Should Medical School Grading Be Tiered or Pass/Fail? A Scoping Review of Conceptual Arguments and Empirical Data

Medical school grading has implications for student well-being, motivation, equity, and residency selection. However, despite more than 50 years of debate, there remains no consensus on whether grading should be tiered or pass/fail, particularly in core clerkships. This scoping review examines conceptual arguments, empirical data, and knowledge gaps regarding tiered versus pass/fail grading in medical school.

OVID MEDLINE, Embase, Web of Science, and ERIC were searched on November 15, 2023, for articles published from 2000 to 2023 focused on (1) conceptual arguments regarding tiered versus pass/fail grading in U.S. medical schools and/or (2) empirical data relevant to this debate. Two reviewers independently assessed eligibility. The authors performed meta-synthesis to group arguments into domains and cross-reference them with relevant data, appraising empirical studies using the Medical Education Research Study Quality Instrument (MERSQI).

Forty articles met inclusion criteria, including 22 empirical studies of variable quality (MERSQI scores, 8.5-13.5 of 18). Conceptual arguments and empirical data spanned 10 domains. Better-supported arguments included the association of pass/fail preclerkship grading with improved short-term well-being and preserved academic performance, the low reliability of individual tiered grades, and racial and ethnic disparities in clerkship grading. Areas of uncertainty included the effects of pass/fail clerkship grading on well-being, motivation, learning, and achievement; potential stress displacement with pass/fail grading; validity of tiered clerkship grades; residency application concerns; and subinternship grading considerations.

Significant controversy about grading exists across 10 domains. Cross-cutting challenges include the diverse purposes of grading leading to conflicting opinions and data interpretations, limited study quality, and overreliance on opinion over data or theory. Recommendations include caution when interpreting small numbers of tiered grades, transparency and research regarding potential clerkship grading disparities, and consideration of all relevant dimensions in system-level assessment approaches. The authors hope these steps encourage assessment that benefits learners and patients.