The Historical Roots of Tiered Grading in US Medical Education

Evaluation of medical students remains one of the most complex and challenging issues in academic medicine. Evaluation occurs in an educational environment that must cultivate a diverse, collaborative, and resilient physician workforce imbued with skills, drive, and stamina for a lifelong commitment to patient care, self-care, and professional development. Additionally, evaluation must not only be valid and reliable but also relevant to the public who medical students will eventually serve. In U.S. medical education, evaluation, and the assessments on which evaluation is based, has evolved over several centuries. Understanding the history of how, when, and why U.S. medical students have been assessed and subsequently evaluated can inform contemporary dialogue on curricular reform. In exploring this history, several important considerations emerge. First, tiered grading arose through the historical assimilation of U.S. medical schools into universities rather than as a mechanism for assessing clinical competence or acumen. Second, even before influences of university academia suffused medical education, imprudent academic emphasis on the memorization of facts over deeper understanding of, and reflection on, medical sciences and practice was already entrenched. Evaluation systems like tiered grading served to validate-if not accelerate-overreliance on the memorization and recall of scientific facts. As a result, other professional attributes important for medical practice, including intrinsic motivation, group cohesiveness, and diversity of the physician workforce were, and remain, adversely affected. Finally, despite early observations that tiered grading is associated with medical student stress and anxiety, there has been insufficient attention to and mitigation of these effects on medical student wellbeing over the last century. Our collective response to controversies surrounding tiered grading should account for the historical rationality of the adoption of this form of evaluation and its enduring effects on contemporary medical education.