Crossword puzzles versus multiple-choice questions as assessment tools in physiology: A counterbalanced comparative study among phase I MBBS students

Background: Competency-based medical education requires assessment strategies that both support learning and measure achievement. Multiple-choice questions (MCQs) are reliable and scalable, whereas crossword puzzles may foster active retrieval, learner participation, and immediate identification of knowledge gaps. Aims and Objectives: This study aimed to compare student performance in MCQ and crossword-based physiology assessments and evaluate learner perceptions of the two formats. Materials and Methods: A single-center, counterbalanced, repeated measures comparative study was conducted among Phase I MBBS students in Telangana, India (October–December 2025). Two physiology topics were assessed using MCQs and crosswords 1 week apart in opposite sequences. Both formats were derived from identical learning objectives and faculty-reviewed blueprints, though item-level matching for cognitive level or psychometric difficulty was not performed. Assessments were formative and excluded from summative decisions. Paired data were available for 140 students (transport across the cell membrane) and 126 students (hemoglobin and red blood cells). Perceptions were collected using a validated 10-item Likert questionnaire, yielding 266 topic-level responses. Results: For transport across the cell membrane, mean MCQ scores were 10.76±2.95/20 (53.8±14.8%), whereas crossword scores were 8.18±2.94/18 (45.4±16.3%), with a significant paired difference (P<0.001). For hemoglobin and red blood cells, MCQ and crossword scores (9.36±0.98 vs. 9.58±0.90/10) showed no significant difference (P=0.065). Feedback indicated strong acceptance: 82% found crosswords more interesting, 82% reported deeper thinking, 84% felt motivated to review, and 77% viewed both formats as complementary. Conclusion: Crossword puzzles were well received and demonstrated potential as engaging formative tools in physiology. Their effectiveness varied by topic, suggesting they should complement rather thanreplace MCQs within multimodal assessment frameworks.