The Two-Stage Examination: A Method to Assess Individual Competence and Collaborative Problem Solving in Medical Students

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Effectively solving problems as a team under stressful conditions is central to medical practice; however, because summative examinations in medical education must test individual competence, they are typically solitary assessments.


Using two-stage examinations, in which students first answer questions individually (Stage 1) and then discuss them in teams prior to resubmitting their answers (Stage 2), is one method for rectifying this discordance. On the basis of principles of social constructivism, the authors hypothesized that two-stage examinations would lead to better retention of, specifically, items answered incorrectly at Stage 1.


In fall 2014, they divided 104 first-year medical students into two groups of 52 students. Groups alternated each week between taking one- and two-stage examinations such that each student completed 6 one-stage and 6 two-stage examinations. The authors reassessed 61 concepts on a final examination and, using the Wilcoxon signed ranked tests, compared performance for all concepts and for just those students initially missed, between Stages 1 and 2.


Final examination performance on all previously assessed concepts was not significantly different between the one-and two-stage conditions (P = .77); however, performance on only concepts that students initially answered incorrectly on a prior examination improved by 12% for the two-stage condition relative to the one-stage condition (P = .02, r = 0.17).

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Team assessment may be most useful for assessing concepts students find difficult, as opposed to all content. More research is needed to determine whether these results apply to all medical school topics and student cohorts.

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