Questions to consider as you read the blog:

1. Both systems, Pass/Fail (P/F) and tiered grading (A-F), are attractive in their idealized state. Can either of them truly achieve their ideals in actual practice? Which one is capable of coming the closest to their ideal state?
2. Undergraduate medical education has two roles: train learners to become doctors and prepare learners to be selected for a specialty-based residency program. Is the choice between P/F and A-F contingent on which of those two UME roles is considered to be primary?
3. Should decisions about grading systems (P/F or A-F) be made independently by medical schools? Or should there be a broader consensus on a uniform system made by a national institution (e.g. an accreditor, a professional organization, or the U.S. Department of Education, etc.)?

In recent years, many undergraduate medical education (UME) programs have modified their grading system for required clerkships to be dichotomous (often called pass/fail grading and referred to here as “P/F”). As of the AAMC/AACOM Curriculum SCOPE Survey 2023-2024, 21.4% of schools reported using P/F for required clerkships. The rationale for P/F is multi-faceted including: better learning outcomes, increased student motivation, improved well-being, and greater assessment validity [1]. Nonetheless, there has been pushback against P/F in clerkships and for USMLE Step 1 [2]. The crux of the objections to P/F has been that students don’t engage fully in course requirements and residency programs don’t know how to evaluate applicants – so schools should revert to tiered grading systems (referred to here as “A-F” but inclusive of Honors/High Pass/etc.).

As a ‘thought experiment,’ picture if the reverse situation were true and P/F was the traditional norm while A-F was a trendy innovation. In this scenario, the reformers would advocate for conversion to A-F, but what case would they make to justify an upheaval in the system? If P/F was the status quo on which medical education had been built, would A-F have sufficient justification for schools to adopt it?

In our thought experiment, the P/F environment would focus on learning for future practice and empower students to ask questions that fill knowledge gaps. It would embolden them to engage with educational experiences which stretch their knowledge without fearing lower grades. Assessments would support learning and be designed to ensure that students achieve standards of competence and the methods would include formats that amplify feedback and learning. Students could focus on non-cognitive skills – even those that are difficult to measure precisely. A panoply of co-curricular activities for medical students would enrich their residency preparation and produce indicators for program directors about which applicants would thrive in their specific residency program. The program directors, in turn, would have experience and insight about scrutinizing medical school data to identify well-suited applicants.

If P/F were the traditional system, then what would be the argument in favor of replacing it with A-F? Advocates of A-F often posit two major benefits of tiered grading: that competition for grades impels students to excel at learning, and grade differentiations between students allow residency programs to make informed selection decisions. But, it is axiomatic that the rewards of competition are only realized if that competition is fair and valid. In a competitive environment, the “rules of the game” must be transparent and evenly enforced.

If changing to A-F was the reform being proposed, then the burden of proof would be on proponents to demonstrate that fair competition is achievable. Yet, our current, real-life, competitive situation clearly demonstrates how elusive that fairness is [3,4]. Valid and bias-free assessments have always been necessary for fair grading; however, persistent, systematic unfairness in A-F is well-known [5].

New ideas inevitably meet resistance; however, given the strong arguments in favor of P/F, we believe that the calls to return to A-F are actually rooted in nostalgia and tradition rather than logic or evidence. If P/F had been the established system for medical education, then making a compelling case for adopting A-F would be problematic. Thus, we conclude that med ed’s move to P/F, despite the disruption to long-standing practices, is justified and that resistance is predominantly a desire for the status quo.

What do you think? Share your thoughts in the comment box below!

References

1. 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.
2. Warm E, Hirsh DA, Kinnear B, Besche HC. The Shadow Economy of Effort: Unintended Consequences of Pass/Fail Grading on Medical Students’ Clinical Education and Patient Care Skills. Acad Med. 2025 Apr 1;100(4):419-424. doi: 10.1097/ACM.0000000000005973.
3. Lomis KD, Mejicano GC, Caverzagie KJ, Monrad SU, Pusic M, Hauer KE. The critical role of infrastructure and organizational culture in implementing competency-based education and individualized pathways in undergraduate medical education. Med Teach. 2021 Jul;43(sup2):S7-S16. doi: 10.1080/0142159X.2021.1924364.
4. Ryan MS, Lomis KD, Deiorio NM, Cutrer WB, Pusic MV, Caretta-Weyer HA. Competency-Based Medical Education in a Norm-Referenced World: A Root Cause Analysis of Challenges to the Competency-Based Paradigm in Medical School. Acad Med. 2023 Nov 1;98(11):1251-1260. doi: 10.1097/ACM.0000000000005220.
5. Hauer KE, Lucey CR. Core Clerkship Grading: The Illusion of Objectivity. Acad Med. 2019 Apr;94(4):469-472. doi: 10.1097/ACM.0000000000002413.

Authors: Hugh A. Stoddard, M.Ed., Ph.D. (Associate Dean for Evaluation, Assessment, and Research) and Nadia Ismail, M.D., M.P.H., M.Ed. (Vice-Dean), Baylor College of Medicine, Houston, TX