The Problematic Persistence of Tiered Grading in Medical School

References

• Association of American Medical Colleges. 2020 Facts: Enrollment, Graduates, and MD-PhD Data, by Institution. https://www.aamc.org/data-reports/students-residents/interactive-data/2020-facts-enrollment-graduates-and-md-phd-data. Accessed June 2, 2021.
   Google Scholar
• Alexander EK, Osman NY, Walling JL, Mitchell VG. Variation and imprecision of clerkship grading in U.S. medical schools. Acad Med. 2012;87(8):1070–1076.
   PubMed Web of Science ®Google Scholar
• Durning SJ, Hemmer PA. Commentary: grading: what is it good for? Acad Med. 2012;87(8):1002–1004. doi:10.1097/ACM.0b013e31825d0b3a.
   PubMed Web of Science ®Google Scholar
• White CB. A standardized approach to grading clerkships: hard to achieve and not worth it anyway. Acad Med. 2013;88(3):295. doi:10.1097/ACM.0b013e318280c933.
   PubMed Web of Science ®Google Scholar
• Hom J, Richman I, Hall P, et al. The state of medical student performance evaluations: improved transparency or continued obfuscation? Acad Med. 2016;91(11):1534–1539. doi:10.1097/ACM.0000000000001034.
   PubMed Web of Science ®Google Scholar
• Mercer WF. What can the college and fitting-school do to aid in the study of medicine? Bull Am Academy Med. 1908;9(2):93–107.
   Google Scholar
• Motter MG. The essentials of a medical education. Bull Am Acad Med. 1908;9:18–28.
   Google Scholar
• Whitehead RH. Medical schools which do not give diplomas. Bull Am Acad Med. 1900;5(7):522–525.
   Google Scholar
• Price PB, Taylor CW, Richards JM, Jacobsen TL. Measurement of physician performance. J Med Educ. 1964;39:203–210.
   PubMedGoogle Scholar
• Dodson JM. On the importance of exact and complete records of the students’ work and the issue of credit cards for the same. Bull Am Acad Med. 1902;5:533–537.
   Google Scholar
• Robins LS, Fantone JC, Oh MS, Alexander GL, Shlafer M, Davis WK. The effect of pass/fail grading and weekly quizzes on first-year students’ performances and satisfaction. Acad Med. 1995;70(4):327–329. doi:10.1097/00001888-199504000-00019.
   PubMed Web of Science ®Google Scholar
• Spring L, Robillard D, Gehlbach L, More Simmas TA. Impact of pass/fail grading on medical students’ well-being and academic outcomes. Med Educ. 2011;45(9):867–877. doi:10.1111/j.1365-2923.2011.03989.x.
   PubMed Web of Science ®Google Scholar
• Lucey CR, Hauer KE, Boatright D, Fernandez A. Medical Education’s Wicked Problem: achieving Equity in Assessment for Medical Learners. Acad Med. 2020;95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments):S98–S108. doi:10.1097/ACM.0000000000003717.
   PubMedGoogle Scholar
• Hauer KE, Lucey CR. Core clerkship grading: the illusion of objectivity. Acad Med. 2019;94(4):469–472. doi:10.1097/ACM.0000000000002413.
   PubMed Web of Science ®Google Scholar
• Low D, Pollack SW, Liao ZC, et al. Racial/ethnic disparities in clinical grading in medical school. Teach Learn Med. 2019;31(5):487–496. doi:10.1080/10401334.2019.1597724.
   PubMed Web of Science ®Google Scholar
• McDuff SGR, McDuff D, Farace JA, Kelly CJ, Savoia MC, Mandel J. Evaluating a grading change at UCSD school of medicine: pass/fail grading is associated with decreased performance on preclinical exams but unchanged performance on USMLE step 1 scores. BMC Med Educ. 2014;14:127. doi:10.1186/1472-6920-14-127.
   PubMed Web of Science ®Google Scholar
• Kim S, George P. The relationship between preclinical grading and USMLE scores in US allopathic medical schools. Fam Med. 2018;50(2):128–131. doi:10.22454/FamMed.2018.145163.
   PubMed Web of Science ®Google Scholar
• Custers EJFM, ten Cate O. The history of medical education in Europe and the United States, with respect to time and proficiency. Acad Med. 2019;93:S49–S54.
   Web of Science ®Google Scholar
• Rothstein WG. American Medical Schools and the Practice of Medicine: A History. New York, NY: Oxford University Press; 1987.
   Google Scholar
• Starr P. The Social Transformation of American Medicine. 2nd ed. New York, NY: Basic Books; 2017.
   Google Scholar
• Welch WH. The relation of Yale to medicine. Science. 1901;14(361):825–840. doi:10.1126/science.14.361.825.
   PubMedGoogle Scholar
• Soutter L. Annual discourse-medical education and the university (1901-1968)). N Engl J Med. 1968;279(6):294–299. doi:10.1056/NEJM196808082790606.
   PubMed Web of Science ®Google Scholar
• Colvin SS. Marks and the marking system as an incentive to study. Educ. 1912;32:560–571.
   Google Scholar
• Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. New York, NY: The Carnegie Foundation for the Advancement of Teaching; 1910. [Database][Mismatch
   Google Scholar
• Tory HM. Universities function in medicine. Bull Assoc Am Med Coll. 1926;1:36–37.
   Google Scholar
• Flexner A. Medical Education—A Comparative Study. New York: The MacMillan Company; 1925.
   Google Scholar
• Meyer M. The grading of students. Science. 1908;28(712):243–250.
   PubMedGoogle Scholar
• Cattell JM. The achievements and shortcomings of the American college. The School Review. 1910;18(6):369–383. doi:10.1086/435578.
   Google Scholar
• Meyer M. Experiences with the grading system of the University of Missouri. Science. 1911;33(852):661–667.
   PubMedGoogle Scholar
• Finkelstein IE. The Marking System in Theory and Practice. Baltimore, MD: Warwick and York, 1913.
   Google Scholar
• Geertsma RH, Chapman JE. The evaluation of medical students. J Med Educ. 1967;42(10):938–948.
   PubMedGoogle Scholar
• Westerman ME, Boe C, Bole R, et al. Evaluation of medical school grading variability in the United States: are all honors the same? Acad Med. 2019;94(12):1939–1944. doi:10.1097/ACM.0000000000002843.
   PubMed Web of Science ®Google Scholar
• Blood AD, Farnan JM, Fitz-Williams W. Curriculum changes and trends 2010-2020: a focused national review using the AAMC curriculum inventory and the LCME annual medical school questionnaire part II. Acad Med. 2020;95(9S A Snapshot of Medical Student Education in the United States and Canada: Reports From 145 Schools):S5–S13.
   PubMedGoogle Scholar
• Association of American Medical Colleges. Curriculum Reports 2020: grading systems use by US medical schools. https://www.aamc.org/data-reports/curriculum-reports/interactive-data/grading-systems-use-us-medical-schools. Accessed September 16, 2021.
   Google Scholar
• Fazio SB, Torre DM, DeFer TM. Grading practices and distributions across internal medicine clerkships. Teach Learn Med. 2016;28(3):286–292.
   PubMed Web of Science ®Google Scholar
• Reiser SJ. The ethics of learning and teaching medicine. Acad Med. 1994;69(11):872–876.
   PubMed Web of Science ®Google Scholar
• Bullock JL, Lai CL, Lockspeiser T, et al. In pursuit of honors: a multi-institutional study of students’ perceptions of clerkship evaluation and grading. Acad Med. 2019;94:S48–S56. doi:10.1097/ACM.0000000000002905.
   PubMed Web of Science ®Google Scholar
• Spaner S. Does evaluation of medical students produce any positive feedback? Can J Surg. 1996;39(5):417–418.
   PubMed Web of Science ®Google Scholar
• Hill MR, Goicochea S, Merlo LJ. In their own words: stressors facing medical students in the millennial generation. Med Educ Online. 2018;23(1):1530558.
   PubMed Web of Science ®Google Scholar
• Stimmel B. The use of pass/fail grades to assess academic achievement and house staff performance. J Med Educ. 1975;50(7):657–661. ():
   PubMedGoogle Scholar
• Moss TJ, Deland EC, Maloney JV. Selection of medical students for graduate training: pass/fail versus grades. N Engl J Med. 1978;299(1):25–27.
   PubMed Web of Science ®Google Scholar
• Lloyd DA. Pass-fail grading fails to meet the grade. Acad Med. 1992;67(9):583–584.
   PubMed Web of Science ®Google Scholar
• Wasson LT, Cusmano A, Meli L, et al. Association between learning environment interventions and medical student well-being: a systematic review. JAMA. 2016;316(21):2237–2252.
   PubMed Web of Science ®Google Scholar
• Miller BM, Kalet A, VanWoerkom RC, Zork N, Halsy J. Can a pass/fail grading system adequately reflect student progress? Virtual Mentor (AMA J Ethics. 2009;11:842–851.
   PubMedGoogle Scholar
• Thompson RH, Lohse CM, Husman DA, Leibovich BC, Gettman MT. Predictors of a successful urology resident using medical student application materials. Urology. 2017;108:22–28. doi:10.1016/j.urology.2017.06.046.
   PubMed Web of Science ®Google Scholar
• Tolan AM, Kaji AH, Quach C, Hines OJ, de Virgilo C. The electronic residency application service application can predict accreditation council for graduate medical education competency-based surgical resident performance. J Surg Educ. 2010;67(6):444–448.
   PubMed Web of Science ®Google Scholar
• Tardiff K. A survey of faculty members, students, and alumni in regard to preferences for grading systems. J Med Educ. 1982;57(12):952.
   PubMedGoogle Scholar
• Eichna LW. Medical school education for whom, student or patient. Bull N Y Acad Med. 1991;67(2):151–161.
   PubMedGoogle Scholar
• Eichna LW. Medical-school education, 1975-1979—a student’s perspective. N Engl J Med. 1980;303(13):727–734.
   PubMed Web of Science ®Google Scholar
• Wilkinson T. Pass/fail grading: not everything that counts can be counted. Med Educ. 2011;45(9):860–862.
   PubMed Web of Science ®Google Scholar
• Kusurkar RA, Croiset G, Mann KV, Custers E, ten Cate O. Have motivation theories guided the development and reform of medical education curricula? A review of the literature. Acad Med. 2012;87(6):735–743.
   PubMed Web of Science ®Google Scholar
• Wilkinson TJ, Wells JE, Bushnell JA. What is the educational impact of standards-based assessment in a medical degree? Med Educ. 2007;41(6):565–572. doi:10.1111/j.1365-2923.2007.02766.x.
   PubMed Web of Science ®Google Scholar
• Chamberlin K, Maï Y, Chiang IA. The impact of grades on student motivation. Active Learn Higher Educ. 2018;:146978741881972. doi:10.1177/1469787418819728.
   Google Scholar
• Gonnella JS, Erdmann JB, Hojat M. An empirical study of the predictive validity of number grades in medical school using 3 decades of longitudinal data; implications for a grading system. Med Educ. 2004;38(4):425–434.
   PubMed Web of Science ®Google Scholar
• Vosti KL, Jacobs CD. Outcome measurements in postgraduate year one of graduates from a medical school with a pass/fail grading system. Acad Med. 1999;74:547–549.
   PubMed Web of Science ®Google Scholar
• Boyse TD, Patterson SK, Cohan RH, et al. Does medical school performance predict radiology resident performance? Acad Radiol. 2002;9(4):437–445.
   PubMed Web of Science ®Google Scholar
• Burkhardt JC, Parekh KP, Gallahue FE, et al. A critical disconnect: residency selection factors lack correlation with intern performance. J Grad Med Educ. 2020;12(6):696–704.
   PubMedGoogle Scholar
• Seegal D. The value of a self-kick in the seat of the pants for the anxious medical student. J Med Educ. 1963;38:605–606.
   Google Scholar
• LIEF HI, LANCASTER RC, SPRUIELL V. Is self-kick the answer. J Med Educ. 1963;38:971–973.
   PubMedGoogle Scholar
• Mann L, Feddes AR, Doosje B, Fischer AH. Withdrawal or affiliate? The role of humiliation during initiation rituals. Cog Emot. 2016;30(1):80–100. doi:10.1080/02699931.2015.1050358.
   PubMed Web of Science ®Google Scholar
• Strecker EA, Appel KE, Palmer HD, Braceland FJ. Psychiatric studies in medical education. AJP. 1936;92(4):937–957. doi:10.1176/ajp.92.4.937.
   Google Scholar
• Strecker EA, Appel KE, Palmer HD, Braceland FJ. Psychiatric studies in medical education II. Neurotic trends in senior medical students. Am J Psychiat. 1937;93:1198–1229.
   Google Scholar
• Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiat. 2008;32(1):44–53.
   PubMed Web of Science ®Google Scholar
• Slavin S. Reflections on a decade leading a medical student well-being initiative. Acad Med. 2019;94(6):771–774.
   PubMed Web of Science ®Google Scholar
• 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.
   PubMed Web of Science ®Google Scholar
• Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA. The benefits of pass-fail grading on stress, mood, and group cohesion in medical students. Mayo Clin Proc. 2006;81(11):1443–1448. doi:10.4065/81.11.1443.
   PubMed Web of Science ®Google Scholar
• 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.
   PubMed Web of Science ®Google Scholar
• Bloodgood RA, Short JG, Jackson JM, Martindale JA. Change to pass/fail grading in the first two years at one medical school results in improved psychologic well-being. Acad Med. 2009;5:655–662.
   Google Scholar
• Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: improving student wellness through curricular changes. Acad Med. 2014;89(4):573–577.
   PubMed Web of Science ®Google Scholar
• Klamen DL, Williams R, Hingle S. Getting real: aligning the learning needs of clerkship students with the current clinical environment. Acad Med. 2019;94(1):53–58.
   PubMed Web of Science ®Google Scholar
• Bullock JL, Seligman L, Lai CJ, O’Sullivan PS, Hauer KE. Moving toward mastery: changes in student perceptions of clerkship assessment with pass/fail grading and enhanced feedback. Teach Learn Med. 2021 May 20;:1–11. doi:10.1080/10401334.2021.1922285.
   Web of Science ®Google Scholar
• Slavin SJ. Medical student mental health: culture, Environment, and the Need for Change. JAMA. 2016;316(21):2195–2196.
   PubMed Web of Science ®Google Scholar
• Hafferty F. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403–407.
   PubMed Web of Science ®Google Scholar
• Merton RK. Some preliminaries to a sociology of medical education. In Merton RK, Reader G, Kendall PL, eds. The Student Physician: Introductory Studies in the Sociology of Medical Education. Cambridge, MA: Harvard University Press. 1957.
   Google Scholar
• Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington D.C.: American Association of Medical Colleges; 2003:16.
   Google Scholar
• Hafferty FW. Socialization, professionalism, and professional identity formation. In: Cruess RL, Cruess SR, Steinert Y, eds. Teaching Medical Professionalism. 2nd ed. Cambridge: Cambridge University Press. 2016:54–67.
   Google Scholar
• Orom H, Semalulu T, Underwood W. The social and learning environments experienced by underrepresented minority medical students: a narrative review. Acad Med. 2013;88(11):1765–1777.
   PubMed Web of Science ®Google Scholar
• Boatright D, Ross D, O’Connor P, Moore E, Nunez-Smith MM. Racial disparities in medical student membership in the Alpha Omega Alpha honor society. JAMA Intern Med. 2017;177(5):659–665. doi:10.1001/jamainternmed.2016.9623.
   PubMed Web of Science ®Google Scholar
• McLaughlin K. The troubling inconsistencies within the medical educator role. Med Teach. 2015;37(4):397–398.
   PubMed Web of Science ®Google Scholar
• Smith JK, Smith LF. Grading in higher education. In: Guskey TR, Brookhart SM, eds. What We Know about Grading: What Works, What Doesn’t, and What’s Next. Alexandria, VA: ASCD; 2019.
   Google Scholar
• Hafferty FW, O’Brien BC, Tilburt JC. Beyond high-stakes testing: learner trust, educational commodification, and the loss of medical school professionalism. Acad Med. 2020;95(6):833–837.
   PubMed Web of Science ®Google Scholar
• Slavin S, Smith G. Taking students as they should be: restoring trust in undergraduate medical education. Acad Med. 2019;94(12):1847–1850.
   PubMed Web of Science ®Google Scholar
• D’Eon M, Overgaard V, Harding SR. Teaching as a social practice: implications for faculty development. Adv Health Sci Educ Theory Pract. 2000;5(2):151–162.
   PubMed Web of Science ®Google Scholar
• Branch WT. Supporting the moral development of medical students. J Gen Intern Med. 2000;15(7):503–508.
   PubMed Web of Science ®Google Scholar
• Morton KR, Worthley JS, Testerman JK, Mahoney ML. Defining features of moral sensitivity and moral motivation: pathways to moral reasoning in medical students. J Moral Educ. 2006;35(3):387–406. doi:10.1080/03057240600874653.
   Web of Science ®Google Scholar
• Larsen DP, Butler AC, Roediger HL. Test-enhanced learning in medical education. Med Educ. 2008;42(10):959–966.
   PubMed Web of Science ®Google Scholar
• Dhaliwal G, Hauer KE. Excellence in medical training: developing talent—not sorting it. Perspect Med Educ. 2021;10(6):356–361.
   PubMed Web of Science ®Google Scholar
• Cook DA, Beckman TJ. Current concepts in validity and reliability for psychometric instruments: theory and application. Am J Med. 2006;119(2):166.e7–166.e16.
   PubMedGoogle Scholar
• Sandars J. When I say…critical pedagogy. Med Educ. 2017;51(4):351–352. doi:10.1111/medu.13150.
   PubMed Web of Science ®Google Scholar
• Govaerts M, van der Vleuten CPM. Validity in work-based assessments: expanding our horizons. Med Educ. 2013;47(12):1164–1174.
   PubMed Web of Science ®Google Scholar
• Valentine N, Durning S, Shanahan EM, Schuwirth L. Fairness in human judgement in assessment: a hermaeutic literature review and conceptual framework. Adv Health Sci Educ Theory Pract. 2021;26(2):713–738.
   PubMed Web of Science ®Google Scholar
• Ten Cate O, Regehr G. The power of subjectivity in the assessment of medical trainees. Acad Med. 2019;94(3):333–337.
   PubMed Web of Science ®Google Scholar
• Dyrbye LN, Sciolla AF, Dekhtyar M, et al. Medical school strategies to address student well-being: a national survey. Acad Med. 2019;94(6):861–868.
   PubMed Web of Science ®Google Scholar
• Seligman L, Abdullahi A, Teherani A, Hauer KE. From grading to assessment for learning: a qualitative study of student perceptions surrounding elimination of cor clerkship grades and enhanced formative feedback. Teach Learn Med. 2021;33(3):314–325. doi:10.1080/10401334.2020.1847654.
   PubMed Web of Science ®Google Scholar
• Kogan JR, Hauer KE. Sparking change: how a shift to step 1 pass/fail scoring could promote the educational and catalytic effects of assessment in medical education. Acad Med. 2020;95(9):1315–1317.
   PubMed Web of Science ®Google Scholar
• Harrison CJ, Könings KD, Schuwirth LWT, Wass V, van der Vleuten CPM. Changing the culture of assessment: the dominance of the summative assessment paradigm. BMC Med Educ. 2017;17(1):73.
   PubMed Web of Science ®Google Scholar
• Roberts C, Khanna P, Lane AS, Reimann P, Schuwirth L. Exploring complexities in the reform of assessment practice: a critical realist perspective. Adv Health Sci Educ Theory Pract. 2021;26(5):1641–1657.
   PubMed Web of Science ®Google Scholar
• Chou CL, Kalet A, Costa MJ, Cleland J, Winston K. Guidelines: the do’s don’t’s and don’t knows of remediation in medical education. Perspect Med Educ. 2019;8(6):322–338. doi:10.1007/s40037-019-00544-5.
   PubMed Web of Science ®Google Scholar
• Hatem CJ, Searle NS, Gunderman R, et al. The educational attributes and responsibilities of effective medical educators. Acad Med. 2011;86(4):474–480.
   PubMed Web of Science ®Google Scholar
• Welker R. Expertise and the teacher as expert: rethinking a questionable metaphor. Am Educ Res J. 1991;28(1):19–35. doi:10.3102/00028312028001019.
   Web of Science ®Google Scholar
• Sklar DP, Hafferty FW. Courage in medical education: cultivating stories for change. Acad Med. 2019;94(11):1623–1625.
   PubMed Web of Science ®Google Scholar