Perceptions of the Progress Test Among Medical Students in Saudi Arabia: A Multi-Institutional Cross-sectional Study

Original Article

Perceptions of the Progress Test Among Medical Students in Saudi Arabia: A Multi-Institutional Cross-sectional Study

Abstract

Background and Aims:

The Progress Test is a longitudinal tool for assessing medical students’ cumulative knowledge throughout their education, regardless of a student’s academic year. While widely implemented, data on how students perceive its utility, structure and overall educational impact—particularly in Saudi Arabia—is limited. This study aimed to investigate medical students’ perceptions of the Progress Test, focusing on its perceived benefits, practical challenges and potential areas for improvement.

Methods: This cross-sectional study used an online questionnaire distributed to undergraduate medical students across various academic years and colleges. The survey collected demographic data and used Likert-scale items to assess test structure and utility. Open-ended questions were used to capture students’ likes, dislikes and suggestions for improvement. Quantitative data were analysed using descriptive and inferential statistics, while qualitative responses were evaluated through thematic content analysis.

Results: Of the 735 participants, most valued the Progress Test for benchmarking and long-term learning; however, concerns emerged regarding its length, difficulty and curricular alignment. Notably, over half reported receiving no institutional feedback following the test. Views on the test’s structure were mixed: while there was strong support for annual administration and four-option multiple-choice questions, fewer students endorsed the 200-question, 4-hour format. Thematic analysis revealed a demand for more relevant content, a concise testing experience and detailed feedback.

Conclusion: Students recognise the Progress Test’s value but advocate for improved design and post-test feedback. Integrating student perceptions into future test planning and follow-up could enhance the test’s educational impact and foster a student-centred assessment culture.

Key words: Progress Test, Medical students, Saudi Arabia, Perception, Post-test feedback

Introduction Assessment is fundamental to medical education, serving not only to gauge student learning but also to drive curricular reform and ensure graduates are prepared for clinical practice. Contemporary approaches increasingly emphasise assessment as a continuous, learning-oriented process embedded within programmatic assessment systems. Among the various assessment modalities, the Progress Test (PT) has emerged as a key longitudinal assessment strategy that measures cumulative knowledge across the entire medical curriculum, regardless of a student’s academic year.^{1, 2} This design aligns closely with the principles of assessment for learning (AfL), which emphasise the role of assessment in supporting ongoing learning rather than solely evaluating performance 3. It has been widely adopted as a tool for benchmarking institutional performance and supporting continuous, mastery-oriented and feedback-driven learning, expanding from its origins in the Netherlands4 and at McMaster University5 to widespread use across Saudi Arabia.^{1, 6} Within programmatic assessment, such longitudinal testing contributes multiple low-stakes data points that collectively inform both learning and progression decisions 7. However, despite its pedagogical promise and alignment with programmatic assessment principles, the test remains demanding in length, resource-intensive to administer and dependent on student engagement and acceptance for its educational effectiveness.

Existing literature frequently examines the PT through an institutional or psychometric lens, focusing primarily on its reliability, blueprinting and overall value for benchmarking.⁸ Within van der Vleuten’s utility framework9, these dimensions represent only part of assessment quality, which also encompasses educational impact and acceptability. While these data are vital, the educational impact and acceptability of the PT—particularly from the student perspective—remain underexplored, especially in the Saudi Arabia context. Understanding their views on the test’s purpose, difficulty, relevance, fairness, curricular alignment, length, item clarity, timing, cognitive load and post-test feedback is essential for a more comprehensive evaluation of the PT, particularly given its intended role as a longitudinal, feedback-oriented learning tool.

Understanding how medical students perceive the PT is far more than an academic exercise; it is vital for maintaining ethical, student-centred assessment practices, particularly as academic stress and well-being become greater priorities.¹⁰ Because large-scale assessments can influence motivation and learning behaviour, exploring the views of Saudi medical students may help provide the insights needed to improve the test’s design, implementation and feedback processes. Importantly, the Progress Test occupies a hybrid position between formative and summative assessment. Although commonly designed to provide formative feedback on knowledge progression, it may also carry summative implications in some institutional contexts, influencing how students engage with and interpret the assessment. Accordingly, this study used a comprehensive multi-institutional survey to examine student perceptions of the PT, specifically focusing on what they value, the challenges they encounter and how the test can more effectively support their learning.

Methods

Study Design

This study employed a cross-sectional descriptive survey to explore how undergraduate medical students perceive the PT. The research involved students from a wide range of academic years and institutional contexts, encompassing both government and private institutions in Saudi Arabia. To be eligible, participants had to be undergraduate medical students who had attempted the PT at least once. Participants were recruited immediately following the release of Progress Test results. As the Progress Test in Saudi Arabia is centrally coordinated by Qassim Medical School, students were invited to participate during this period when individualised results were made available through secure access using their unique identifiers. Because the survey invitation was distributed broadly through this centralised system, an exact response rate could not be calculated.

Survey Instrument

Data were collected using a self-administered online questionnaire developed in Google Forms. The questionnaire was designed to explore students’ perceptions of the PT, based on relevant literature on assessment perception in medical education, and was subsequently refined through expert review to ensure content validity. Where appropriate, items were adapted from previously published studies on student perceptions of assessment, while others were newly developed to reflect the local context. Given the exploratory nature of the study, formal psychometric validation (e.g., pilot testing or internal consistency reliability) was not undertaken. Instead, emphasis was placed on clarity and relevance. It included four sections: participant demographics, PT administration and feedback, perceptions of the PT and open-ended questions regarding students’ experiences and suggestions.

Data Analysis

Quantitative data were exported from Google Forms to Microsoft Excel and analysed using SPSS (version 26.0). Descriptive statistics, including frequencies, percentages and means, were used to summarise participant demographics and Likert-scale responses. The associations between categorical independent variables (such as gender, academic year, type of college and educational approach) and the primary dependent variables were initially explored. To simplify these comparisons, five-point Likert scale responses were collapsed into a single ‘Agree’ category by combining ‘Strongly Agree’ and ‘Agree’ responses. This approach is commonly used in large-scale perception studies to facilitate clearer group comparisons and reduce sparsity in subgroup analyses. Because the aim of this study was to identify broad patterns of agreement rather than fine-grained attitudinal distinctions, collapsing categories supported more stable and interpretable statistical modelling. This allowed for the calculation of the percentage of agreement for each statement across different participant groups.

Linear regression was then performed to investigate the independent effects of key demographic variables on student perceptions. Although Likert responses are ordinal, the dependent variables were analysed as aggregated agreement outcomes, a common approach in perception studies.¹¹ Preliminary checks showed that ordinal regression produced substantively similar patterns, supporting the appropriateness of linear regression for examining broad directional associations. For these analyses, the regression coefficient (β), R² value, F-statistic and significance level (p-value) were reported. In addition, Pearson correlation coefficients (r) were calculated to assess the direction and strength of the linear relationship between specific pairs of variables. Finally, qualitative data from the open-ended questions were analysed using conventional content analysis to identify recurring patterns and suggestions. An inductive coding approach was used, allowing categories to emerge directly from the data. As the study was conducted by a single author, all coding was performed independently by the researcher. To enhance trustworthiness, the researcher engaged in repeated reading of the dataset, iterative refinement of codes and constant comparison across responses to ensure consistency. Coding decisions were documented throughout the process, and categories were reviewed multiple times to ensure that they accurately reflected the data.

Results

Participant Characteristics

A total of 735 medical students from various academic years and institutions completed the questionnaire. The gender distribution was relatively even, with 57.8% males (n = 425) and 42.2% females (n = 310). All academic years were represented, with Year 5 students forming the largest group (28.7%). A majority of respondents were enrolled in government colleges (85.2%), and the most common educational approach reported was problem-based learning (PBL) (58.2%), followed by lecture-based curricula (31.0%). Detailed demographic data are summarised in Table 1.

Table 1. Participant demographics (n = 735)
Variable	Category	Frequency (n)	Percentage (%)
Gender	Male	425	57.8%
Female	310	42.2%
Academic year	Year 1	119	16.2%
Year 2	128	17.4%
Year 3	134	18.2%
Year 4	143	19.5%
Year 5	211	28.7%
Times participated in the PT	Once	245	33.3%
Twice	250	34.0%
3 times	47	6.4%
4 times	79	10.7%
5 times	114	15.5%
Type of college	Government	626	85.2%
Private	109	14.8%
Educational approach	PBL	428	58.2%
LBL	228	31.0%
TBL	54	7.3%
CBL	25	3.4%

Perceptions of PT Administration and Feedback

Most students (64.2%) reported receiving participation marks for completing the PT. However, a key finding was that 60.5% did not receive any institutional feedback following the exam. Although students could access their numerical results online, many expressed that this did not constitute meaningful feedback (Figure 1). This aligns with qualitative comments such as “I wish we got detailed feedback to know what we missed.”

Figure 1. Perceptions of test administration and feedback (n = 735)

Student Perceptions of the PT

Overall, students expressed positive views about several structural aspects of the PT. A large majority (84.3%) agreed that administering the test once per year was reasonable, and 68.9% felt that the timing in early March was appropriate. Most students (67.7%) believed the items reflected core graduate‑level knowledge, and 67.5% felt that 200 questions were appropriate. Similarly, 68.4% agreed that the test difficulty was reasonable.(Figure 2). Qualitative responses supported these findings, with students describing the PT as a useful benchmarking tool: “It helps me know where I stand among all other students.”

Figure 2. Students’ perceptions of the PT (n = 735)

Gender-based comparison

Perceptions of the PT were highly consistent across genders, with regression analysis showing no meaningful association between gender and perceived test difficulty. These results are summarised in Table 2 and illustrated in Figure 3. The lack of variation suggests that male and female students experience the PT in similar ways.

Table 2. Regression analysis of the impact of gender on the response to the ‘level of difficulty is reasonable’ variable
Model	Sum of Squares	df	Mean Square	F	Sig.
Regression	.002	1	.002	.003	.960a
Residual	664.833	733	.907
Total	664.835	734

Educational approach comparison

Students from PBL, lecture‑based, team‑based and case‑based curricula reported similar perceptions of the PT. Regression analysis confirmed that educational approach did not predict perceptions of test difficulty. These findings are presented in Table 3 and visualised in Figure 4, indicating that the PT is experienced consistently across diverse curricular environments.

Table 3. Regression analysis of the impact of educational approach on the response to the ‘level of difficulty is reasonable’ variable
Model	Sum of Squares	df	Mean Square	F	Sig.
Regression	.025	1	.025	.027	.869a
Residual	664.811	733	.907
Total	664.835	734

Academic year comparison

Perceptions were largely stable across academic years, with one notable pattern: senior students were more likely to view the test difficulty as reasonable (77.3% in Year 5 vs. 63% in Year 1). Regression analysis supported this trend, showing a small but statistically significant effect of academic year on perceived difficulty. These results are shown in Table 4 and illustrated in Figure 5. Qualitative comments help explain this finding: junior students often felt less prepared for the breadth of PT content, whereas senior students recognised its alignment with end‑level expectations.

Table 4. Regression analysis of the impact of academic year on the response to the ‘level of difficulty is reasonable’ variable
Model	Sum of Squares	df	Mean Square	F	Sig.
Regression	3.597	1	3.597	3.988	.046a
Residual	661.238	733	.902
Total	664.835	734

Figure 5. Effect of participants’ academic year on questionnaire responses

College type comparison

Students from government and private institutions reported similar perceptions of the PT, as shown in Figure 6. This consistency indicates that institutional context did not meaningfully influence student experience.

Figure 6. Effect of college type on questionnaire responses

Regression analysis

Across demographic variables, regression analyses indicated that gender, educational approach and college type were not meaningful predictors of PT perceptions (Tables 2–4). The only variable showing a small but significant association was academic year, with more advanced students perceiving the test difficulty as more reasonable. Overall, the findings suggest that perceptions of the PT are broadly consistent across student groups, with differences emerging primarily as students progress through the curriculum.

Content Analysis of Open-Ended Responses

Qualitative responses provided important context for the quantitative findings. Students valued the PT for its benchmarking function and its ability to highlight strengths and weaknesses. However, several concerns emerged:

• Test length and fatigue: Many students reported declining concentration after two hours, consistent with the quantitative finding that some questioned the 200‑item format. One student noted, “It’s too long—it affects my focus after 2 hours.”

• Lack of meaningful feedback: Despite having access to numerical results, students emphasised the absence of interpretive or actionable feedback. This helps explain why 60.5% reported receiving “no feedback,” even though score reports were available.

• Curricular alignment: Some students—particularly in earlier years—felt the test content did not match their current level of study, echoing the quantitative pattern where Year 1 students were less likely to view the difficulty as reasonable.

• Suggestions for improvement: Students recommended reducing the number of questions, aligning content more closely with recently covered topics and providing detailed performance analytics.

Discussion

This study explored medical students’ perceptions of the PT in a multi-institutional context across various curricular models. Overall, the findings suggest a dual reality: while students recognised the test’s value in benchmarking their performance and promoting longitudinal learning, their experience was often marred by practical challenges. Specifically, concerns regarding test length, perceived curricular misalignment and limited feedback following the examination present significant barriers to its success. These findings suggest that, although the PT has clear educational value, its impact is currently limited by implementation strategies that overlook the student experience. Interpreting these findings through established educational frameworks, such as cognitive load theory, feedback, and the principle of assessment‑for‑learning, helps explain why these challenges persist and how they may be addressed.

A large proportion of students perceived the PT as a valuable benchmarking tool, allowing them to measure their performance against both curricular standards and their peers. This feedback aligns with the test’s core purpose: to foster continuous learning and track longitudinal knowledge development.⁴ These results mirror a previous scoping review,8 which found that students appreciate how the PT reinforces cumulative knowledge and discourages rote learning typically seen before high-stakes summative exams.⁸ However, the benefits of benchmarking must be considered alongside the cognitive demands imposed by the test. According to cognitive load theory, prolonged tasks with high information density can overwhelm working memory, leading to cognitive fatigue and reduced decision‑making quality.¹² This provides a theoretical explanation for students’ reports of declining focus during the 4‑hour, 200‑item test, echoing findings from a previous study in which students reported decreased focus and motivation after the second hour.¹³ This clear tension between assessment value and student well-being suggests that the test’s structure needs revisiting. Potential solutions such as reducing the number of items or introducing optional breaks could help maintain student engagement without compromising test reliability.

One notable concern for many students was the perceived disconnect between the test content and their curriculum, particularly during the early years of study.⁶ Although the PT is designed to be curriculum-independent and measure end-level outcomes,1 early-phase students may perceive it as misaligned or premature. This mismatch may not indicate a flaw in the test itself but rather a lack of scaffolding or orientation provided to students. Previous research from the Maastricht model has emphasised the importance of pre-test briefings and contextual framing to enhance student acceptance.¹⁴ Institutions implementing the PT in newer contexts must therefore invest in preparatory workshops and explain the rationale for such assessments, particularly to junior students. Doing so may mitigate anxiety and increase perceived relevance.

A particularly important finding was that over half of the students received no feedback from their institutions following the exam. While students did receive reports comparing their performance with peers nationwide, the lack of institution-level feedback, such as identifying which areas of the current curriculum were not covered or where students underperformed relative to PT item coverage, represents a missed educational opportunity. This aligns with the qualitative finding in which a student explicitly expressed a desire to know “what was missed,” highlighting a gap in feedback provision. Within an assessment for learning framework, feedback is not merely the transmission of information but a process that supports sense making, planning, and improvement.³ Moving forward, institutions should aim to complement national reports with individualised or cohort-level feedback that highlights performance trends, strengths and areas requiring further development. Integrating this feedback could further enhance the PT educational value. At the same time, most students found the structure and content of the results report useful. This suggests that students value feedback when it is available and that the main concern lies not in the report itself, but in the inconsistency of its dissemination and explanation.

Another factor that may influence students’ perceptions is whether performance on the PT is rewarded. In this study, a substantial proportion of students reported receiving participation marks rather than performance‑based rewards. This distinction may shape how students interpret the purpose of the PT: when performance is not incentivised, students may view the test primarily as a formative tool rather than a high‑stakes assessment. Conversely, in contexts where performance contributes to academic performance, students may experience greater pressure, which could influence perceptions of test difficulty, fairness and relevance.¹⁵ Although the present study did not analyse performance‑reward effects separately, future research should examine how different reward structures influence student motivation, engagement and perceptions of the PT’s educational value.

Our findings showed general support for several structural elements of the PT, including its annual administration, scheduling in early March and the use of four-option multiple-choice questions. This level of agreement suggests that students value a predictable and consistent test design. While views on the exam’s test duration and difficulty were more mixed, these elements must be viewed through the lens of the test’s fundamental purpose. Unlike traditional exams that focus on recent coursework, the PT is designed to provide a snapshot of students’ knowledge in relation to the level expected at the completion of the medical programme.¹ Therefore, while students’ concerns are important and should inform implementation, some degree of challenge and breadth is inherent to the design and educational purpose of the PT.²

An additional factor that may shape students’ perceptions is the number of times they have previously taken the PT. Students in advanced years not only possess greater curricular exposure but also have repeated experience with the test format, item style and breadth of content. Repeated participation may reduce uncertainty, enhance familiarity and strengthen students’ understanding of the PT’s purpose, which could partly explain why senior students were more likely to view the test difficulty as reasonable. From an educational perspective, repeated exposure to the PT can have a cumulative learning effect: each administration provides an opportunity for retrieval practice, self‑monitoring and calibration of knowledge over time. This aligns with the principles of longitudinal assessment, where repeated testing supports knowledge consolidation and promotes deeper engagement with the curriculum. Future research should therefore distinguish between the effects of academic progression and the effects of repeated test exposure to better understand how each contributes to students’ perceptions and learning.¹⁶

The findings of this study offer several practical implications for both policy and practice. First, national and regional agencies using the PT as a benchmarking tool should consider integrating student feedback into their formal quality assurance frameworks. Second, institutions should view the PT not merely as an assessment exercise but as an educational event—one that requires preparation, explanation, follow-up and reflection. This includes supporting students’ feedback literacy, clarifying the intended construct alignment of the PT and providing additional supports to make the PT a more engaging and enjoyable experience. Third, as medical education continues to emphasise competency-based and student-centred approaches, student voice must play a central role in the evolution of assessment systems. This study contributes to that goal by providing data-driven insights into what students value, struggle with and wish to see improved.

This study also has several limitations. First, due to its cross-sectional design, this study provides a snapshot of student perceptions at one specific moment; it does not account for how these views might evolve as students progress through their academic years or gain repeated exposure to the PT. Second, the use of a self-administered questionnaire may have introduced response and recall bias. In addition, because participation was voluntary, there is a possibility of selection bias, as students who chose to respond may have been more motivated, more engaged or held stronger views about the PT than non‑respondents. Third, although the study included students from multiple institutions, participation was voluntary, which may limit the generalisability of the findings. Moreover, the analysis was conducted at the individual student level rather than the institutional level; differences in how colleges implement, prepare for or communicate about the PT could not be examined. Finally, while the open-ended responses provided useful insights, in-depth qualitative methods—such as interviews or focus groups—may have offered a richer understanding of students’ experiences. The contextual specificity of the Saudi medical education system should also be acknowledged, as structural, cultural and curricular factors unique to this setting may limit the transferability of the findings to other countries or educational systems.

Conclusion

This study provides a comprehensive exploration of medical students’ perceptions of the PT within a multi-institutional and multi-curricular context. While many students acknowledged the value of the PT in benchmarking their knowledge and fostering long-term learning, several challenges were identified—particularly regarding test length, feedback mechanisms and perceived alignment with the curriculum. These findings highlight the importance of not only designing valid and reliable assessments but also ensuring they are student-centred, transparent and supported by meaningful feedback.

To maximise the educational potential of the PT, medical schools and regulatory bodies must engage students as active stakeholders in the assessment process. Doing so requires clear communication about the test’s purpose, regular provision of actionable feedback, and a willingness to adapt design elements based on student input. Ultimately, a well-executed PT can serve as more than just a tool for knowledge tracking; it can be a powerful driver of reflective learning, curricular alignment and institutional improvement.

Future research should investigate the longitudinal impact of PT participation on learning behaviours and academic outcomes. Furthermore, incorporating qualitative methods like interviews or focus groups may offer deeper insights into student experiences, enriching the evidence base for assessment reform in medical education.

References

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PT: Progress Test; PBL: problem-based learning; LBL: lecture-based learning; TBL: team-based learning; CBL: case-based learning

*Significant difference (P < 0.05)

Figure 3: Effect of participant gender on questionnaire responses

Predictors: Gender

Dependent Variable: Level of difficulty is reasonable

* The Pearson correlation between gender and the perceived sufficiency of the 200-item PT was negligible (r = 0.013, p = 0.362, one-tailed), suggesting no meaningful association between gender and perceptions of test length.

**At the same time, a weak but statistically significant Pearson correlation (r = 0.096, p = 0.005, one-tailed) was found between gender and views on the inclusion of the ‘I don’t know’ option, indicating that gender has only a minimal association with this specific perception.

CBL: case-based learning; LBL: lecture-based learning; PBL: problem-based learning; TBL: team-based learning

Figure 4. Effect of educational approaches on questionnaire responses

Predictors: (Constant), educational approach of the college

Dependent Variable: Level of PT difficulty is reasonable

PT: Progress Test

Predictors: (Constant), academic year

Dependent Variable: Level of difficulty is reasonable

Table 5. Thematic summary of open-ended responses
Theme	Description	Sample Quote
Valued benchmarking	Students appreciated knowing their level in comparison to peers	‘It helps me know where I stand among all other students’.
Test length concerns	Students found the 4-hour duration and 200 questions mentally draining	‘It’s too long—it affects my focus after 2 hours’.
Lack of feedback	Many expressed frustration with delayed or vague feedback	‘I wish we got detailed feedback to know what we missed’.
Motivational impact	Some felt demotivated by low scores or unclear benefits	‘It’s hard to see the point when I don’t get my results back’.
Suggestions	Improve timing, give targeted feedback and reduce item number	‘Maybe reduce it to 150 questions and align it with our modules’.