Simplify or Stratify? The Debate over Medical School Grading Systems
Harleen Marwah, Abhinav Suri, Clarence H. Braddock III, et al
N Engl J Med 2025;393:2268-2270
CASE VIGNETTE
A Medical School Evaluating the Grading System
Harleen Marwah, M.D.
You have recently been named the dean in charge of preclinical curriculum for your medical school. There is debate among the faculty and students in your school regarding the approach to grading in the preclinical years. The current policy is a five-tier grading system (A, B, C, D, F), but there are calls to change to a pass/fail system. Potential benefits have been raised for each approach, and you must decide whether to implement a pass/fail system or continue the use of the five-tier grading system for the preclinical years in your school.
OPTIONS
Which one of the following approaches would you choose? Base your choice on the literature, your own experience, published guidelines, and other information.
- Implement a pass/fail system.
- Continue the five-tier grading system.
To aid in your decision making, we asked two experts in the field to summarize the evidence in favor of approaches assigned by the editors. Given your knowledge of the issue and the points made by the experts, which approach would you choose?
OPTION 1
Implement a Pass/Fail System
Abhinav Suri, M.P.H.
Clarence H. Braddock III, M.D., M.P.H.
Tiered grades in the preclinical years of medical school should be replaced by a pass/fail grading system. Tiered grading shows little evidence of benefit yet much evidence of harm. A pass/fail grading system sustains positive academic progress and competitiveness for residency selection, while improving personal well-being.
There is concern that converting to a pass/fail system would worsen student performance on the U.S. Medical Licensing Examinations (USMLE), which are widely used to measure readiness for clinical rotations and residency. A pass/fail grading system does not, however, correlate with lower performance on the USMLE Step 1 (the examination taken on completion of the preclerkship curriculum). In an analysis of 96 U.S. medical schools that controlled for students’ Medical College Admission Test (MCAT) scores, the pass rate on the Step 1 examination among schools using pass/fail preclinical grading was noninferior to that among schools using tiered grading.1 An assessment of Step 1 scores at one U.S. medical school showed no decrease in scores after a change from a three-tiered system to a pass/fail system.2
USMLE Step 1examinations serve an important role as a standardized, psychometrically sound grading system that aims to ensure knowledge competency before students enter clinical training. This national system may offer broader validity and reliability than preclinical course assessments at individual schools as a predictor of success in the clinical phase of training.
Proponents of a tiered grading system may argue that this system helps residency program directors assess candidates. However, evidence suggests that residency programs do not heavily weigh preclinical academic performance when making selections. A 2024 survey of more than 1000 residency programs showed that preclinical grades are not among even the top 10 most important factors program directors rely on. Indeed, these grades ranked last of 22 variables.3 Another study showed that the quality of residency programs (as judged by specialty board examination pass rates) into which students matched was no different with a pass/fail system than with a tiered grading system.4
Furthermore, tiered grading systems have negative effects. Medical students at one medical school had lower scores on an assessment of well-being (the 124-point Dupuy General Well-Being Schedule) in their preclinical curriculum before a change to pass/fail grading.4 At another institution, moving from a five-tier scale to pass/fail grading sustained overall performance while narrowing the gap between students who are underrepresented in medicine and those who are not underrepresented across most subject-specific examinations (in both preclinical and clinical years) and the USMLE Step examinations.5
For these compelling reasons, our institution switched to a pass/fail system years ago. Our experience is that the flexibility of this curriculum has enabled our students to develop individual interests and explore different specialties. Our students can engage in a wide range of activities during their preclinical year, including leading research projects, managing student-run clinics, and engaging in clinical experiences earlier in medical school — all without sacrificing academic performance as assessed by written examinations and clinical rotation evaluations.
A pass/fail preclinical curriculum offers substantial benefits in bolstering student well-being, improving satisfaction with medical education, and bridging academic disparities without resulting in deficits in assessment-based markers of academic success. To the dean in the vignette, we highly recommend implementation of a pass/fail preclinical curriculum.
OPTION 2
Continue the Five-Tier Grading System
Dawn E. DeWitt, M.D.
Rhett Oellrich, B.S.
Most U.S. medical schools use pass/fail grading in preclerkship courses owing to concerns that tiered grading causes student stress, encourages in-class competition rather than collaboration, and fosters performance over learning. Unfortunately, in a climate of competitive residency selection, preclerkship pass/fail grading in medical school is presenting unintended challenges for applicants and residency programs.
Tiered grades in preclerkship courses may provide learners with earlier, more specific feedback on performance, which may guide study habits. Furthermore, metrics that help future physicians aim beyond meeting minimum standards are arguably helpful. For example, since the USMLE Step 1 transitioned to a pass/fail system, Step 1 pass rates have fallen, while scores on Step 2 examinations (taken during clerkships) have risen, paralleling the greater perceived importance of Step 2 examination scores.6 These trends support the argument that numerical or tiered results and extrinsic motivation may drive study behavior — especially in the current residency match environment.
Residency selection remains highly competitive, and pass/fail grading in preclerkship courses and licensing examinations may not decrease stress but merely shift the focus of student stress.7 Since the only standardized metric available to residency program directors is the Step 2 score, the rise of preclerkship pass/fail grading has sacrificed the potential benefits of early feedback and extrinsic motivation in the classroom and has redirected the stress previously associated with earlier measures to later in medical school.6 Now students face heightened stress during clerkships and Step 2, when they already have rigid, rigorous schedules. This timing may further distract students from focusing on clinical excellence.8
In the information vacuum of pass/fail grading, a “shadow economy” has emerged, in which students prioritize research or other extracurricular activities over coursework to optimize their residency applications.9 A tiered grading structure may put students on a more even playing field than a “shadow economy.” Since most schools make standard study resources available to all students, and preclerkship tiered grades have predictive validity for future physician performance,10 the opportunity to achieve high grades may also help nontraditional students (e.g., students from underrepresented groups, those with non-STEM [science, technology, engineering, and mathematics] backgrounds, those with a military background, or mature students) distinguish themselves. In addition, it may combat inequities that may emerge in the “shadow economy,” in which connections and financial resources might facilitate the availability of prestigious extracurricular opportunities.
Preclerkship tiered grades could also facilitate earlier and more targeted residency planning. Without metrics to help indicate likely competitiveness for specific residency applications, students may inadvertently invest substantial time and effort toward a particular specialty, only to discover later that they are not well positioned to compete for available slots. Some students may feel pressured to take yearlong leaves of absence to engage in activities to increase their competitiveness, thus prolonging medical training and increasing debt. Furthermore, leaves of absence may delay and disrupt training.
Preclerkship tiered grading and additional metrics (such as course grades) might de-escalate the growing “shadow economy,” decrease costly leaves of absence, and provide earlier and more specific feedback for skill development and career planning without increasing student stress overall. Early feedback from tiered grading ultimately better serves students’ interests while refocusing them on excellence in core knowledge and clinical skills.
