The paradigms of structure, delivery, and medical education, like many others, have been affected by the COVID-19 pandemic. Therefore, undergraduate and graduate medical education in order to adapt to the conditions of this crisis have inevitably changed their approaches to virtual education. Observance of physical distance and health protocols has led to the implementation and application of remote electronic technologies in medical education and assessment. However, it is important to note that the effective use of these technologies in the first step requires an accurate understanding of their features, and in the next step, knowledge about these platforms and their opportunities and limitations for those who involved in medical education is essential (13).
Exam anxiety is one of the common problems of medical students that has been considered in various studies and many reports have been provided in this regard (14–16). The objective of this study was to assess levels of online exam anxiety among medical students in the Mashhad School of Medicine, one of the top five medical schools in Iran in 2020. Findings showed that the prevalence of mild, moderate, and severe anxiety was 27.9%, 36.9%, and 35.2% respectively. In addition, the difference in test anxiety among the students of basic science and Pre-clinical was not significant, yet the results indicated that the level of anxiety in females is significantly higher than males.
Students typically experience multiple stressors from a variety of sources. The challenges that may be encountered in controlling the situation can lead to various psychological and emotional pressures (17). The main concerns among students that lead to anxiety are about their academic achievements, success, and post-graduation plans (18). Studies have shown that medical students experience anxiety in different ways in various stages of education (19). Medical education is more stressful than other disciplines, and that anxiety is one of the most common challenges among medical students (16). However, excessive anxiety can weaken students and, if not properly managed, can lead to impaired performance, lack of motivation, reduced academic achievement, and psychological problems (20). Paying attention to the issue of anxiety in medical students requires more care because of the important consequences it can have (21, 22).
Evidence suggests that medical students become anxious before and during exams (23–26) and moderate test anxiety is usually observed in them (27). Quek et al. nalyzed data from 40348 medical students while studying 69 studies. Findings showed that the prevalence of anxiety in medical students was 33.8% in global and among them the highest rate of anxiety in medical students was from the Middle East and Asia (21). The other study reported average anxiety score as 12.86 among the participants (28). Latas et al. investigated test anxiety of medical students of Belgerad University of Medical Sciences and stated that most of these students suffered from test anxiety (27). Jadoon et al. announced anxiety level of medical students as 28% (29). Darabi et al. declared that 66% of students experienced moderate and severe anxiety (30). Results from a study by Tsegay et al. showed that in Ethiopia test anxiety dedicates a significant percentage of medical students (52.30%) and the findings suggest that between test anxiety and factors such as gender, being a freshman, oral exam, level of social support and the existence of psychological problems there is a significant relationship (31). Therefore, the amount of test anxiety that causes the problem, which the results of studies indicate is common among medical students, should be given more attention. Outcomes of this study are consistent with other researches that has declared medical students’ high prevalence of test anxiety.
In the study of Simran et al., the mean of anxiety prior to examination was 70.89 ± 14.55 in females and 63.91 ± 11.73 in males, as the results show, female students experienced more test anxiety (16). In our study, gender was also observed as an influential factor in the level of test anxiety, which led to significant differences. The findings of many studies indicate that the gender factor leads to a significant difference in the level of test anxiety and in general female students experience more anxiety before the test compared to male (27, 32–39). It is said that the probable reason for the difference in test anxiety levels in females compared to males could be due to the increase in women's emotional vulnerability (40). Some studies have justified differences in women's self-confidence and anxiety levels with competency issues compared to men (41). Considering the factors that increase test anxiety in medical students, it has been reported that females experience memory loss in exams and as a result, they have to make more efforts to memorize than males (35). Nevertheless, some studies showed no significant difference between mean score of anxiety and gender (21, 28).
On the other hand, findings indicated that the difference in test anxiety among the students of basic science and Pre-clinical was not statistically significant; consistent with some other studies which did not report a significant relationship between test anxiety and academic year (21, 28, 42, 43). Although, a previous study of medical students in the basic sciences reported that 50% of students suffer from severe test anxiety (44).
Consistent among the studies, it was proven that assessment and measurement can lead to stress or anxiety. There may be a relation between test anxiety and dysfunction (38). Problematic test anxiety rates of 25 to 40% in undergraduate medical students can have devastating effects on academic performance and student achievement (31). Anxiety can lead to mental distress and negatively affect students' cognitive performance and learning (45). Studies have reported that if medical students learn skills such as time management, then applying these skills can help reduce anxiety and lead to improvement of their academic performance (46). Studies have recommended that students should have the opportunity to experience more formative tests so that they receive meaningful feedback during these continuous assessments and are guided to correct their deficiencies and thus can improve their learning (47).
A survey conducted by the International Association of Universities (IAU) of higher education institutions around the world found that more than 90% of them have switched to virtual education or are developing distance education to continue the teaching and learning processes (37). Despite the notion that E-learning is of lower quality than face-to-face classroom, emerging studies offer something opposite (48). However, this is obvious that the migration to virtual education has posed significant concerns for universities and educational institutions, and in the meantime, the implementation of assessment and evaluation processes in the form of remote online exams has faced major challenges (49). Currently, although online exams can be a useful topic for distance learning with the possibility of providing real-time feedback, which seems challenging due to the increasing number of students for faculty members (50, 51), but time constraints are still a concern in E-exams (52) and it is even more worrying if the examinations are held remotely. There is another concern, the navigation protocol and policy adopted to move between exam questions can be confusing and time consuming, leading to more stress for students. For example, this navigation policy, in which students are not able to return to the previous question, is not favorable for them. Other factors reported by students include that the exam questions do not match the content taught, and this affects their grades. This can be due to the unpreparedness of students and educators to participate in E-learning and virtual education. Academic dishonesty was another issue that was noted, especially by students who believed that remote E-exams were more stressful (37). Totally, digital technology in all areas has improved the efficiency of processes and the effectiveness of systems, and obviously higher education is no exception (53). Learning and teaching is transforming away from the conventional lectures. In the current context, this issue is exacerbated by the COVID-19 crisis (54), students are transitioning from face-to-face examinations to the remote online exams. However, with students' frequent use of online exam platforms, their anxiety decreased. However, it is recommended that this information be disclosed to students in order to change their perceptions and reduce anxiety during the online test (53). While the researches related to online examinations are in progress, discussions at the educational level still need to be completed and it is necessary that the study will continue to find and share experiences.