Medical school is a grueling time for future physicians. In a short time, they must acquire vast sums of knowledge that they will apply in clinical practice with life or death consequences. Many physicians look back on their pre-clinical medical school years as a time of intense study done mostly in the service of reaching their ultimate goal: to provide clinical patient care in 3rd and 4th years of medical school. As they had in their academic past, students may feel pressured to achieve excellent grades in order to distinguish themselves in their medical school classes. As a result, educators became concerned that the grading system added to an atmosphere of intense competition, dis-incentivizing the teamwork and comradery necessary for optimal medical care.
As early as the 1960s, some top tier schools like Harvard, Stanford and Yale decided that changing the preclinical grades to a two-tiered system of pass/fail would help to change this atmosphere. There was an initial backlash as others in the medical education community instead encouraged “elitism in education.” This group feared that sub-par students in pass/fail schools would erroneously enter prestigious residencies and, unable to live up to the standards, fail as future physicians.1 Despite this concern, there has been an ongoing trend towards pass/fail grades in the preclinical years. For example, in the 2016-17 school year, 66% of medical schools used the pass/fail system versus 53% in 2012-2013.
Is the pass/fail system beneficial for medical students?
There are alarming levels of burnout among physicians, residents, and medical students Medical school educators are searching for ways improve the wellbeing of future doctors. The pass/fail grading system is seen as one potential solution. Research indicates that schools with pass/fail systems had lower levels of stress, exhaustion, and depersonalization.2 In addition, students in these schools were less likely to have considered dropping out of medical school, a sign of early burnout in their career. In contrast to the initial fears of some educators, there is no difference in United States Medical Licensing Exam (USMLE) Step1 scores and residency placements in students in pass/fail systems.3 A theorized benefit of the two-tiered system is that it will instill in young physicians an internal motivation for life-long learning they must foster throughout their careers.3 Furthermore, the American Medical Student Association (AMSA) and the American Medical Association (AMA) both approved policy urging medical schools to adopt a pass/fail grading system.
What are the drawbacks?
The pass/fail grading system is not perfect. For better or worse, medical students must somehow be differentiated to allow residency program directors to select their new interns. Increasingly, this need for differentiation has led to an overemphasis on the USMLE Step 1 scores. The test, which must be completed prior to entering the clinical years, is often regarded as a daunting rite of passage all medical students must overcome. In light of pass/fail grades, residency programs and certain specialties use it as the litmus test for admission to hopeful medical students. In fact, many students feel their future career and specialty rely solely on their scores on the test. Unfortunately, high USMLE Step 1 scores do not necessarily predict medical knowledge and clinical aptitude in the future.4
Where do we go from here?
A fine line should be drawn between medical student wellness and ensuring students are adequately prepared to care for patients. Physicians endure myriad tests and challenges to ensure this ability, and providing a respite is a useful goal. The fact of physician burnout and shortages should encourage medical schools to produce an environment that delivers a group of well-adjusted and learned students that will provide excellent care for their community well into the future. Maintaining a nurturing and healthy environment in medical schools is paramount to the goals of education. We must ensure that students are evaluated by assessments that adequately test knowledge, not test taking skills. Ideally, the metrics by which we evaluate medical school students should directly correlate with their ability to become competent physicians.
1. Moss TJ, Deland EC, Maloney JV, Jr. Selection of Medical Students for Graduate Training: Pass/Fail Versus Grades. N Engl J Med. 1978;299(1):25-27. doi:10.1056/NEJM197807062990106
2. Reed DA, Shanafelt TD, Satele DW, et al. Relationship of Pass/Fail Grading and Curriculum Structure with Well-Being among Preclinical Medical Students: A Multi-Institutional Study. Acad Med. 2011;86(11):1367-1373. doi:10.1097/ACM.0b013e3182305d81
3. White CB, Fantone JC. Pass-Fail Grading: Laying the Foundation for Self-Regulated Learning. Adv Health Sci Educ Theory Pract. 2010;15(4):469-477. doi:10.1007/s10459-009-9211-1
4. Sutton E, Richardson JD, Ziegler C, Bond J, Burke-Poole M, McMasters KM. Is Usmle Step 1 Score a Valid Predictor of Success in Surgical Residency? Am J Surg. 2014;208(6):1029-1034; discussion 1034. doi:10.1016/j.amjsurg.2014.06.032