Our initial hypothesis was that medical students may experience increased anxiety toward a test even when it is low-stakes in its nature. However, the results of the current study indicate that the students’ anxiety levels during the test session trend downward compared with their anxiety levels during the practice session that took place beforehand. This unexpected outcome may have been influenced by the fact that the students perceived the test to be low-stakes and that it was conducted in a group setting. The finding thus lends support to the prevailing approach to programmatic assessment, which seeks to aggregate the performance outcomes of low-stakes examinations without unduly stressing the students. This approach also aims to provide students with prompt feedback on their performance in low-stakes examinations.

Testing is recognized as a significant source of stress for medical students, contributing to elevated levels of anxiety in academic settings [24]. In response to these findings, medical educators have sought to mitigate the adverse effects of examination-related anxiety by implementing strategies to optimize the examination environment. For example, group-based learning and the perception of interdependence between students throughout the group activity can serve to mitigate students’ anxiety [25]. This is because this pedagogical approach can facilitate psychological safety and a sense of group cohesion among the students. Therefore, instructors may consider implementing low-stakes group assessments with clearly defined expectations, supportive guidance, and immediate feedback to minimize test anxiety.

In addition, the process and mechanism for reducing their anxiety in our finding might be interpreted by applying the knowledge from cross-cultural psychology that East Asian people manage their emotions by mixing positive and negative emotions. Research in cultural psychology suggests that East Asian students often experience blended emotions—such as simultaneous negative and positive emotions — in collaborative settings. In our scenario, a slight increasing trend in the joy score was observed during the test session, which may correspond to a mixing of anxiety and joy [19, 26,27,28].

While the low-stakes, collaborative approach appears to have reduced negative emotions, it also presents certain limitations. The retrospective sampling method of emotional responses might have introduced recall bias. In addition, group-based testing may obscure individual performance, as more vocal or confident group members can dominate decision-making. We also acknowledge that individual emotional experiences might have varied based on group composition and interpersonal dynamics. Moreover, we did not control for pre-existing friendships or group hierarchies, which could have influenced outcomes. These limitations highlight important considerations for educators implementing group assessments. One solution is to combine group-based tests with individual reflective components, allowing for both peer collaboration and personal accountability. Statistical limitations of this study should be noted. The post hoc power analysis indicated a power level of 0.41, suggesting the sample size may have been insufficient to detect a significant difference in anxiety levels. In addition, the study’s anonymous survey design limited the ability to conduct paired t-test analyses, which would have allowed more precise tracking of individual emotional shifts. While these are common challenges in educational research constrained by class sizes and ethical concerns, future studies with larger cohorts and robust design would be better positioned to verify the observed trends with greater statistical confidence.

In conclusion, this study suggests that extremely low-stakes, group-based assessments may help reduce test anxiety among medical students. Even when framed as a “test,” the minimal stakes and collaborative setting appear to buffer emotional stress. While findings did not reach statistical significance, the consistent downward trend supports further exploration of these formats. These results align with the goals of programmatic assessment, emphasizing formative, low-pressure experiences that support long-term academic performance or reduce burnout, learning, and well-being. Educators may consider incorporating structured, low-stakes group assessments with clear guidance and feedback into their curricula. Future research should examine long-term emotional and academic impacts, as well as cross-cultural applicability, to strengthen the evidence base for emotionally supportive assessment practices in medical education.