Student Perspectives: Sounding the Alarm on the Dreaded Bell-Ringer Exam

The traditional bell-ringer exam is a long-standing anatomy exam format frequently criticized by students for inducing anxiety. And reasonably so—imagine walking into your exam, anatomical specimens are scattered throughout the room, everyone scrambles to a starting station, and a bell rings every 60 seconds signalling everyone to march forward from one question station to the next. It’s an environment that can feel intimidating, which is the last thing you need as a student about to write a high-stakes exam.

Would you then prefer the sound of the bell to guide the pace of the exam, or would you prefer no bell—moving along to question stations at your own pace? What if you had the option to choose between different pacing structures?

Here at the ATLAS Research Lab, we have been investigating alternatives to the dreaded bell-ringer exam as a way to mitigate test anxiety and enhance the testing experience for students. This is important to us! We want students to be able to properly demonstrate their learning with as little getting in the way as possible.

We first investigated a novel, self-paced (SP) lab exam timing structure. Instead of the traditional bell-paced (BP) exam where progression through the question stations is guided by a bell chime, in the SP format, all students advance to the next station at their own discretion, without an auditory aid. In either case, BP or SP, students are not allowed to return to a previously-completed station, and all other exam elements remain consistent (total number of question stations, total time limit, placement of rest stations, scattered starting stations, and marking scheme).

Image caption: a student writing an anatomy laboratory exam expressing feelings of anxiety and nervousness about time management.

We first compared the impact of BP vs. SP timing structures among senior undergraduate students enrolled in our one-of-a-kind anatomy dissection course (ANA400H1, Anatomy Dissection, Faculty of Arts & Science). This study marked the start of our Pacing Project, and was implemented in the Winter semesters of both the 2017/2018 and the 2018/2019 sessions (n = 35). This study utilized a randomized cross-over design; so students were randomized to either BP/SP for the midterm exam, and then switched to the alternate pacing condition for the final exam. Interestingly, we found that even though students were more anxious in the BP condition, they indicated a preference for the BP structure over the SP structure. Student comments revealed that this preference for the BP structure seemed to be associated with a previous familiarity with bell-ringer examinations, as our sample consisted of undergraduate anatomy students who had already completed at least one junior-level anatomy course that would have included bell-ringer exams.

So we decided to see if familiarity impacted preference for, and test anxiety between, the BP vs. SP timing structures among junior undergraduate students. This was the second study in our Pacing Project, involving n = 131 students enrolled in ANA300Y1, an introductory anatomy course in the Faculty of Arts & Science, with little to no previous experience in anatomy or with bell-ringer exams. Retaining the same study design, we were surprised to see that these junior students were more anxious in the BP structure but still preferred it! So ultimately, familiarity didn’t seem to be driving students’ preference for the BP timing structure. This time around, however, student comments revealed that having the autonomy to choose between BP vs. SP for their exam may be the way to mitigate test anxiety.

This valuable insight inspired our third and final study in the Pacing Project, investigating the impact of self-selecting lab exam timing structure (BP vs. SP) on test anxiety and academic performance. This study was less a question of comparing BP vs. SP, but rather, seeing how student autonomy impacted their testing experience. We returned to our senior ANA400H1 undergraduate students to conduct this study in the Winter semester of 2023. Here, all n = 17 students also wrote two lab exams for the course: a midterm and a final, but this time, prior to each exam, students could freely choose between BP vs. SP timing structures. What this meant was that students could choose BP for both exams, SP for both, or switch between the two from one exam to another. In either case, of course, all other exam elements remained consistent. We also measured test anxiety and collected open-text feedback before and after each exam to gauge student perceptions about the pacing structures, and being able to choose between the two.

On average, we found that test anxiety and academic performance remained consistent between self-selected BP vs. SP writers through mixed-effects modelling. This meant that average test anxiety was equalized between the BP and SP conditions across both exams. We also found that self-selected pacing structure did not impact academic rigour, as average test performance between the two conditions was equivalent across both exams. However, when we separate the midterm exam data from the final exam data, some unexpected trends emerged. Interestingly, linear regression revealed that female students experienced higher test anxiety during the midterm but not at the final, independent of chosen pacing structure. During the midterm, we also found that students who chose BP were more likely to be more anxious. However, the story takes a bit of a turn; for the final exam, these effects did not persist! The association between female students and higher test anxiety, as well as BP writers and higher test anxiety, diminished during the final.

This shift supports the idea that giving students the autonomy to choose between BP and SP timing structures facilitates course-correction; allowing students to adjust their exam pacing may help mitigate test anxiety by enabling them to switch to a format better suited to their preferences. As one anonymous student in this study had expressed, “[self-selection] gives you flexibility to control pacing based on your knowledge” - student DC. Indeed, other student feedback revealed that both BP and SP writers reported that their selected pacing structure offered a unique sense of control: “Better control of timing so I don’t lose track” - student DD, about the BP format; “Did bell-paced during midterm [...] Really messed up my timing [...] Self-paced makes me feel more in control” - student DJ, who switched from BP in the midterm to SP in the final.

One of our ATLAS Lab graduate researchers, Callie Silverton, was a student in ANA400 while this study was ongoing, and openly shared her preference for the BP format: "Bell-pacing is personally helpful because I don't have time to ruminate about a question and overthink it — it's just guess and go, whereas in the self-paced I was worried about spending too long at a station.” However, she also emphasized the value of autonomy: “I do think it's important to consult students and interrogate traditional testing structures. There are certainly student needs that are not being met, and asking students for their perspective may illuminate the ways to fill those gaps — maybe it is exam format autonomy, or maybe it's something else we haven't considered.”

Callie’s reflections highlight the complexity of investigating interventions for test anxiety, but also the importance of appraising long-standing teaching methods. Should we do things a certain way because that’s how it’s always been done? But how do our methods impact the student experience in practice? Is there a way for us to intervene and improve certain aspects of our teaching modalities?

In anatomy, assessments are foundational to the learning process and have been argued to be more impactful to learning than even the style and modality of the teaching itself. [1,2] Bell-ringer exams, while easier to administer and more scalable for larger class sizes, are criticized for not just being conducive to test anxiety, but also for a lack of alignment with how teaching is delivered, and how learning is assessed in vocational practice. Self-pacing, on the other hand, while flexible, is logistically harder to implement—especially in larger class sizes. 

All in all, our findings suggest that allowing students to self-select their pacing structure offers a means to enhance perceived control, which may mitigate test anxiety. It’s important for us educators to explore how such flexibility can be scaled to larger cohorts, and whether incorporating other forms of student autonomy in the classroom can further align both pedagogical goals and vocational demands purposefully.

The three studies associated with the ATLAS Research Lab’s Pacing Project are being prepared for publication. We will update this page with links to our three publications, from the three different studies, once they become available later this year. Two posters on this work that have been presented in Anatomy Connected 2024 and 2025 are linked here. If you’d like to hear more about our unique undergraduate anatomy dissection course in the Faculty of Arts & Science, ANA400H1, we are also working on a project investigating the impact of this course on student career outcomes and trajectories (The UDE Project, led by our undergraduate student researcher Jana Hamoud Ali). Stay tuned!

1. Alraddadi A, Hoja I, Alhawas H, Khawaji B, Alharbi Y, Agha S, Masuadi E, Magzoub ME. 2021. Introducing free response short answer questions in anatomy spot tests: Experiment study. Surgical and Radiologic Anatomy, 43(4), 497–503. https://doi.org/10.1007/s00276-020-02550-3

2. Collins TJ, Given RL, Hulsebosch CE, Miller BT. 1994. Status of gross anatomy in the U.S. and Canada: Dilemma for the 21st century. Clinical Anatomy, 7(5), 275–296. https://doi.org/10.1002/ca.980070509