Formative assessment: the grade that does not count
Table of contents
The preceptor finishes the observation and says: "This doesn't count toward your grade. I just want to show you what I saw." One part of your mind relaxes. Another part is suspicious: does it really not count? That tension is the heart of formative assessment in medical education. In theory, it exists to guide the next step in learning. In practice, students and teachers live in a system where almost every piece of data can, one day, feed into a progression decision.
NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.
This text explains what formative assessment is, how it differs from summative assessment, what the literature says about feedback and programmatic assessment, and how to study and teach without turning every encounter into a final judgment. There is a table, frequently asked questions and a checklist. It connects with feedback in clinical cases, reflective portfolio, calibration of confidence and EPAs.
Key points
- Formative assessment guides learning; summative assessment decides progression or certification.
- The same data can serve both purposes if the system is clear; without clarity, the student treats everything as a threat.
- Specific, timely feedback tied to an action plan is the engine of formative assessment.
- Programmatic assessment combines many low-pressure data points over time.
- A culture of pure performance limits exploration, productive error and honesty.
- Practicing with cases and reviewing reasoning is everyday formative assessment, inside or outside school.
Summary
- What formative assessment is
- Formative versus summative (and the gray zone)
- Feedback that changes the next shift
- Programmatic assessment in plain language
- How to study under formative assessment
- How NEXO helps you practice
- Frequently asked questions
- References
What formative assessment is
Formative assessment is the collection and interpretation of information about student performance with the main purpose of improving learning, not issuing a final verdict. In competency-based medical education, formative assessments help place the learner on the continuum of milestones and point to the next stage of mastery (Ryan et al., 2021).
Miller described levels of assessment (knows, knows how, shows how, does). Formative assessment can act at several levels, but it gains power when it observes performance (shows how / does) and returns actionable information (Miller, 1990).
What formative assessment is not
It is not an "easy test". It is not the absence of a standard. It is not empty praise. It is a comparison between current performance and desired performance, with a route to close the gap. Without an explicit standard, it becomes opinion. Without a route, it becomes a diagnosis with no management plan.
Formative versus summative (and the gray zone)
Summative decides: pass, progress, certify. Formative informs: keep doing this, adjust that, practice this. Watling and Ginsburg describe the contemporary tension: the same data feed judgment and growth, and the line between the two often blurs in the student's eyes (Watling and Ginsburg, 2018).
Why the student "feels" summative
A history of surprises ("that was going to count"); a ranking culture; feedback given in the tone of a verdict; no chance to try again. In these climates, even the phrase "it doesn't count toward your grade" arrives filtered through suspicion. The solution is not just repeating the phrase: it is making the purpose visible in the system (Watling and Ginsburg, 2018).
Practical table
| Dimension | Formative | Summative |
|---|---|---|
| Main purpose | Improve the next performance | Decide progression or certification |
| Timing | Continuous, close to the task | Decision points in the curriculum |
| Tone of the return | Descriptive and plan-oriented | Judgment against a standard |
| Error | Learning material | Evidence that weighs on the decision |
| Next attempt | Expected and desired | May not exist |
| Risk if poorly used | Becomes theater or disappears | Generates fear and studying only for the test |
Feedback that changes the next shift
Useful attributes
Effective feedback tends to be specific, timely, understandable, tied to observable behavior and followed by a plan. Reviews of feedback in medical students find a positive influence on knowledge, skills and attitudes when compared with no feedback or unstructured return, with heterogeneity of formats. When in doubt, prioritize clarity and a plan over a volume of adjectives.
Ask-tell-ask and variations
Ryan and colleagues describe the ask-tell-ask method: ask for self-assessment, tell the observation, ask about the student's plan (Ryan et al., 2021). The value lies in giving back agency (autonomy) and in crossing perception with evidence (calibrated competence). See also feedback in clinical cases.
When feedback does not land
Vague message; humiliating tone; no chance to practice again; dissonance with what the student saw other preceptors reward; cognitive overload at the moment of the return. Feedback at the elevator door after a twelve-hour shift rarely becomes a plan. Set aside a protected minute.
Preceptor checklist (two minutes)
- Did I name the purpose ("this is to adjust the next case, not for today's final assessment")?
- Did I describe observable behavior (not a personality trait)?
- Did I cross it with the student's self-assessment?
- Did we agree on a concrete next step?
- Is there a nearby opportunity to try again?
- Did the tone preserve enough connection for the message to land?
Programmatic assessment in plain language
Programmatic assessment organizes many low-pressure assessment points over time, uses mentoring to interpret the whole and reserves high-impact decisions for moments when evidence has accumulated (van der Vleuten et al., 2012; twelve tips). In plain Portuguese: several photos of performance, a conversation about the album, and only then the decision to move to the next stage.
What changes for the student
Less "all or nothing" in a single exam; more responsibility to engage with continuous feedback; the need to understand which data are only for learning and which feed the progression dossier. Without that key, programmatic assessment becomes summative in disguise (Watling and Ginsburg, 2018).
What changes for the teacher
Record observations with quality; calibrate with colleagues; resist turning every mini-CEX into a verdict. Assessment literacy becomes a teaching competence, not just clinical content (twelve tips programmatic).
Connection with EPAs and milestones
In CBME, formative assessment places the student on the milestone and points to the next supervised trust. EPAs make the conversation concrete: "in this activity, I still want presence; in this one, remote supervision is enough" (Ryan et al., 2021; EPAs).
How to study under formative assessment
Treat formative assessment as data, not as destiny
A weak observation on a Tuesday does not define your career. It defines Wednesday's practice. If you catastrophize every return, formative assessment loses its function. If you ignore every return, so does it. The middle ground is calibration: adjusting confidence to the evidence.
Ask for the criterion before the task
"What will you observe today?" changes the session. A clear criterion reduces the feeling of arbitrary judgment and increases autonomy (self-determination theory).
Close the loop
Heard the feedback, wrote a next step, practiced, asked for a new observation. Without the practice in between, formative assessment becomes a file. A short portfolio helps close the loop (reflective portfolio).
Student checklist
- Before the task, ask about the observation criterion.
- Afterwards, do a self-assessment in one sentence.
- Ask for one specific behavior in the return.
- Turn the return into an observable next step.
- Schedule an attempt with a chance for new feedback.
- Record the gap in the error notebook or short portfolio.
- Emotionally separate "formative data" from "career verdict", unless the system states otherwise.
Culture: performance versus improvement
Watling and Ginsburg warn that a culture focused only on performance restricts exploration and honesty. A culture of improvement authorizes trying, erring safely and adjusting (Watling and Ginsburg, 2018). Students can reinforce this culture at micro scale: thank others for specific feedback; do not mock the colleague who erred in the simulation; ask for opportunities to try again.
What formative assessment asks of the school
Protected time for observation and feedback; teacher training; clarity about the purpose of the instruments; alignment between what is taught and what is observed; support when feedback reveals a large gap (a plan, not abandonment). Without structure, formative rhetoric becomes overload.
Signs of healthy formative assessment versus in name only
Healthy: direct observation; the student knows what was formative and what was summative that day; shared language of milestones; an error in training generates a plan; mentors calibrate what is expected for the year; the time series matters more than a single episode.
In name only: everything "can count later"; feedback only near the final report; too many instruments and too little conversation; self-assessment without cross-checking evidence; no second chance; public and embarrassing feedback.
Connection with cognitive load and motivation
Giving back ten points at once saturates working memory. Choose one or two. Supporting autonomy in choosing the focus of feedback increases engagement (cognitive load; SDT).
Formative in solo study
You can create formative assessment without a preceptor: a question with commentary, a case with a hypothesis written before the answer, a before/after map, a recording of a presentation to yourself with a rubric. NEXO and the error notebook are formative data machines if you close the loop.
A week's script with explicit formative assessment
Monday: a short observation with an agreed criterion. Tuesday: deliberate practice of the weak point (fifteen minutes). Wednesday: a new attempt. Thursday: record in a short portfolio what changed. Friday: a case session with a hypothesis before the answer. Sunday: review the error notebook and choose the focus for the following week. The script is an example, not a fixed grid; the principle is a rhythm of attempt and return, not accumulating judgment without practice.
In placements with little access to a fixed preceptor, use pairs: one observes the other with a three-item rubric and they swap. Pairing does not replace a teacher, but it avoids weeks without any external mirror. Agree on rules of respect and of focus on behavior, not on personality.
When the school mixes formative and summative in the same instrument, ask for the legend in writing. If there is none, ask at the placement meeting: "Which of these mini-CEXs go into the report and which are only practice?". The question is legitimate and improves everyone's use of the data (Watling and Ginsburg, 2018; van der Vleuten et al., 2012).
Three formative scenes (fictional teaching cases)
Scene A. The preceptor observes the history taking, asks for a self-assessment, points out that the patient's agenda was not negotiated, agrees that at the next appointment the student will open with "what is most important to you today?" and observes again in the afternoon. Complete formative assessment: data, plan, new attempt.
Scene B. At the end of the rotation, the student receives a surprise report based on hallway impressions. There was no declared observation and no chance to adjust. Label in the system: "continuous assessment". Effect: lasting distrust of any "this doesn't count".
Scene C. A simulation group holds a debrief with an explicit rule: the first fifteen minutes are formative and protected; the station grade comes from another rubric announced beforehand. The group risks more hypotheses. Clarity of purpose changes behavior (Watling and Ginsburg, 2018).
Formative assessment and the student's mental health
When everything seems summative, anxiety rises and honesty falls. Reliable formative assessment does not eliminate exam stress, but it reduces the feeling of permanent surveillance. If anxiety prevents you from studying or sleeping, seek the help you need. Assessment is part of the craft; intense suffering does not have to be.
The role of the record
Recording formative feedback helps memory and the portfolio. Recording too much, in a legalistic tone, inhibits. Balance: short notes oriented to behavior and plan, accessible to the student, with a legend of purpose. Avoid copying into the summative report excerpts that were promised as formative only without warning about the rules of the game.
How to align formative assessment with NEXO and case-based study
Before the case: write the hypothesis. After: compare it with the outcome of the reasoning. Extract one behavior ("I will force three hypotheses before the first clue"). At the next session, check whether you followed through. That is self-administered formative assessment with evidence. Combine it with concept maps if the gap is in structure, or with metacognition if the gap is in monitoring.
Questions for the placement coordination
"Which instruments are purely formative in this rotation?" "How soon do I get written feedback?" "Is there a structured chance for a new attempt after feedback?" "Who calibrates the preceptors?" "Where is the rubric?" Coordinators who answer clearly save conflict and improve learning (twelve tips programmatic; van der Vleuten et al., 2012).
Formative in practical exams and practice OSCEs
Practice stations with immediate debrief are high-value formative if the debrief is specific. Stations that only say "pass/fail" without feedback waste the observation. If your course offers a mock OSCE, demand the debrief as part of the design, not as a favor.
Operational summary
Quality formative assessment = clear purpose + observation + actionable feedback + chance for a new attempt + a culture that tolerates training error. If any piece is missing, the name "formative" becomes pedagogical marketing. With the pieces, the student gains a map of the next step and the school gains better data for the decisions that really need to be summative.
Formative in the transition from basic to clinical
In the basic cycle, "formative" often means an unweighted quiz. In the clinical setting, it comes to mean someone watching you work. The change to public exposure increases perceived threat. Preceptors can name this: "I will observe for ten minutes and give back two points; it does not go into today's report." The short sentence reduces cortisol and improves listening to feedback (Ryan et al., 2021).
Students can prepare for the transition by practicing formative assessment in the basic cycle: explain a mechanism out loud, take a question from a colleague, adjust. The muscle of hearing feedback without collapsing is trained early.
What to do with unfair or poorly given feedback
Not all feedback is gold. If it is vague, ask for an example. If it is humiliating, record the fact and seek the school's safe channel; no one is obliged to absorb abuse in the name of "training". If it is technically doubtful, cross-check with another source and with the literature. Quality formative assessment is dialogue based on performance evidence, not an exercise of power.
Relationship with large-scale exams
Even those preparing for national exams benefit from formative cycles: commented mock exams, error review by type of decision, method mentoring. The final exam is summative; the path to it needs a thousand formatives. The series of posts about exams (USMLE, MIR, ENARM and related) describes the format of each; the formative logic is transversal: train the gesture before the day.
Teachers: how to start tomorrow without curricular reform
Choose an observable task. Announce the criterion in one sentence. Observe. Ask for self-assessment. Give back one behavior and one plan. Offer a new chance in the same week. Record in two lines. Repeat. This microcycle is formative even without a new platform (Norcini and Burch, 2007; Lefroy et al., 2015).
If the workload prevents daily observation, arrange weekly quality observation with empty-corridor feedback. Frequency without quality becomes noise; quality without any frequency becomes abandonment.
Students: how to extract formative assessment from a rushed service
Arrive with a specific request: "Can you observe me just at the opening of the consultation?". Offer the three-item rubric. Thank them for the specific feedback. Show the following week what changed. Busy preceptors respond better to surgical requests than to "give me some general feedback".
Closing
Well-done formative assessment is structured kindness: it tells the truth about performance in time to change course. Without structure, kindness becomes omission; without kindness, structure becomes fear. The medical craft needs both. Use formative assessment to learn in public safely; reserve summative assessment for the moments when society needs a clear decision about competence.
Formative and teamwork
Feedback only from the preceptor leaves out peers and other professionals. In mature wards, the nurse or nursing technician who saw the student communicate with the family also offers formative data. Including these voices requires culture and explicit permission: the student needs to know that this feedback is for learning, not to "fill the dossier". When well done, it enriches the picture; when poorly done, it becomes a denunciation network. The difference lies in the announced purpose and the right of reply.
Myths that get in the way
Myth 1: "If it is formative, nobody makes an effort." Evidence from CBME and programmatic assessment suggests the opposite when the culture is one of development (van der Vleuten et al., 2012). Myth 2: "Formative does not need rigor." Rigor in observation and in language is exactly what makes it useful. Myth 3: "Summative is enough." Summative without prior formative usually surprises and punishes gaps that were trainable. Myth 4: "Feedback is hallway talk." Without structure, the talk fades from memory; with minimal structure, it becomes a plan.
A quick mental checklist before calling something formative
Before labeling an activity as formative, check: was the purpose said out loud? Was there observation of behavior, not just an impression? Does the return point to a concrete next step? Is there a window for a new attempt? If two of these answers are missing, treat the episode as something intermediate and tell the student so. Honesty about the design is worth more than a pretty label.
One paragraph to keep
If you remember only one sentence from this text, remember this one: announce the purpose, observe the behavior, give back a next step and offer a new chance. Everything else (platforms, long rubrics, committees) serves that sequence. Without it, the word "formative" is decoration.
How NEXO helps you train
NEXO offers fictional cases with a real clinical presentation, up to six clues and feedback on your reasoning. Each session is a formative point: you form hypotheses, see where you diverged and adjust for the next case. It does not replace observation on the ward; it creates a frequency of attempts and returns between one shift and the next.
See the Economy. For groups and leagues, NEXO Closer. For research, curation and creation, NEXO Researcher, NEXO Curator and NEXO Creators. To follow the curve, how to track your progress.
Frequently asked questions
Does formative assessment count toward passing the year?
It depends on the local design. In many programmatic systems, formative data feed the dossier that supports the summative decision. Ask for your course's legend (van der Vleuten et al., 2012).
If "it does not count toward the grade", why take it seriously?
Because it is the rehearsal before the play. Ignoring formative means training only on game day.
What is the difference from informal feedback?
Informal feedback can be formative. Formative assessment tends to be more explicit, sometimes recorded, with declared criteria and purpose (Ryan et al., 2021).
Can I self-assess in a formative way?
Yes, and you should, as long as you cross it with external evidence (a question, a preceptor, a recording, the case outcome). Self-assessment on its own without data becomes opinion.
What should I do with contradictory feedback from two preceptors?
Ask each one for their criteria; look for a pattern over time; use mentoring to interpret it. An isolated episode weighs less than the series (twelve tips programmatic).
Does formative assessment eliminate test anxiety?
It does not eliminate it. It can reduce the feeling that "everything is decided in one day", if the system is reliable. Intense anxiety deserves support: seek the help you need.
How can a student ask for formative assessment without seeming insecure?
Ask for criteria and observation of a specific behavior. That signals professionalism, not fragility.
Play the case of the day on NEXO and treat the result as formative data: a behavior to adjust tomorrow, not a verdict on your career. If the gap is in knowledge structure, go back to the concept maps. If it is in motivation and autonomy, reread the self-determination theory. If it is in recording your learning, use the reflective portfolio. The grade that does not count, when well used, is the one that counts most for changing the gesture before the summative decision.
References
- Watling CJ, Ginsburg S. Assessment, feedback and the alchemy of learning. Med Educ. 2019. PMID: [30073692](https://pubmed.ncbi.nlm.nih.gov/30073692/)
- Ryan MS, et al. Assessment and feedback methods in competency-based medical education. Acad Med. 2021. PMID: [34929390](https://pubmed.ncbi.nlm.nih.gov/34929390/)
- van der Vleuten CPM, et al. Programmatic assessment: From assessment of learning to assessment for learning. Med Teach. 2012. PMID: [21609177](https://pubmed.ncbi.nlm.nih.gov/21609177/)
- van der Vleuten CPM, et al. Twelve Tips for programmatic assessment. Med Teach. 2015. PMID: [25410481](https://pubmed.ncbi.nlm.nih.gov/25410481/)
- Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990. PMID: [2400509](https://pubmed.ncbi.nlm.nih.gov/2400509/)
- Bok HGJ, et al. Programmatic assessment of competency-based workplace learning: when theory meets practice. BMC Med Educ. 2013. PMID: [24020944](https://pubmed.ncbi.nlm.nih.gov/24020944/)
- Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach. 2007. PMID: [18070333](https://pubmed.ncbi.nlm.nih.gov/18070333/)
- Miller A, Archer J. Impact of workplace based assessment on doctors' education and performance: a systematic review. BMJ. 2010. PMID: [20870696](https://pubmed.ncbi.nlm.nih.gov/20870696/)
- Saedon H, et al. The role of feedback in improving the effectiveness of workplace based assessments. BMC Med Educ. 2012. PMID: [22563722](https://pubmed.ncbi.nlm.nih.gov/22563722/)
- Bing-You R, et al. Feedback for learners in medical education: what is known? Med Teach. 2017. PMID: [28097949](https://pubmed.ncbi.nlm.nih.gov/28097949/)
- Lefroy J, et al. Guidelines: the do's, don'ts and don't knows of feedback for clinical education. Perspect Med Educ. 2015. PMID: [26644395](https://pubmed.ncbi.nlm.nih.gov/26644395/)
- Heeneman S, et al. What programmatic assessment in medical education can learn from healthcare. Perspect Med Educ. 2017. PMID: [28397009](https://pubmed.ncbi.nlm.nih.gov/28397009/)
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