Spot(ters) the difference: Bringing traditional anatomical examinations online.

The COVID-19 pandemic caused a shift in anatomy education forcing institutions to find innovative ways to teach and assess online. This study details the development of an online spotter across multiple modules that allowed students to sit the examination at home whilst still maintaining the integrity of the assessment. The online spotter consisted of individual, Zoom calls between students and examiners whereby slides with images and questions were screen shared. To examine the viability of this spotter in non-lockdown scenarios several parameters were considered. Mean marks were compared to traditional versions and Pearson's r correlation coefficients were calculated between online and traditional spotters and between online spotters and overall performance in anatomy modules. A survey was carried out to determine the students' view of the assessment. Pearson's r was between 0.33 and 0.49 when comparing online spotters to the traditional format, and between 0.65 and 0.75 (p < 0.01) when compared to a calculated anatomy score. The survey indicated overall student satisfaction as 82.5% reported that it was a fair way to test their knowledge and 55% reported the same or lower levels of anxiety when compared to traditional spotters. However, there was nothing to indicate that the students preferred this format over laboratory-based spotters. These results indicate that this new exam format would be useful for small cohorts who are undertaking online or hybrid courses, or in circumstances when running a full spotter is too costly, and represents a fair and robust way to assess practical anatomical knowledge online.

Evaluating Surgical Complexity of Endoscopic Hysterectomy: An Inter-rater and Intra-rater Agreement Study of Novel Scoring Tool.

STUDY OBJECTIVE: Evaluate inter-rater and intrarater reliability of a novel scoring tool for surgical complexity assessment of endoscopic hysterectomy. DESIGN: Validation study. SETTING: Academic medical center. PARTICIPANTS: Total of 11 academic obstetrician-gynecologists with varying years of postresidency training, clinical practice, and surgical volumes. INTERVENTIONS: Application of a novel scoring tool to evaluate surgical complexity of 150 sets of images taken in a standardized fashion before surgical intervention (global pelvis, anterior cul-de-sac, posterior cul-de-sac, right adnexa, left adnexa). Using only these images, raters were asked to assess uterine size, number, and location of myomas, adnexal and uterine mobility, need for ureterolysis, and presence of endometriosis or adhesions in relevant locations. Surgical complexity was staged on a scale of 1 to 4 (low to high complexity). MEASUREMENTS AND MAIN RESULTS: Number of postresidency years in practice for participating surgeons ranged from 2 to 15, with an average of 8 years. A total of 8 obstetrician-gynecologists (72.7%) had completed a fellowship in minimally invasive gynecologic surgery. Six (54.6%) reported an annual volume of >50 hysterectomies. Raters reported that 95.4% of the images were satisfactory for assessment. Of the 150 sets of images, most were found to be stage 1 to 2 complexity (stage 1: 23.8%, stage 2: 41.6%, stage 3: 32.8%, stage 4: 1.8%). The level of inter-rater agreement regarding stage 1 to 2 vs 3 to 4 complexity was moderate (κ = 0.49; 95% confidence interval [CI], 0.42-0.56). Moderate inter-rater agreement was also found between surgeon raters with an annual hysterectomy volume >50 (κ = 0.49; 95% CI, 0.40-0.57) as well as between surgeon raters with fellowship experience (κ = 0.50; 95% CI, 0.42-0.58). Intrarater agreement averaged 80.2% among all raters and also achieved moderate agreement (mean weighted κ = 0.53; range, 0.38-0.72). CONCLUSION: This novel scoring tool uses clinical assessment of preintervention anatomic images to stratify the surgical complexity of endoscopic hysterectomy. It has rich and comprehensive evaluation capabilities and achieved moderate inter-rater and intrarater agreement. The tool can be used in conjunction with or instead of traditional markers of surgical complexity such as uterine weight, estimated blood loss, and operative time.

Introducing free response short answer questions in anatomy spot tests: experiment study.

PURPOSE: A spot test is commonly used to assess practical knowledge through a series of specific questions related to the marked anatomical structures on cadavers. However, the continuous reviewing and developing of the medical curricula demands the need to improve the assessment method of the practical examination of anatomical knowledge. Therefore, the aim of the study was to examine the effectiveness of a free response short-answer questions (FRSAQs) test and traditional questions on medical students' performance. METHODS: This is an experimental study using a Randomized Posttest-Only Control Group Design to compare the mean of students' performance in addition to their perceptions about the two versions of the spot tests. Two hundred and ninety preclinical-year medical students were invited to participate in this study. RESULTS: Only 109 (38%) students participated in this study. The data analysis showed a significant improvement in students' performance in the FRSAQs test (5.3 ± 2.7) than the traditional spot test (4.7 ± 2.6), (P = 0.04). The majority of the students (70%) preferred the FRSAQs spot test, citing that it is good test to assess practical knowledge. The psychometric analysis revealed that the FRSAQs produced more ideal stations (60%) when compared to the traditional spot test (10%). CONCLUSION: The current study found that the FRSAQs spot test had a significant impact on students' performance, and it was considered an ideal, flexible, and stress-free assessment method when compared to the traditional spot test. Implementation of the strategy in teaching and in assessment is recommended.

Incorporating Augmented Reality Into Anatomy Education in a Contemporary Medical School Curriculum.

Anatomy education in the medical school curriculum has encountered considerable challenges during the last decade. The exponential growth of medical science has necessitated a review of the classical ways to teach anatomy to shorten the time students spend dissecting, allowing them to acquire critical, new knowledge in other disciplines. Augmented and mixed reality technologies have developed tremendously during the last few years, offering a wide variety of possibilities to deliver anatomy education to medical students. Here, we provide a methodology to develop, deliver, and assess an anatomy laboratory course using augmented reality applications. We suggest a novel approach, based on Microsoft® HoloLens II, to develop systematic sequences of holograms to reproduce human dissection. The laboratory sessions are prepared before classes and include a series of holograms revealing sequential layers of the human body, isolated structures, or a combination of structures forming a system or a functional unit. The in-class activities are conducted either as one group of students (n = 8-9) with a leading facilitator or small groups of students (n = 4) with facilitators (n = 4) joining the groups for discussion. The same or different sessions may be used for the assessment of students' knowledge. Although currently in its infancy, the use of holograms will soon become a substantial part of medical education. Currently, several companies are offering a range of useful learning platforms, from anatomy education to patient encounters. By describing the holographic program at our institution, we hope to provide a roadmap for other institutions looking to implement a systematic approach to teaching anatomy through holographic dissection. This approach has several benefits, including a sequential 3D presentation of the human body with varying layers of dissection, demonstrations of facilitator-selected three-dimensional (3D) anatomical regions or specific body units, and the option for classroom or remote facilitation, with the ability for students to review each session individually.

Transcatheter Aortic Valve Implantation (TAVI) Planning with Dual-Layer Spectral CT Using Virtual Monoenergetic Image (VMI) Reconstructions and 20 mL of Contrast Media.

Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical implantation and its implementation is progressively increasing worldwide. We routinely perform pre-procedural aortic angiography CT to assess aortic dimensions and vascular anatomy. This study aims to evaluate the image quality of CTA for TAVI planning using dual-layer spectral CT, with virtual monoenergetic image reconstructions at 40 keV. Thirty-one patients underwent a CTA protocol with the injection of 20 mL of contrast media. Image quality was assessed by measuring the mean density in Hounsfield Units (HU), the signal-to-noise ratio, and the contrast-to-noise ratio in VMI reconstructions. Additionally, a blinded subjective analysis was conducted by two observers. The results showed significant enhancement at all sampled vascular levels with a gradual decrease in HU from proximal to distal regions. Favourable subjective ratings were given for all parameters, with greater variability in the evaluation of iliac axes. A significant negative correlation (p < 0.05) was observed between BMI and CA at all vascular levels, indicating reduced contrast enhancement with increasing BMI. Spectral CT, along with reducing iodine load, allows for obtaining high-quality images without a significant increase in noise. The reduction in iodine load can have positive implications in clinical practice, improving patient safety and resource efficiency.

Two-stage collaborative group testing does not improve retention of anatomy among students studying medical radiation technology.

INTRODUCTION: Two-stage collaborative group testing is an assessment format where students first complete a summative assessment independently, and then immediately convene in a small group to complete the same assessment again. Research on two-stage collaborative group testing has shown that it increases immediate learning, improves communication and teamwork, and can lead to enhanced retention of course material; the latter of which is especially important for basic anatomical concepts among health care professionals such as medical radiation technologists. However, such previous research has often employed quasi-experimental designs that may limit both internal and external validity. METHODS: Using a randomized crossover design with both quantitative and qualitative data analyses including robust intra-individual statistical comparisons, this research compared the educational impact of the two-stage collaborative group testing format (the COL condition) to traditional independent testing (the IND condition). Students (n=196) from two successive renditions of an introductory anatomy course were randomly assigned into groups of 3-5 students. Groups worked together throughout the term on various course elements, including three in-class, non-cumulative term tests (TTs). After practicing the collaborative format during TT1, during TT2 half the groups were assigned to the COL condition while the other half were assigned to the IND condition. Groups crossed over for TT3. All students completed a cumulative final examination independently, with performance data from that examination coded and extracted according to previous TT condition. Educational impact was evaluated as both immediate learning (by comparing IND and COL performance on the associated TT) as well as retention (by comparing final examination performance for topics previously IND tested versus previously COL tested). Students' qualitative reflections were coded into categories and juxtaposed against quantitative Likert-style feedback to comprehensively explore students' perception of the testing format for evidence of enjoyment, acceptability, and influence on relevant CAMRT professional competencies. RESULTS: 167 students (85%) consented to data inclusion, with a final course grade of 75.5 ± 10.0%. On average, TT performance was 13.6 ± 11.6% greater on the COL test (90.4 ± 7.6%) than the IND test (76.7 ± 14.3%) (p<0.01, r = 0.76), results that support immediate learning. Contrary to expectations, final examination performance specific to the two experimental conditions was similar, with students earning an average of 69.6 ± 18.3% on questions that pertained to material they were previously IND tested on, and 67.4 ± 19.1% on questions they were previously COL tested on (ns). Students' overall perceptions of the two-stage collaborative group testing format were overwhelmingly positive, with 84% indicating a belief that the format was a constructive learning opportunity and 74% recommending continued use. Written reflections revealed that students believed that collaborative testing enhanced their learning by both clarifying previous mistakes and reinforcing correct knowledge. Relevant CAMRT professional competencies included oral communication and interprofessional skills, capacity for productive teamwork, and collaborative practice. SIGNIFICANCE: Although the results of this study do not support the use of two-stage collaborative group testing for retention of course material, they simultaneously reveal how the testing structure may be uniquely beneficial to students studying within the field of medical radiation sciences while also presenting a pragmatic example of how to implement this unique testing format.

Multiple-Choice versus Open-Ended Questions in Advanced Clinical Neuroanatomy: Using a National Neuroanatomy Assessment to Investigate Variability in Performance Using Different Question Types.

Methods of assessment in anatomy vary across medical schools in the United Kingdom (UK) and beyond; common methods include written, spotter, and oral assessment. However, there is limited research evaluating these methods in regards to student performance and perception. The National Undergraduate Neuroanatomy Competition (NUNC) is held annually for medical students throughout the UK. Prior to 2017, the competition asked open-ended questions (OEQ) in the anatomy spotter examination, and in subsequent years also asked single best answer (SBA) questions. The aim of this study is to assess medical students' performance on, and perception of, SBA and OEQ methods of assessment in a spotter style anatomy examination. Student examination performance was compared between OEQ (2013-2016) and SBA (2017-2020) for overall score and each neuroanatomical subtopic. Additionally, a questionnaire explored students' perceptions of SBAs. A total of 631 students attended the NUNC in the studied period. The average mark was significantly higher in SBAs compared to OEQs (60.6% vs. 43.1%, P < 0.0001)-this was true for all neuroanatomical subtopics except the cerebellum. Students felt that they performed better on SBA than OEQs, and diencephalon was felt to be the most difficult neuroanatomical subtopic (n = 38, 34.8%). Students perceived SBA questions to be easier than OEQs and performed significantly better on them in a neuroanatomical spotter examination. Further work is needed to ascertain whether this result is replicable throughout anatomy education.

Participation in Dissection Affects Student Performance on Gross Anatomy Practical and Written Examinations: Results of a Four-Year Comparative Study.

The role of human dissection in modern medical curricula has been a topic of intense debate. In part, this is because dissection can be time-consuming and curricular hours are being monitored more carefully. This has led some to question the efficacy and importance of dissection as a teaching method. While this topic has received considerable attention in the literature, the question of how dissection impacts learning has been difficult to evaluate in a real-world, high-stakes setting since participation in dissection is often one of many variables. In this study, this challenge was overcome due to a change in the curriculum of a Special Master Program (SMP) that permitted a comparison between two years of students that learned anatomy using prosection only and two years of students that participated in dissection laboratories. Since each class of SMP students took courses in the medical school, and the medical school anatomy curriculum was constant, medical student performance served as a control throughout the study period. Results demonstrate that SMP students who learned through prosection had lower performance on anatomy practical and written examinations compared to medical students. When the SMP program changed and students started participating in dissection, there were measurable improvements in both practical and written examinations. These findings provide evidence of dissection's role in learning and applying anatomy knowledge both within and outside the gross anatomy laboratory.

Performance equivalency between computer-based and traditional pen-and-paper assessment: A case study in clinical anatomy.

The time, material, and staff-consuming nature of anatomy's traditional pen-and-paper assessment system, the increase in the number of students enrolling in medical schools and the ever-escalating workload of academic staff have made the use of computer-based assessment (CBA) an attractive proposition. To understand the impact of such shift in the assessment method, an experimental study evaluating its effect on students' performance was designed. Additionally, students' opinions toward CBA were gathered. Second-year medical students attending a Clinical Anatomy course were randomized by clusters in two groups. The pen-and-paper group attended two sessions, each consisting of a traditional sectional anatomy steeplechase followed by a theoretical examination, while the computer group was involved in two similar sessions conducted in a computerized environment. At the end of each of the computer sessions, students in this group filled an anonymous questionnaire. In the first session, pen-and-paper group students scored significantly better than computer-group students in both the steeplechase (mean ± standard deviation: 66.00 ± 14.15% vs. 43.50 ± 19.10%; P < 0.001) and the theoretical examination (52.50 ± 12.70% vs. 39.00 ± 21.10%; P < 0.001). In the second session, no statistically significant differences were found for both the steeplechase (59.50 ± 17.30% vs. 54.50 ± 17.00%; P = 0.085) and the theoretical examination (57.50 ± 13.70% vs. 54.00 ± 14.30%; P = 0.161). Besides, an intersession improvement in students' perceptions toward CBA was registered. These results suggest that, after a familiarization period, CBA might be a performance equivalent and student accepted alternative to clinical anatomy pen-and-paper theoretical and practical examinations. Anat Sci Educ 11: 124-136. © 2017 American Association of Anatomists.

The effect of images on item statistics in multiple choice anatomy examinations.

Although multiple choice examinations are often used to test anatomical knowledge, these often forgo the use of images in favor of text-based questions and answers. Because anatomy is reliant on visual resources, examinations using images should be used when appropriate. This study was a retrospective analysis of examination items that were text based compared to the same questions when a reference image was included with the question stem. Item difficulty and discrimination were analyzed for 15 multiple choice items given across two different examinations in two sections of an undergraduate anatomy course. Results showed that there were some differences item difficulty but these were not consistent to either text items or items with reference images. Differences in difficulty were mainly attributable to one group of students performing better overall on the examinations. There were no significant differences for item discrimination for any of the analyzed items. This implies that reference images do not significantly alter the item statistics, however this does not indicate if these images were helpful to the students when answering the questions. Care should be taken by question writers to analyze item statistics when making changes to multiple choice questions, including ones that are included for the perceived benefit of the students. Anat Sci Educ 10: 68-78. © 2016 American Association of Anatomists.

Medical student use of Facebook to support preparation for anatomy assessments.

The use of Facebook to support students is an emerging area of educational research. This study explored how a Facebook Page could support Year 2 medical (MBChB) students in preparation for summative anatomy assessments and alleviate test anxiety. Overall, Facebook analytics revealed that in total 49 (19.8% of entire cohort) students posted a comment in preparation for either the first (33 students) or second (34) summative anatomy assessments. 18 students commented in preparation for both. In total, 155 comments were posted, with 83 for the first and 72 for the second. Of the 83 comments, 45 related to checking anatomical information, 30 were requiring assessment information and 8 wanted general course information. For the second assessment this was 52, 14 and 6, respectively. Student perceptions on usage, and impact on learning and assessment preparation were obtained via a five-point Likert-style questionnaire, with 119 students confirming they accessed the Page. Generally, students believed the Page was an effective way to support their learning, and provided information which supported their preparation with increases in perceived confidence and reductions in anxiety. There was no difference between gender, except for males who appeared to be significantly less likely to ask a question as they may be perceived to lack knowledge (P < 0.05). This study suggests that Facebook can play an important role in supporting students in preparation for anatomy assessments. Anat Sci Educ 10: 205-214. © 2016 American Association of Anatomists.

Using generalizability analysis to estimate parameters for anatomy assessments: A multi-institutional study.

With integrated curricula and multidisciplinary assessments becoming more prevalent in medical education, there is a continued need for educational research to explore the advantages, consequences, and challenges of integration practices. This retrospective analysis investigated the number of items needed to reliably assess anatomical knowledge in the context of gross anatomy and histology. A generalizability analysis was conducted on gross anatomy and histology written and practical examination items that were administered in a discipline-based format at Indiana University School of Medicine and in an integrated fashion at the University of Alabama School of Medicine and Rush University Medical College. Examination items were analyzed using a partially nested design s×(i:o) in which items were nested within occasions (i:o) and crossed with students (s). A reliability standard of 0.80 was used to determine the minimum number of items needed across examinations (occasions) to make reliable and informed decisions about students' competence in anatomical knowledge. Decision study plots are presented to demonstrate how the number of items per examination influences the reliability of each administered assessment. Using the example of a curriculum that assesses gross anatomy knowledge over five summative written and practical examinations, the results of the decision study estimated that 30 and 25 items would be needed on each written and practical examination to reach a reliability of 0.80, respectively. This study is particularly relevant to educators who may question whether the amount of anatomy content assessed in multidisciplinary evaluations is sufficient for making judgments about the anatomical aptitude of students. Anat Sci Educ 10: 109-119. © 2016 American Association of Anatomists.

Evaluation of the effectiveness of 3D vascular stereoscopic models in anatomy instruction for first year medical students.

The head and neck region is one of the most complex areas featured in the medical gross anatomy curriculum. The effectiveness of using three-dimensional (3D) models to teach anatomy is a topic of much discussion in medical education research. However, the use of 3D stereoscopic models of the head and neck circulation in anatomy education has not been previously studied in detail. This study investigated whether 3D stereoscopic models created from computed tomographic angiography (CTA) data were efficacious teaching tools for the head and neck vascular anatomy. The test subjects were first year medical students at the University of Mississippi Medical Center. The assessment tools included: anatomy knowledge tests (prelearning session knowledge test and postlearning session knowledge test), mental rotation tests (spatial ability; presession MRT and postsession MRT), and a satisfaction survey. Results were analyzed using a Wilcoxon rank-sum test and linear regression analysis. A total of 39 first year medical students participated in the study. The results indicated that all students who were exposed to the stereoscopic 3D vascular models in 3D learning sessions increased their ability to correctly identify the head and neck vascular anatomy. Most importantly, for students with low-spatial ability, 3D learning sessions improved postsession knowledge scores to a level comparable to that demonstrated by students with high-spatial ability indicating that the use of 3D stereoscopic models may be particularly valuable to these students with low-spatial ability. Anat Sci Educ 10: 34-45. © 2016 American Association of Anatomists.

Association between learning style preferences and anatomy assessment outcomes in graduate-entry and undergraduate medical students.

An improved understanding of the relationship between anatomy learning performance and approaches to learning can lead to the development of a more tailored approach to delivering anatomy teaching to medical students. This study investigated the relationship between learning style preferences, as measured by Visual, Aural, Read/write, and Kinesthetic (VARK) inventory style questionnaire and Honey and Mumford's learning style questionnaire (LSQ), and anatomy and clinical skills assessment performance at an Irish medical school. Additionally, mode of entry to medical school [undergraduate/direct-entry (DEM) vs. graduate-entry (GEM)], was examined in relation to individual learning style, and assessment results. The VARK and LSQ were distributed to first and second year DEM, and first year GEM students. DEM students achieved higher clinical skills marks than GEM students, but anatomy marks did not differ between each group. Several LSQ style preferences were shown to be weakly correlated with anatomy assessment performance in a program- and year-specific manner. Specifically, the "Activist" style was negatively correlated with anatomy scores in DEM Year 2 students (rs = -0.45, P = 0.002). The "Theorist" style demonstrated a weak correlation with anatomy performance in DEM Year 2 (rs = 0.18, P = 0.003). Regression analysis revealed that, among the LSQ styles, the "Activist" was associated with poorer anatomy assessment performance (P < 0.05), while improved scores were associated with students who scored highly on the VARK "Aural" modality (P < 0.05). These data support the contention that individual student learning styles contribute little to variation in academic performance in medical students. Anat Sci Educ 9: 391-399. © 2016 American Association of Anatomists.

A scoring framework for assessing anatomy competence of undergraduate preclinical students.

Recent higher education changes toward outcomes-based education emphasize competent learners, but a widely accepted definition of competence is still lacking. Although the importance of anatomy in health professions education is recognized, there is still uncertainty about what anatomical competence entails and how to assess it. This study aimed to provide a framework for assessing anatomical competence, using an anatomy competence score, for the anatomy course in the undergraduate medical learning program at the University of the Free State in South Africa. All assessments within the dissection program of two student groups (July 2012 to June 2014) were explored to determine the representation of the three competence domains: knowledge, skill and application in context. Student performance in the final objective structured practical examination (OSPE) was investigated for the three domains and the different body regions. Knowledge had ±50% representation in assessments and the different body regions (in final OSPE) for both groups, and skill and application represented ±25% each in both groups. The best average student performance was in the skill domain (64% and 67% for the respective groups). All domains showed good reliabilities (> 0.75) and student performance correlated well between the domains (P < 0.001). This study suggests a representation ratio of 2:1:1 between knowledge, skill and application (i.e., 50% knowledge and 25% skill and application respectively), for anatomical competence assessment. However, this ratio depends on the assessment type, the stage of the anatomy course and the institutional context. Nonetheless, it provides a guideline for ensuring that assessments address all competence domains. Anat Sci Educ 9: 319-329. © 2015 American Association of Anatomists.

Do collaborative practical tests encourage student-centered active learning of gross anatomy?

Benefits of collaborative testing have been identified in many disciplines. This study sought to determine whether collaborative practical tests encouraged active learning of anatomy. A gross anatomy course included a collaborative component in four practical tests. Two hundred and seven students initially completed the test as individuals and then worked as a team to complete the same test again immediately afterwards. The relationship between mean individual, team, and difference (between team and individual) test scores to overall performance on the final examination (representing overall learning in the course) was examined using regression analysis. The overall mark in the course increased by 9% with a decreased failure rate. There was a strong relationship between individual score and final examination mark (P < 0.001) but no relationship for team score (P = 0.095). A longitudinal analysis showed that the test difference scores increased after Test 1 which may be indicative of social loafing and this was confirmed by a significant negative relationship between difference score on Test 4 (indicating a weaker student) and final examination mark (P < 0.001). It appeared that for this cohort, there was little peer-to-peer learning occurring during the collaborative testing and that weaker students gained the benefit from team marks without significant active learning taking place. This negative outcome may be due to insufficient encouragement of the active learning strategies that were expected to occur during the collaborative testing process. An improved understanding of the efficacy of collaborative assessment could be achieved through the inclusion of questionnaire based data to allow a better interpretation of learning outcomes. Anat Sci Educ 9: 231-237. © 2015 American Association of Anatomists.

Equivalence of students' scores on timed and untimed anatomy practical examinations.

Untimed examinations are popular with students because there is a perception that first impressions may be incorrect, and that difficult questions require more time for reflection. In this report, we tested the hypothesis that timed anatomy practical examinations are inherently more difficult than untimed examinations. Students in the Doctor of Physical Therapy program at Thomas Jefferson University were assessed on their understanding of anatomic relationships using multiple-choice questions. For the class of 2012 (n = 46), students were allowed to circulate freely among 40 testing stations during the 40-minute testing session. For the class of 2013 (n = 46), students were required to move sequentially through the 40 testing stations (one minute per item). Students in both years were given three practical examinations covering the back/upper limb, lower limb, and trunk. An identical set of questions was used for both groups of students (untimed and timed examinations). Our results indicate that there is no significant difference between student performance on untimed and timed examinations (final percent scores of 87.3 and 88.9, respectively). This result also held true for students in the top and bottom 20th percentiles of the class. Moreover, time limits did not lead to errors on even the most difficult, higher-order questions (i.e., items with P-values < 0.70). Thus, limiting time at testing stations during an anatomy practical examination does not adversely affect student performance.