Pass/Fail Versus Tiered Grades and Academic Performance in Undergraduate Medical Education: Crossover Study

The impact of Pass/Fail or Tiered grade assessment for exams in undergraduate medical education has caused much debate, but there is little data to inform decision-making. The increasing number of medical schools transitioned to a Pass/Fail assessment has raised concerns about medical students' academic performance. In 2018, during the undergraduate medical curriculum reform at the Faculty of Medicine, Aalborg University changed some exams from Pass/Fail to Tiered grade and vice versa for other exams. These changes provide an opportunity to evaluate the different assessment forms.

This study aimed to evaluate medical students' academic performance at the final licensing exam in relation to the exam grading principle.

This single-center cohort study at Aalborg University Medical School, North Denmark Region, assesses the change from 2-digit Tiered grade to Pass/Fail evaluation and vice versa of undergraduate medical students' exams after the 4th and 5th year clinical training modules from Autumn 2015 through Spring 2023. The primary outcome was (1) the average grades at the final licensing exam and (2) the number of students failing exams during the previous two years.

Among the total of 7634 exams, 7164 4th and 5th year clinical training exams were included in the comparisons, of which 3047 (42.5%) were Pass/Fail exams and 4117 (57.5%) were Tiered grade exams. The frequency of students failing exams was 3.3% (n=101/3047) at Pass/Fail and 1.97% (81/4117) with Tiered grade exams (P<.001). This difference was leveled out when counting the near-failure tiered grade as Fail. Tiered grade exams did not differ between semesters (P=.99) nor show a time trend at the 4th year (P=.66). The final licensing exam grades were unaltered (P=.47).

Contrary to our expectation, Pass/Fail exams exhibited a higher fail rate compared to Tiered grade exams without lowering the final academic performance. These results suggest that a shift from Tiered grades to Pass/Fail assessment redirects the focus from rewarding high performance to ensuring standards are maintained among underperforming students.