In 2019 Elsevier launched a formative assessment tool as part of the ClinicalKey Student digital product suite for medical education. Review of literature on formative assessment shows how effective it is to maximize learning outcomes, and user research conducted over the past two years shows that formative assessment is a widespread practice all over the globe. While we observed a huge interest in formative assessment worldwide to engage students, build confidence, self-learning capability and provide timely and effective feedback, our research also revealed some culture differences, surely, but some resistance and challenges to the adoption of formative assessment.

From July to September 2019, we conducted a round of qualitative research with 59 instructors from different countries to do a deep-dive on that resistance and document the reasons for such resistance.

We have identified three main challenges.

- Time constraint. Even if an institution encourages the formative mindset, it's hard for instructors to "make it to the top of the to-do pile". For instructors who are also practicing clinicians, it is difficult to find enough time. In India for example, faculty working in the public hospitals have high workload that bars them from good academic activities. The patient load is too high.

- For written formative assessments, coming up with questions is time consuming. Instructors write their own questions – based on their own clinical experience or other content they provide students – so they match learning objectives and are of known quality. While writing their own questions ensures they are always tied to learning objectives, it is one of the most challenging steps.

- Distrust of open formative assessment & cheating. True cheating is a problem in certain countries. Formative assessments where students can work together, and review resources is seen as a negative by some instructors; it hinders both the students' learning and the instructor's ability to determine what students "really know". These instructors believe this can affect patient outcomes when they transition to practice.

Even though instructors worldwide have positive attitude towards formative assessment, cultural differences and workload act as barriers to the adoption of formative assessment in a lot of countries. The question is now how to help instructor overcome those barriers?