By Laurel B. Witt, M.D.;M.Phil. | November 29, 2023 Article Citation: Smith Jr JF, Piemonte NM. The problematic persistence of tiered grading in medical school. Teach Learn Med 2023; 35(4):467-76. DOI: 10.1080/10401334.2022.2074423 What is this article about? In this well-written, well-cited article, the authors argue that systems of tiered grading in medical school are highly variable, inaccurate, and, most importantly, inequitable. They report that the tradition of tiered grading has dubious origins. As an institution, its instruments lack the validity evidence required to interpret true achievement, which is what grade tiers are inherently meant to do. Eventually, the argument posits, tiered grading methodologies are misaligned with medical education’s goal of “producing a diverse, holistically trained, effective, resilient, and agile physician workforce.” Why should you read the article? Most U.S. medical schools have moved to pass/fail assessment within their pre-clerkship curricula, but still, most schools employ tiered grading in the clerkship curriculum. Meanwhile, anxiety is high this year regarding what metrics residency programs will use in offering interviews in the absence of a USMLE Step 1 numeric score. At many schools, current assessment discussions are about how to increase the number of tiers within the grading schema, rather than how to eliminate tiers altogether. In this article, a reader, who might be part of those discussions or involved in curriculum revision projects, will find an excellent review of the literature on tiered grading. The article also summarizes many evidence-supported deleterious effects of tiered grading on student professional identity formation, well-being, and diversity. How can you use this article? This article contributes to a growing body of literature—one that includes Gauer et al.’s “Race and Gender Bias in Clerkship Grading,” which was reviewed by Dr. Anh-Thu Ngo Vu (Demographic Bias in Clerkship Grading, July 17, 2023 Med Ed Brief), that reconsiders the place of tiered grading in medical school. The article discusses (and, indeed, calls for) “heroic curricular change.” Its authors propose initial steps toward a vision for alternative assessment instruments and methods. Review Author: Laurel B. Witt, M.D.; M.Phil.; Assistant Dean for Medical Education and Associate Professor of Family Medicine, University of Kansas School of Medicine, Kansas City, KS. Organization: Society of Teachers of Family MedicinePersistent Tiered Grading Problem