Some schools swear by pass-fail systems, but do those with “high pass” and other tiers deliver on the promise to reduce competition?
Before Mayo Medical School used pass-fail grading for first- and second-year courses, students didn’t usually share notes or ask classmates for help because of stiff competition. They argued with professors over grades and didn’t always have time for clinical electives, interesting lectures or extracurricular activities. Stress was common among students.
It wasn’t a good introduction to medicine, either, according to Dr. Joseph P. Grande, dean of academic affairs at Mayo, because so much of today’s health care is collaborative.
Grande has seen stress and competition subside and collaboration increase since about a decade ago when the curriculum went to pass-fail in the first and second years.
“I think medicine is by its very nature a collaborative venture,” Grande says. “And really what we need to do in the curriculum is to try to promote cooperation rather than competition…. In clinical practice nowadays, if I am not 100 percent sure of how to take care of a patient, what I would do is ask for help from a colleague. But by medical school rules, that was called ‘cheating.’”
But the debate is far from over, with traditional grading advocates touting A, B, C, D, F—a five-interval system—and descriptive grades as necessary to motivate students and help schools identify top residency candidates.
Traditional grades were the norm until the 1970s, when some schools began discussing whether letters or numbers were the best way to monitor student progress and whether it might promote too much competition and stress.
Medical schools today use a variety of grading systems for required basic science courses. According to the Association of American Medical Colleges, 40 schools use a two-interval (pass-fail) system, 35 schools use three intervals, 32 schools use four intervals, and 26 schools use five intervals. (See examples on Page 24.)
An entire group of students can be evaluated as outstanding (or satisfactory or unsatisfactory) under the University of Illinois at Chicago (UIC) College of Medicine’s three-interval system without worrying about whether they reach some point on a curve used in traditional grading systems. Students must show a certain level of competency in a subject to meet each designation, according to Loreen Troy, the associate dean for educational planning, but their evaluations tell more about their performance when they apply for residencies than pass-fail.
Medical school administrators attribute at least some of the shift toward pass-fail to a public dissatisfaction with doctors, which led to an emphasis on clinical skills in the first few years of medical school and an examination of important “competencies.” In 1999, the Accreditation Council for Graduate Medical Education identified six competencies that medical schools now use: patient care, medical knowledge, practice-based learning and improvement, interpersonal communication skills, professionalism and systems-based practice.
“Only one of these relates to medical knowledge,” notes Grande, adding that Mayo recruits such strong students that their ability to master basic science courses is not an issue.
Osteopathic schools have seen a similar trend toward pass-fail grades “associated with competency-based curriculum in many schools” in the past 15 years, according to Dr. Stephen C. Shannon, president of the American Association of Colleges of Osteopathic Medicine.
Research on grading systems is sparse, but medical schools considering a change tend to base their decisions on a smattering of journal articles, student surveys, program and course director opinions, and grading intervals used by other schools.
But researchers at the University of Virginia School of Medicine found in a study published in Academic Medicine in May 2009 that pass-fail grades had no deleterious effect on performance or residency placement. The study compared the 2006 class, which received traditional grades at the school, with the 2007 class, which received pass-fail grades, finding no significant difference in academic performance.
Students who received pass-fail grades also experienced less anxiety and depression during the first few years of school, according to Robert A. Bloodgood, the lead author of the study and a professor at the University of Virginia School of Medicine who holds a doctorate in cell biology.
“We showed that without grading, it didn’t change the amount of effort they put into their education in the first two years,” Bloodgood says. “If your medical school can bring in a good enough medical class, they’re going to succeed despite almost anything we do to them.”
Stress and anxiety returned in the fourth semester when students were preparing for Step 1, Bloodgood ex-plains, adding that stress from exams is detrimental to students, though grades in the third and fourth years are necessary for procuring top residencies.
“There are two major academic sources of stress in medical school, the kind of stress clinicians experience and need to be able to deal with, but then there’s a whole category of education-related stress without any particular value,” Bloodgood says. He thinks sys--tems with intervals like “satisfactory” and “honors” are similar to letter grades.
Randy Miles, a fourth-year at Mayo Medical School, says Mayo’s pass-fail system helped him focus on learning material, rather than on getting the highest grade, and that he and fellow students shared study guides.
“We come here because we’re interested in the material, interested in helping people in the future, helping treat their illnesses,” Miles says. Grading did not factor in his choice of medical schools, but pass-fail was a welcome surprise. He might have factored it into his choice had he known the benefits.
Though UIC’s medical school ad--ministrators have discussed the merits of pass-fail grading, they think traditional grades offer an important measure of achievement and predictor of future performance. Also, the university’s tiered system (unsatisfactory, satisfactory and outstanding) focuses on individual performance, rather than on a comparison with other students.
“It’s believed that it provides an incentive or motivator to encourage students to achieve at a higher level,” says Troy, who holds a master’s in health professions education. “If students are prodded a bit to perform better, we think that’s going to carry forward into their professional lives.”
Certainly we encourage teamwork,” she explains, “but if you consider one goal of an evaluation is better performance, ultimately your goal is to produce excellent clinicians.”
Carrie Nieman, a fourth-year medical student at UIC, who is also working toward a master’s in public health, says the university’s three-tiered system helped her focus on the material at hand and kept her on track. She says the university and fellow students offered plenty of support.
“We have a lot of different tutoring and study groups through the university, but there’s also the informal groups that kind of help with the study process and stress level,” Nieman says.
Dr. Barbara Schindler, vice dean for educational and academic affairs at Drexel University College of Medicine, says as long as a school starts out with a strong cohort, offers a supportive learning environment, and “anchors” evaluations with specific information on requirements for each interval, grades are a viable system.
“Less has to do with the numeric grades and more to do with the kind of learning environment you create in your institution,” Schindler says.
Rewarding excellence is an important reason for using traditional grades, according to Dr. Richard J. Si-mons, vice dean for educational affairs at Pennsylvania State University College of Medicine.
“If you don’t have a grading system,” Simons says, “you may be shortchanging some of your top-notch students who deserve to be in the best residency programs.”
Simons points to a March 2009 study, also published in Academic Medicine, which showed grades play an important part in residency selection. The study found the following top academic selection criteria for residency programs, in order of importance: grades in required clerkships; Step 1 scores; grades in senior electives in specialty; number of honors grades; and Step 2-CK scores.
Schools with pass-fail in the first or second years and regular grades in the third and fourth contend the combination offers students the best of both worlds, lessening stress and competition, while boosting residency placement.
At the University of Wisconsin School of Medicine and Public Health, which switched to pass-fail for first-year courses in the 2008–2009 academic year, administrators also said that the system “leveled the play-ing field.”
“There was really a significant advantage to those students who came from traditional science backgrounds [before the change],” says Dr. Christine S. Seibert, associate dean for medical education, explaining the school tried to attract students with traditional science and other disciplines.
Other medical school administrators see no reason for using grades at all, believing even in clinical rota-tions that narrative comments are more important.
Dr. Sheila Rutledge Harding, associate dean for medical education at the University of Saskatchewan College of Medicine, says she did not believe grades provided an accurate idea of a student’s potential ability as a physician in any year. Harding says before the school changed to a pass-fail system in 2003, she saw students so obsessed with grades, they ignored opportunities to learn more about clinical practice. She says only a “largely content-driven” course that required memorization might be better suited to grades.
“Students would elect to miss other learning opportunities to prepare for an exam,” says Harding, referring to opportunities to interact with patients with unusual disorders and perform a physical exam, which can’t be replicated in a lab.
“Speaking from a scientist’s point of view, there are some things you can measure to a third decimal point and will be statistically meaningful but won’t be truly meaningful,” says Harding. “What I really want to see is how they go rescue that person in the simulation. That’s what people want to see.”
Janice Neumann is a freelance writer based in Chicago.