaining seated in one place (123) [Figure 2a]. On 
the other hand, slow Internet connectivity and fear 
of computer software/hardware failure were some 
of the major concerns expressed by students who 

preferred the traditional format [Figure 2b].
When asked about the influence of the type of 

examination format (online or traditional) on their 
mode of preparation and study habits, 129 (78%) 
of senior students indicated being significantly 
influenced by the examination format while, only 27 
(8%) of junior students agreed that the examination 
format had influenced their study habits and mode 
of preparation [Figure 3]. In addition, 119 (72%) of 
senior students and 116 (33%) of junior students 
said that they did not study on cadaveric specimens 
when the examination was conducted in the online 
format [Figure 4].

0

10

20

30

40

50

60

70

Good Specimen Quality

What important reasons made you prefer the online examination format? (n = 229)

Seating during Exam Time Management MCQ Format

%
 o

f s
tu

de
nt

s

 
Figure 2a: Distribution of the most important reasons for student preference of online examination format.

0

10

20

30

40

50

60

70

80

Slow Internet 
Connection

What important reasons made you prefer the traditional examination format? (n = 190)

Computer Glitch Technophobia Eye Strain

%
 o

f s
tu

de
nt

s

 
Figure 2b: Distribution of the most important reasons for student preference of traditional examination format.



Perceptions and Attitudes of Medical Students towards Two Methods of Assessing Practical Anatomy Knowledge

388 | SQU Medical Journal, August 2011, Volume 11, Issue 3

Discussion
The computer-based examination setting has been 
in use for over four decades.17 Such a setting is 
attractive because it makes automated marking 
possible, and the students receive instant feedback. 
Recently, apart from formative assessment, 
computer-based examinations are increasingly 
being used for end point, summative examinations 
(such as the US medical licensing examination). 
Its acceptability as a means of assessment in high 

stakes examinations is now well established. Several 
surveys have shown that computer-based tests were 
more popular than traditional tests. The preference 
for online assessment found in our results is similar 
to that reported earlier in the literature regarding 
computer-based tests.5,7 Based on the results 
[Table 1a and Figure 2a], the main reasons for 
this preference were higher quality specimens and 
easier time management whereby students could 
scan through the questions at their own pace. This 
is in contrast to the traditional format where they 

0

25

50

75

100
Significantly n = 156
Not Significantly n = 227
Less likely n = 132

When the spotter is online does it influence the way you prepare for the examination? (n = 515) 

Junior students Senior students

%
 o

f s
tu

de
nt

s

 
Figure 3: Distribution of student responses and their mode of preparation and study habits when asked if the examination 
format (online or traditional steeplechase) significantly influenced the way they prepare for the examination.

0

10

20

30

40

50

60

70

80

Significantly n = 156
Not Significantly n = 227
Less likely n = 235

What is the likelihood of you studying on cadaveric specimen in the dissecting room 
when the spotter will be conducted online? 

Junior students Senior students

%
 o

f s
tu

de
nt

s

 
Figure 4: Distribution of student responses when asked about the likelihood of them studying on cadaveric specimen 
when the examination format is conducted online.



Ibrahim M Inuwa, Varna Taranikanti, Maimouna Al-Rawahy, Omar Habbal

Clinical and Basic Research | 389

are restricted to the same length of time for each 
question regardless of difficulty.

Being seated for online format examinations 
as opposed to moving about constantly during 
the examination could potentially be beneficial in 
reducing the level of anxiety. This could be an added 
explanation for student preference of the online 
format.

The impact of gender on computer related 
attitudes, abilities, and usage has been actively 
documented.19,20 Many findings in the literature 
indicated that males had more positive attitudes, 
higher ability, and used computers more.21 Other 
studies, however, suggest that the differences 
between males and females may be on the decline, 
although male dominance is still prevalent with 
respect to attitude, ability, and use of computers.19,20 
In this study, we found a clear overall gender 
difference in the preference for examination 
format with female students more likely to prefer 
the traditional than the online format. Amongst a 
single cohort of students senior or junior, however, 
the proportion of males and females who preferred 
the online format was similar. This suggests that 
the gender ‘digital divide’ within the same group of 
students in our setting is not as wide as has been 
reported elsewhere.22 

When asked about the influence of the 
examination format on their study habits and 
preparation, the majority of students indicated 
that they usually study as normal before an 
examination. However, a great majority of senior 
students indicated that their study habits and 
preparation for the practical examination later 
became influenced by the format of examination. 
We observed a growing tendency amongst the 
majority of students to prepare for examination 
using image atlases rather than dissected 
specimens. This is not surprising considering the 
fact that assessment is well known to be a major 
determinant of how students learn.23 A likely 
explanation for this occurrence could be due to the 
difference in specimen quality in both examination 
formats. Because of the extreme wear and tear on 
some of our specimens, the traditional format has 
been associated with examination difficulty since 
exact identification in some situations became 
problematic. The senior students became aware of 
this reality and thereby modified their preparation 
according to the examination formats. This was in 

sharp contrast with junior students, possibly due to 
their lack of both experience and exposure to the 
two examination formats.

 The results in this study have a number of 
implications for anatomy teaching in settings 
similar to ours. First, medical students are in 
general favourably disposed to and comfortable 
with the use of computer-based technology for the 
assessment of learning. This attitude should help to 
reassure faculty members intending to include such 
tools in their teaching. Another equally important 
implication is to what extent should one rely on 
anatomy learning on cadavers if the assessment of 
such learning will be conducted differently? In a 
situation where the physical condition of cadaveric 
specimens is not appropriate for learning, or the 
specimens are in short supply, should the use of 
technology be given more emphasis for teaching? 
A more crucial implication of this study is related to 
the quality of students certified through computer-
based assessment; will they be any better or worse 
than students who are assessed in the traditional 
format? Are both formats equally valid? Clearly, 
further research is indicated to address some of the 
questions raised above.

Conclusion
In conclusion, computer-based practical 
examinations in anatomy appear to be generally 
popular with medical students in our setting. 
However, we found a clear split in this popularity, 
with students in senior classes more favourably 
disposed to computer-based practical examination. 
The majority of students adopted a different 
approach to study when informed that the 
practical examination would be conducted online 
as compared to the traditional format. We suggest 
further investigation to determine whether there 
is a significant difference in student performance 
between the two examination formats.

a c k n o w l e d g e m e n t s

We wish to thank The Research Council (TRC), 
Oman, for funding this project and Mr. Alexander 
George of the Anatomy Department for helping 
with the compilation of student questionnaire 
responses.



Perceptions and Attitudes of Medical Students towards Two Methods of Assessing Practical Anatomy Knowledge

390 | SQU Medical Journal, August 2011, Volume 11, Issue 3

c o n f l i c t o f i n t e r e s t
The authors reported no conflict of interest.

References
1.  Peterson MW, Gordon J, Elliott S, Kreiter C. 

Computer-based testing: Initial report of extensive 
use in a medical school curriculum. Teach Learn 
Med 2004; 16:51–9.

2. Ogilvie RW, Trusk TC, Blue AV. Students' attitudes 
towards computer testing in a basic science course. 
Med Educ 1999; 33:828–31.

3. Kreiter CD, Ferguson K, Gruppen LD. Evaluating 
the usefulness of computerized adaptive testing 
for medical in-course assessment. Acad Med 1999; 
74:1125–8.

4. Ferguson KJ, Kreiter CD, Peterson MW, Rowat JA, 
Elliott ST. Is that your final answer? Relationship 
of changed answers to overall performance on a 
computer-based medical school course examination. 
Teach Learn Med 2002; 14:20–3.

5. Butzin DW, Friedman CP, Brownlee RC. A pilot 
study of microcomputer testing in paediatrics. Med 
Educ 1984; 18:339–42.

6. Rattan A, Mittal S, Gupta A. Role of computers 
in learning - application in formative assessment. 
Indian J Pediatr 1994; 61:139–44.

7. Miller AP, Haden P, Schwartz PL, Loten EG. Pilot 
studies of in-course assessment for a revised medical 
curriculum. II. Computer-based. Acad Med 1997; 
72:13–15.

8. Abu Hijleh MF, Habbal OA, Moqatash S, Harris 
PF. Clinical anatomy and anatomical skills: An 
innovative course. Med Teach 1995; 17:283–8.

9. Gunderman RB. Giving ourselves: The ethics of 
anatomical donation. Anat Sci Educ 2008; 1:217–19.

10. Cantillon P, Irish B, Sales D. Using computers for 
assessment in medicine. BMJ 2004; 329:606–9.

11. Inuwa IM, AlRawahy M, Taranikanti V, Habbal O. 
Anatomy "steeplechase" online: Necessity sometimes 
is the catalyst for innovation. Anat Sci Educ 2010; 
4:115–18.

12. Kukolja-Taradi S, Dogas Z, Dabic M, Drenjancevic 
PI. Scaling-up undergraduate medical education: 
Enabling virtual mobility by online elective courses. 
Croat Med J 2008; 49:344–51.

13. Shah IM, Walters MR, McKillop JH. Acute medicine 
teaching in an undergraduate medical curriculum: 
A blended learning approach. Emerg Med J 2008; 
25:354–7.

14. Carley S, Kway-Jones K. Developing a virtual learning 
course in emergency medicine for F2 doctors. Emerg 
Med J 2007; 24:525–8.

15. Carbonaro M, King S, Taylor E, Satzinger F, Snart F, 
Drummond J. Integration of e-learning technologies 
in an interprofessional health science course. Med 
Teach 2008; 30:25–33.

16. Romanov K, Nevgi A. Do medical students watch 
video clips in eLearning and do these facilitate 
learning? Med Teach 2007; 29:484–8.

17. Swets JA, Feurzeig W. Computer-aided instruction. 
Science 1965; 150:572–6.

18. Neuderth S, Jabs B, Schmidtke A. Strategies 
for reducing test anxiety and optimizing exam 
preparation in German university students: A 
prevention-oriented pilot project of the University of 
Wurzburg. J Neural Transm 2009; 116:785–90.

19. Adrianson L. Gender and computer-mediated 
communication: Group processes in problem 
solving. Comput Human Behaviour 2001; 17:71–94.

20. Atan H, Sulaiman F, Rahman Z, Idrus RM. Gender 
differences in  availability, internet access and rate 
of usage of computers among distance education 
learners. Educ Media Internat 2002; 39:205–10.

21. Kay Robin. Addressing gender differences in 
computer ability, attitudes and use: The laptop effect. 
J Educ Computing Res 2006; 34:187–211.

22. Brosnan M, Lee W. A cross-cultural comparison 
of gender differences in computer attitudes and 
anxieties: The United Kingdom and Hong Kong. 
Comput Human Behav 1998; 14:559–77.

23. Duffield KE, Spencer JA. A survey of medical 
students' views about the purposes and fairness of 
assessment. Med Educ 2002; 36:879–86.