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Pass/Fail, and Other Trends in Med School Grading

In recent years, there have been vast changes in the way medical students are evaluated and graded. Most notably, many medical schools have replaced their letter or tiered grading system (honors, high pass, etc.) with a much simpler one: pass or fail. According to a recent AAMC initiative, the number of schools using a pass/fail system in the pre-clerkship increased to 87 in 2014 from 71 the previous year. A school’s grading policies have far-reaching implications on its academic culture and community, informing everything from stress levels and competitiveness to the methods by which students are evaluated. As such, it is important that prospective medical students take grading policies into careful consideration as they evaluate different opportunities. 

Rationale for Pass/Fail Grading for Pre-Clerkship Years

This change can be largely attributed to a greater concern for medical student’s overall well-being. One study in Academic Medicine found that the class of University of Virginia (UVA) medical students who were graded pass/fail showed a significant increase in satisfaction as compared to their counterparts who were evaluated using a standard letter grading system. An even broader study surveyed students from seven different medical schools, and found that students evaluated using grading schemes with three or more categories had higher levels of stress and emotional exhaustion, and were more likely to experience burnout than those who were graded pass/fail. Many schools also find that a this system fosters a greater sense of collaboration and cooperation among students, while diminishing competitiveness.

The benefits of this pass/fail grading scheme extend beyond the students themselves, as it may also be helpful to schools as they seek to attract the best and brightest to their institution. In fact, a survey at UVA Medical School found that 81% of the entering class cited the pass/fail grading system as somewhat to very important in their decision to accept the offer of admission.

Examples of Pass/Fail Medical Schools

Schools that employ pass/fail grading during the pre-clerkship years include  Case Western School of Medicine, Albert Einstein College of Medicine and Rochester School of Medicine.

Even within the standard pass/fail grading system, however, there are small differences that distinguish one school from another. Students at Harvard Medical School, for example, are given grades of “satisfactory” or “unsatisfactory” during their pre-clerkship years, but students of exceptional merit can receive a Letter of Excellence that is added to their permanent file.

Many students are wary of pass/fail schools that may still track grades and establish ranking orders behind the scenes. However, schools such as Yale School of Medicine explicitly state that “there are no grades and there is no class ranking.”

Concerns (and Rebuttals)  

As expected, there are some concerns associated with a pass/fail grading scheme. Some worry that a non-tiered grading system may negatively impact students’ residency placement, scores on medical licensing exams (USMLE Step 1 and 2) or overall academic performance. If students are placed into only two categories, is there less incentive and, therefore, less motivation for them to work hard?

These concerns, however, have largely been refuted. The study cited above, involving UVA students, found that a change from a letter grading scale to a pass/fail system did not result in a decline in students’ academic performance or USMLE Step 1/2 scores. Furthermore, there was no negative affect on residency placement, as demonstrated by the quality of residency programs to which students were matched.

Alternatives to Pass/Fail for Pre-Clerkship Years

Despite the hype about pass/fail grading, there are still a significant number of schools (~81 according to AAMC) that evaluate their students using greater than two categories during the pre-clinical years. Pittsburgh School of Medicine, for example, employs a three-tiered grading structure: Honors/Satisfactory/Unsatisfactory for the first two years. The University of Maryland School of Medicine employs a letter grading approach: Honors, A, B, C, D, F.

Different Grading Approaches for Different Years

 Schools often employ different grading schemes depending on course types or year of medical school. The pass/fail system discussed above largely applies to the pre-clerkship years of medical school, when students are learning and reviewing the sciences before entering clinics. The majority of schools recently surveyed by AAMC also use the simple pass/fail system for grading students in electives. However, many schools utilize an entirely different grading scheme when evaluating students in their later years of medical school. In fact, the majority of schools surveyed by AAMC use a four-tiered grading system: honors, high pass, pass, and fail for required clerkships and fourth year electives and sub-internships.

Evaluation Components

In the same way grading frameworks are changing, so are the actual methods used to evaluate students. Schools not only assess their students using standard written exams, but now also use a variety of novel evaluation techniques. Although Yale does not give grades for the first two years, it still employs unique forms of evaluation such as direct questioning during seminars and laboratories to deem acceptable performance or not. Feinberg School of Medicine at Northwestern provides feedback to students using conventional methods such as examinations, as well as skills assessments, and narrative evaluations. Moreover, as of 2012, students at Northwestern build an electronic portfolio that is continuously reviewed with their mentors to ensure they are meeting the school’s required competencies.

Schools such as Perelman School of Medicine at UPenn utilize particularly innovative assessment methods, including simulations and standardized patients. Made possible by recent advances in technology, these assessments involve a patient simulator in a realistic hospital environment. Standardized patients, however, are trained individuals or in some cases, actual patients who help to create real-life medical scenarios.

Academic Honors

Often, these evaluation techniques are used to identify students for academic honors. Boston University School of Medicine awards Latin honors (e.g. summa cum laude) based on a number of factors: performance in courses, scores on medical licensing exams, and other more subjective criteria, such as “extreme initiative and talent.” Other types of academic recognition include membership in the medical honors society Alpha Omega Alpha, as well as distinction in research, and various clerkship and departmental awards.

Every medical school differs slightly in its approach to grading, and it is imperative to thoroughly research schools of interest in order to properly understand these nuances. For more information on medical school grading or any other part of the medical school application process, contact Collegiate Gateway – as always, we’re happy to help.