The Great Grading Debate: Tiered or Pass/Fail Grading?
by Hiu Ying Joanna Choi, M.D.; Marisyl De La Cruz, M.D. | May 26, 2026
Article Citation: Iyer AA, Hayes C, Chang BS, Farrell SE, Fladger A, Hauer KE, Schwartzstein RM. Should Medical School Grading Be Tiered or Pass/Fail? A Scoping Review of Conceptual Arguments and Empirical Data. Acad Med. 2025 Aug 1; 100(8):975-985. doi: 10.1097/ACM.0000000000006085.
What is this article about?
This article is a review of 40 articles from 2000 to 2023 and their conceptual arguments and empirical data on tiered grading versus pass/fail (P/F) grading, spanning several domains:
- Student well-being: Preclerkship P/F grading was associated with improved short-term well-being. With clerkship P/F grading, faculty and students perceived reduced student stress and greater collaboration, but had concerns that stress was displaced to other areas (standardized exams,subinternship grades and ability to differentiate from other students).
Motivation and educational climate: P/F grading was associated with growth mindset, with greater evidence for clerkship than for preclerkship. With clerkship P/F grading, students perceived increased freedom to take learning risks and ask questions, and faculty perceived increased ability to focus on teaching. - Learning outcomes: Preclerkship P/F grading was not associated with reduced performance (course performance, clerkship grades or standardized exam scores). Clerkship P/F grading was associated with increased student perception of the importance of patient/family rapport in determining their final grades.
- Validity and Reliability: Tiered grading was more reliable in preclerkship than clerkship courses (43% vs 25% of grade variance attributable to true differences among students, needing 5 vs 10 courses to achieve high reliability). Regarding tiered clerkship grades, medical students and faculty doubted their validity, while residency program directors (PDs) agreed that they reflected residency preparedness.
- Equity: Tiered clerkship grading favored women and white students. In a study at one institution, after adjusting for USMLE Step 1 and undergraduate GPA, there were significant relationships between both gender and race and clerkship grades, with women receiving higher grades than men, and white students receiving higher grades than nonwhite students.
- Residency selection: Preclerkship P/F grading did not affect residency match outcomes. Most residency PDs denied preferentially selecting applicants from schools with tiered gradings, but agreed that P/F clerkship grading would make it more difficult to compare applicants and reported that they would increase emphasis on other aspects of their application (Step 2 scores, narrative assessments, subinternship evaluations, reference letters, awards, professional development and medical school prestige), and favored tiered grading.
Why should you read the article?
For decades, there has been much discussion about tiered versus P/F grading in undergraduate medical education, with arguments for and against both grading systems, with no consensus on which is optimal. There has been little empirical data on the impact of the grading systems on different stakeholders (students, faculty and residency PDs). Most schools use P/F grading for preclerkship courses and tiered grading for clerkship courses. This topic has again garnered increased attention over the past few years due to increased awareness of bias and inequity in grading, interest in learner well-being and the change of Step 1 to P/F, leading some notable medical schools to adopt P/F clerkship grading over recent years.
How can you use this article?
This article will likely be of greatest interest to undergraduate medical educators at the leadership level, who are involved in making decisions about assessments and grading, especially those who are currently considering changes to their grading structures. It provides a comprehensive review of arguments and data from the viewpoint of different stakeholders, separated out by preclerkship versus clerkship. The article covers a comprehensive list of factors to be considered in discussions of assessments and grading, with P/F grading showing the largest benefits for well-being and learning environment, particularly in clerkships, with ongoing questions about assessment reliability and residency selection.
Review Authors: Hiu Ying Joanna Choi, M.D.; Associate Professor of Family Medicine, Family Medicine Clerkship & Subinternship Director; Temple University Hospital Lewis Katz School of Medicine, Philadelphia, PA (Co-authored with Marisyl De La Cruz, MD, Vice Chair of Education & Associate Professor, Family and Community Medicine Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA). Organization: Society of Teachers of Family Medicine