It was a Quasi Experimental, Open labelled, Mixed method study (QUAN→qual). Students of first professional year in faculty of Medicine (Batch 2016) enrolled in Jawaharlal Nehru Medical college, Sawangi (M), Wardha were included in the study by non probability convenience sampling (n=200). Study was conducted at Department of Physiology and School of Health Professionals Education and Research, DMIMS (DU).

Ethical considerations: The relevance and feasibility of the educational research work were evaluated by the Scrutiny committee for educational research. Ethical issues were assessed by Institutional Ethical committee (Ref no: DMIMS(DU)/IEC/2016-17/6040). Written informed consent of study population was obtained before the study.

Material/Test instrument: Six standardized and one validated method of FACTs were implemented as stated below;

A. Formative Assessment Classroom Techniques;

Standardized Methods: 1) Classroom quiz; 2) One sentence summary; 3) Exit ticket; 4) Directed Paraphrasing; 5) One-minute paper; 6) Muddiest point [12-15].

Validated Method: 7) Logic model for physiological regulation [16].

B. Evaluation was done by: Pre test, Post test and Feedback questionnaire

Seven thematic areas (‘must know’ of Physiology curriculum) were chosen for implementation of seven types of FACTs catering to varied learning styles and learning preferences. The selection of content areas was based on three features, namely:

The content areas selected were Immunity, Action Potential, Electrocardiogram, Regulation of Blood Pressure, Regulation of respiration, Counter-current mechanism of kidneys and limbic system. The FACTs employed for these content areas were Classroom quiz, Exit slip, One minute paper, Logic model, One sentence summary, Directed paraphrasing and muddiest point respectively. These seven FACTs were selected on basis of: 1) Level of cognition that needs to be addressed; 2) Suitability to the nature of content; and 3) Catering to different learning styles viz., Visual, Aural, Verbal, Social, Solitary and Logical.

Workflow: The first year professional students student in faculty of Medicine (n=200) were randomly assigned to experimental (n=100) and control (n=100) group by Lottery method. Both the groups were subjected to pre-test. After the selected classroom Instructional activity, the selected FACT was conducted for the Experimental group. After FACTs, responses were collected anonymously, analysed and learning issues identified. Based on the identified learning issues, subsequent learning activity was planned for experimental group. It was taken care that the least comprehended part of the content was suitably dealt in the subsequent instructional activity by revising the teaching strategy and learning objectives. The control group was subjected to conventional method of classroom instruction with pre-defined learning objectives and strategies. The second Instructional activity was followed by post test for both the groups. Seven similar cycles were followed including seven thematic areas in physiology with seven selected FACTs, within a period of one year. Quantitative and Qualitative data were sought through a feedback questionnaire for capturing the perception and preferences of learners (Experimental group) towards the intervention. [Table/Fig-1] shows project work flow chart.

[Table/Fig-1]:

Project work flow chart.

The instructional activity of experimental group was conducted in four phases namely; Planning, Implementation, Analysis and Amendment. The stepwise intervention is depicted in the Schema of Formative Medical classroom [Table/Fig-2] [17,18].

[Table/Fig-2]:

Schema of formative medical classroom (Copyright no.: L-68933/2017, Tripti K Srivastava, Vedprakash Mishra, Lalitbhushan Waghmare) [17].

The detailed description of selected FACTs as against thematic area, its process of conduction, supported learning style and formative attributes are as depicted in [Table/Fig-3] [15,16].

Analysis of data: The analysis of data were done keeping in view the predefined objectives of the study. Statistical tool used for the analysis was SPSS version 16. [Table/Fig-4] depicts the analysis of data, based on the purpose as per objectives of the study by using appropriate statistical tools.

The experimental group consisted of 49 (49%) male and 51 (51%) female students. The control group had 38 (38%) and 62 (62%) male and female students respectively. The pre test and post test scores of every FACT group (total 7) and every parallel control group (total 7) were compared by paired t-test and were found to be statistically significant for every group (p<0.05 was considered statistically significant). The pre test scores of every FACT group was compared with parallel control group to assess any baseline difference in knowledge between two groups. However, all seven (experimental with control groups) were statistically non-significant thereby establishing the fact that both groups were comparable with respect to baseline knowledge about the thematic area under consideration.

Post test scores between experimental and parallel control group (for every FACT) were compared for significance by unpaired t-test and were found to be statistically significant as depicted in [Table/Fig-5].

Comparison of sum of post test scores for all 7 FACTs in experimental groups and control groups: From [Table/Fig-6] it is observed that in experimental group after exposure to all the seven type of FACTs, the mean score was 7.43±0.82, 95% CI (1.6,1.8) as compared to controls who had mean score of 5.65±0.96, 95% CI (1.6,1.8). These differences were statistically significant (p<0.01).

Effect size: The effect size estimates the effectiveness of an intervention by comparing it with a standard in quantitative terms. The effect size of the intervention (by FACTs) was calculated to be 1.12 by STATA version 14.1 software (StataCorp). The effect size of 1.12 suggests a percentile gain of 37 percentile. That is, students scoring at the 50^th percentile on conventional instructional model would be predicted to score at the 87^th percentile after incorporation of FACTs.

Learning gain for every FACT (Experimental) and Control group: The [Table/Fig-7] depicts learning gain for after every FACT group and control group, based on pre test and post test scores. The ALG was in the range of 68.5–75% in FACTs group and 51.8 – 57.1% in control group. The class average normalized gain was high, within the range of 0.71-0.76 for all FACTs and was medium for all control groups i.e., within the range from 0.52 – 0.58.

Analysis of feedback: In response to the question “Do you feel that in-class assessments should be practiced by teachers? Why?”100% students in experimental group agreed towards regular practice of FACTs in regular instructional activities.

The reasons quoted by students for regular practice of FACTs within instructional activity were grouped into eight categories viz., 1) Revision; 2) Better learning; 3) Better memorization; 4) Conceptual understanding; 5) Dealing with learning issues; 6) Improved confidence; 7) Self assessment; 8) Makes learning interesting. The verbatim responses are depicted in [Table/Fig-8]. The categorized themes are in congruence with the inherent merits of Classroom based Assessments for better learning.

Triangulation of data for interpretation: For a better interpretation of ALG, it was triangulated with the qualitative responses of the learners by sequential explanatory strategy. It was inferred that the learning gain was maximum with ‘Directed Paraphrasing’, followed by ‘one sentence summary’. Both the techniques include summarizing the contents taught during instruction that enables quick revision. The qualitative comments reflect the same wherein maximum responses favoured the ‘quick revision’ quality of FACT. Next in line was classroom quiz that require effortful retrieval of contents. The same was observed in qualitative comments wherein learners quoted ‘better memorization’ as next best attribute of FACT.

The analysis of responses to formative assessment gives a rich repertoire of information that can be explored for subsequent instructional activities to close the learning gaps. One useful concept is an assessment triangle that shows the presence of three elements in any type of assessment: a model of student cognition, which describes how students develop competencies in an academic domain and how they organize their knowledge at different levels of development; observations, which are the tasks or activities in which students‘ performance can be observed, scored, and evaluated for the purpose of gathering evidence of learning; and interpretation, which is the rationale for making sense of and deriving inferences from the evidence gathered [19]. In formative assessment, a fourth element needs to be present i.e., effective translation of the interpretation of assessment performance to instructional decisions and actions. The quality of inferences derived from the assessment will depend on how well these four elements have been linked [15].

In the present study, the responses of every FACT was analysed and remedial actions were planned as depicted in [Table/Fig-9]. It is important to state that learning gaps existed after every instructional activity.

[Table/Fig-9] shows analysis of FACT responses for identifying learning issues and teaching modifications thereof.

The implementation of FACTs in the present project specifically addressed four essential elements of classroom formative assessment process: 1) identifying the learning gap; 2) feedback; 3) student involvement; and 4) learning progressions. Identifying the gap, Royce Sadler’s seminal work involves understanding the difference between what students know and what they need to know, and how instruction will be most effective to meet desired learning goals [19]. All FACTs in the said project incorporated group feedback in subsequent classroom instruction which was based on student responses. It actively involved the learners and their learning status was shared by the researcher.

Learning progressions break down a larger learning goal into smaller sub-goals. It is necessary for helping teachers locate students’ current learning status in relation to a continuous set of skills needed to master the learning standard. Popham defines learning progressions as a “carefully sequenced set of building blocks that students must master en route to a more distant curricular aim” [20]. Learning progressions carefully lay out the progression of concepts and skills learners acquire overtime and that leads to deeper connections among a larger network of concepts and skills. In pre clinical phase of Medical education, the learners need to be assessed on a broader range of level of knowledge and skills. Through continual evidence gathering and fine tuning of student instruction, as acquired through FACTs, teachers can begin to narrow their differentiated focus and move towards the specific learning goals. It is important to understand that properly articulated learning progressions, and their subsequent assessments, will allow teachers to understand where their students are and allow them to refine that process with more granularities to move students toward their goals throughout the year. This very concept of explicitly defining learning objectives and focussed assessments as against LO were explored within the said project.

Learning through classroom Formative Assessments: Present study demonstrates better learning gain after implementation of classroom formative assessments as compared to control group. Better learning was a consistent feature with every FACT as compared to controls. Supporting evidences documented by Paul Black and Dylan Wiliam states that, students who are taught by teachers practising classroom formative assessments, achieve in six/seven months what otherwise would take a year [9]. More importantly, these improvements were consistent across countries (including Canada, England, Israel, Portugal, and the United States), as well as across age brackets and content areas. Similar gains were recorded when student achievement was measured with externally mandated standardized tests [5]. Most claims about the benefits of formative assessment begin with the Black and William’s review of research on formative assessment. These studies had some common features like the use of some of the features of formative assessment (e.g., feedback, teacher questioning, student self-assessment). These features were associated with moderate-to-large effect sizes. In analysing studies conducted on wide range of students, the average effect sizes from those receiving formative assessment treatments were between 0.4 and 0.7. Common effect size guidelines put an effect size of 0.2 in the “small” category. A “medium” effect size is 0.5. A “large” effect size is 0.8.

Meta-analysis of studies on the impact of classroom formative assessment on K–12 student achievement concludes that - if only the studies hewing to rigorous methods are examined; the effect sizes of formative assessment are usually positive [21]. The impact of formative assessment in improving the performance of students in exams was also documented by Greer L [22]. This study compared the performance of students from different cohorts; one that used non-formative assessment, and another that used a new formative assessment strategy. The findings indicated that changing the mode of assessment effects student performance, which on the whole was better for the cohort that used the formative assessment. Study by Paschal CB denotes that learning of systems physiology concepts is effective when in-class quizzes and activities with instant feedback via., a wireless classroom communication system are used in place of traditional learning activities [23]. In a related study, authors concluded that when effective communication principles are adhered to in classroom formative assessments; an effect size of 0.79 is obtainable [24]. The effect size in the present study was estimated to be 1.12, large enough to indicate the efficacy of FACTs in better learning.

Literature suggest the possibility of Classroom FAs exerting more influence on teaching practices (e.g., creating a positive learning environment) than on learning. It helps students learn how to be better learners [24,25]. There is no best FACT or collection of FACTs that can improve teaching; rather, it is a choice essentially on the basis of established curricular goals and is targeted towards improving instruction. Before selecting a FACT, key ideas to be borne in mind are: 1) The type of pedagogy embedded within the FACT as the best match for the contents; and 2) The FACT that can produce best information to inform my teaching. It is important to be aware that irrespective of the method of FACT employed with educational interventions, due consideration must be given to the different learning styles of the students from the different disciplines as considered in the present study.

Feasibility Aspects: Training of medical teachers is of prime importance if classroom based formative assessments are to be included within the curriculum. The other challenge is reorganising instructional time for effective inclusion of FACTs in the already existing time constraints within the curriculum. This can be tided over by proper planning in terms of specific areas within the subjects that are of prime importance and judicious selection of the type of FACT (in terms of its suitability to the content being taught, time required for administration, and time required for analysis). Actual FACT should not take more than 8-10 minutes of classroom instruction time and should be simple and engaging for the learners, as observed in the present study. The cognitive demand for FACTs is yet another attribute which should be taken care of while planning for FACT. Literature suggests a mix of the levels of cognition. Ease of use is the most important indicator for acceptability of the technique, as also evidenced by the present study wherein Classroom Quiz, One Minute Paper and One Sentence Summary were the most preferred methods that are the simplest to administer and respond. The general implementation attributes of the FACTs used for the present study is shown in [Table/Fig-10].

The ideal interim period between two successive class (on the same topic) where FACT is administered should be of two days, thus providing adequate time for analysis of responses and instructional modifications. The probes within FACTs should be specifically based upon the learning objectives of the instructional activity. The administration time can be further abridged by using technology based classroom assessments, though it has its own limitations. The limitation realised was that the responses were not prompt and therefore the analysis took longer time than anticipated.

The present study has put forth an instructional model that judiciously incorporates classroom based assessments to monitor student’s conceptual learning and timely remediation within instruction to close the learning gaps. The study concludes that FACTs can be seamlessly integrated within instructional activities in medical classrooms and incorporation of such activities improves learning. Learners’ favour FACTs that enable quick revision and FACT strategies catering to different learning styles make it more suitable and sustainable within classroom dynamics. Resultantly; this may strengthen the scientific concepts taught in the classroom through a well monitored navigation towards higher levels of learning.