Non-randomized, purposive, questionnaire and interview based study started after approval from Sumandeep Vidyapeeth Institution Ethics Committee (SVIEC). All the students of first MBBS (150) for the academic year 2015 to 2016 batch were enrolled in the study while repeater students were excluded from the data collection and analysis of the study.

An innovative internal assessment method, CCES in addition to traditional method has been in cooperated in Sumandeep Vidyapeeth University. After every lecture faculty uploads five MCQ’s on the newly developed CCES online server from the taught topic which students have to attempt them within 10 minutes of time frame on their tablets using their institutional ID and password. Questions and its options presented to students are shuffled thus, chance of copying decreases. After completion of test students know their grade but cannot identify the correct answer for the posed question.

For the present study, the author provided feedback for CCES questions, 20 topics related to cardiovascular system, four related to regional circulation and nine linked to higher functions of central nervous system in the physiology department lecture hall. Feedback was provided on alternate weeks for five to six lecture topics designed for CCES program (25-30 questions per feedback session).

Pre and post-test was conducted for all the six feedback sessions to assess the learning outcome. Perception for the feedback process on CCES was collected after validating questionnaire by subject experts using five point Likert scale. Focus group discussion in three groups having eight students per group was also conducted to reconfirm our findings under the facilitation of three different instructors to minimize a biased approach.

Students paired t-test and descriptive statistical analysis and correlation analysis for gender variation was done using SPSS version 23.0 software. Data analysis allowed us to prepare evaluation matrix up to the level II i.e., we can find reaction as well as learning of the students.

The [Table/Fig-1] shows descriptive analysis for pre and post-test with correlation statistical significance (p<0.05) for feedback session 1,3,4 and 6. [Table/Fig-2] shows significant paired sample t-test significant difference (2-tailed <0.001) for each feedback session.

Twenty-one questions asked to assess the effect on learning enhancement if feedback is given for CCES question having Cronbach’s Alpha value >0.784 i.e. data for 21 items is reliability statistically. [Table/Fig-3] shows frequency distribution for 21 questions regarding effect of feedback for CCES question for learning enhancement agreement for all the asked question expect for Q5, Q6, Q7, Q10. Which implies that the students felt that there is improvement in the process of learning enhancement by receiving feedback. [Table/Fig-4] shows independent t-test showing significant statistical values for Q3, Q4, Q5, Q9, Q14 and Q17 when comparing male and female were value (p<0.05). Focus group discussion was done among 15 students with three keys question and their comments are stated in [Table/Fig-5].

Feedback has been the most powerful tool to improve academic performance and students interaction with their instructor. Our study has also shown significant improvement in learning process of students after providing feedback on formative assessment as CCES at our institute. This goes with the study by Rowe and Wood who concluded that the provision of appropriate and timely feedback promoted deep learning in students [12]. Sichinga KT et al., in their study showed that quality of feedback has significant influence on the academic achievement of students [7]. Duffield and Spencer highlighted that maximum respondents in their study expressed desire for the provision of more feedback on performance in assessment in order to guide future learning [13]. In our study, students disagreed or strongly disagreed as per frequency distribution for the difficulty faced with the CCES questions, or time allocation for completion. Students were confident about the answers written by them for the questions asked. Although, 35% of students did feel that the options given were confusing, 65.6% students agreed that feedback increased their internal grades, 69% approved that feedback motivated them to work for the course while 73% granted that it enhanced their self-planning for other topics. Crisp BR found that, a greatest increase in marks was associated with greatest reductions in the number of problem areas which was due to the consistent feedback for assessed work [14]. While Price M et al., in his study showed that some students saw a distinction between marks and feedback and disliked feedback that just provided justification of the grades [15]. However, those unsure about the purpose of feedback had adjusted and limited their view to align with the grade justifying feedback they were receiving. Moreover, staff commented in their study that they provided feedback in the hope that it would support students in later stage of the course, although, students saw limited opportunities for feed-forward [15].

In our study, 72.5% students approved that feedback enhanced their learning although 46% students disagreed and 32% had indifferent approach towards applying feedback to their future exam. Although, 68% agreed that feedback built on their previous learning and clarified concepts with reasoning was agreed by 74% of students in our study. Hernander R showed that 63% students suggested that feedback given was applicable to their future assignments [16]. Even a significant number of students reported that the feedback comments received by them were limited and did not suggest how to improve their learning. In Doan L study, 165 students accepted that tutors’ feedback was very important for their learning, were majority of them read or acted on tutors feedback [17]. One hundred eighty five students even agreed that feedback helped them to know what they had to achieve and improve in future learning process. Goel K and Ellis B, results revealed that 80.5% students responded for feedback identifying gaps in knowledge, 68.3% said that feedback identifies strengths and encouraged them to do better on future assignment while 73.2% students said that feedback showed their level of achievement against the marked criteria [18]. Study done by Dulloo P and Nazwani N showed that feedback for assessment provided better opportunity for students to improve skill of solving MCQ’s and understand the content to be focussed more upon. Even perception of faculty for feedback showed better learning process for students with conceptual understanding of topic, motivates weak students to come forward to communicate [3]. Hepplestone based on online feedback found that students expressed difficulty in feeding understanding and forwarding comments made on their work to future assignments or between modules [19]. Paul O et al., recommended that student’s feedback could be linked to ‘feed-forward’ by making clarity in structural progression and feedback [20].

In our study, 71.4% students found feedback a relaxed way of learning with interactive and supportive environment. 72.1% students accepted that feedback provides good compatibility with instructor, while 70.5% agreed to have good interaction with peer. Weaver MR showed in his study, that large majority of students felt positive feedback to be very important and confirmed that it increased their confidence [21]. Thus, more balanced feedback should be ensured to motivate rather discourage students. Havnes A et al., study found peer students help was more useful than from a teacher [22]. While teachers in their study expressed concern on various aspects including students capability to respond to feedback whether the students were interested or able to follow up feedback they received. Some researchers found feedback a helpful tool to build trust in the instructor other than motivate faculty to write better MCQ’s for further assessment [3]. Archer JC study showed that feedback enabled students to make their own revisions through dialogue, helps students to gain new understandings without dictating what these understanding will be [23]. Although, Martens R et al., found no difference in students performance as per the way of feedback provided [24].

Gender difference emerged for some of the perception and preferences, with male and female differing significantly across all measures pertaining to this: female students had strong agreement with the identification of the mistakes from the feedback with better clarification of doubts and better reasoning for key answers. Other than this female student significantly agreed that feedback helped them study seriously and increased their internal grades compared male students. They also enjoyed feedback method and appreciated facilitator for explaining concept which led to good compatibility with the instructor. It is difficult to compare the present gender findings to previous studies of Rucker ML and Thomson S because of the measurement of different constructs [25]. However, Rowe and Wood did show some of the similarity with our results as far as satisfaction with the amount of feedback or type of feedback are concerned [12].

A time constraint was the major limitation which forced author to conduct feedback after completion of five to six lecture sessions, rather than after each lecture.

The present study illustrates students perceptions about the implementation of newer approach of providing feedback after continuous formative assessment. It shows improvement in student learning outcome and experience. The survey and FGD presented students reflection for the process specifying that concepts were clarified and they were able to identify their mistake which is statistically proven to be significant for the study. The findings highlight the importance of this method since students agreed that they could remember things by discussion and had idea about the type of questions asked during exam.

Way the students perceives the taught context and the way they approach learning affects their learning outcome thus it is important to know the students approach to teaching, learning and feedback methodology. Indian medical institutes are increasingly recognizing feedback as mode to improve their teaching ratings. Future direction for research is to further explore the relationship between student’s preferences and approaches to learning. Improving the methodology of feedback in present setup is another promising area of investigation were students are taught skill of self and peer assessment since, it develops the self-regulation skill necessary for using any feedback.