In recent decades, the majority of U.S. allopathic medical schools have shifted their preclinical grading systems to a Pass/Fail (P/F) model as studies have shown this grading system increases student wellness and promotes a more collaborative environment among classmates. While few schools still implement the traditional five-tiered A-F grading system, a subsection of schools exist that utilize a three-tiered grading system known as Honors/Pass/Fail (H/P/F). This system is designed with the intent to increase student wellness as seen in P/F systems while incorporating the beneficial aspects of the A-F grading system by giving top-performing students the ability to distinguish themselves from their classmates with the distinction of “Honors” on their transcript in place of “Pass.” While this system in theory seems to combine the benefits of both tiered and un-tiered grading systems, issues exist that are not readily apparent. As a student at a program that utilizes an H/P/F grading system during the preclinical curriculum, I’d like to bring to light how three-tiered grading systems often paradoxically increase student stress and decrease overall well-being, especially for students that would traditionally achieve a “B” in an A-F grading system.
The main advantage to a P/F system is its impact on student well-being, as levels of self-reported stress, anxiety, and depression are reduced for students compared to those in tiered systems. Since students do not have the ability to academically distinguish themselves from their classmates, less stress related to the competitive nature of tiered grading systems is experienced. While student performance is not significantly reduced in these systems, critics raise concerns that academic excellence is not recognized for top performers as it is in A-F systems. H/P/F systems attempt to reach a middle ground between these two systems by essentially combining “B,” “C,” and “D”-level grades into a “Pass” and reserving “Honors” for students that would have normally achieved an “A.” This three-tiered system is inherently most beneficial to students who would normally achieve a “D” as this lower grade is masked from residency directors as a “Pass.” “B”-level students, however, are most harmed by this system as their relatively high level of achievement within the “Pass” cohort is not recognized and is viewed the same as a “D”-level performance.
While the overall competitiveness and levels of stress for students in the “C” and “D” grade range may be reduced within the H/P/F system, a hypercompetitive culture forms among students attempting to achieve “Honors.” These students that would traditionally achieve an “A” or “B” now must operate within the all-or-nothing system of achieving “Honors.” In many scenarios at my institution, students miss the threshold to achieve “Honors” by one or two questions on a final exam consisting of around 90 questions total. This means that one question could determine the difference between receiving “Honors” from a grade that is achievable by those who just narrowly pass their coursework.
These issues are compounded even further at our institution as our class ranking is not based on the numerical score we receive in the class but rather the total amount of “quality points” each student has. These “quality points” are given to students based solely on the H/P/F grade they received. Students that achieve “Honors” receive double the amount of “quality points” than students who receive a “Pass.” This begs the question as to the original purpose of ranking medical students. Ranking systems are a way in which medical schools can objectively communicate to residency programs individual student performance relative to his or her classmates.
For example, at our school, if “Student A” received a course total score of 90% in a class, they would receive a grade of “Honors.” If “Student B” received a course total score of 89%, they would receive a “Pass.” While the actual difference in relative performance between these two students is 1% and is essentially negligible, “Student A” is presented to residency directors as having performed twice as well in his/her coursework than “Student B.” This is obviously not reflective of actual student performance and demonstrates an inaccurate and unjust ranking reporting system.
Although all students in three-tiered grading systems on average experience higher levels of stress, students that narrowly miss the threshold to receive “Honors” are prone to experiencing even higher levels of stress, disappointment, and reduced self-worth for their academic shortcomings even though their performance was relatively high among their peers. These students are also likely to feel that the extra time and effort put toward their coursework was futile since a lower level of preparation would have likely resulted in the same academic outcome. This paradigm could decrease these students’ performance as they may start to experience learned helplessness in their pursuit of “Honors” and failure to achieve recognition for their relatively high level of success. Additionally, a more hostile culture may develop between “B”-level students and their educators since these students are highly incentivized to challenge the validity and fairness of questions on their assessments in an attempt to improve their test scores and reach the “Honors” threshold.
The issues related to H/P/F grading ultimately draw into question the fairness of which students benefit most. Is it fair to implement a grading system that arbitrarily decides which students receive recognition? Is it appropriate to distinguish academic performance only for the highest of achievers while presenting “B”-level performances within the same category as students who passed coursework by the narrowest of margins to residency program directors? It is my hope that the insight provided in this article can help the medical education community address these questions in the pursuit of a grading system that maximizes both student well-being and performance.
How do you think medical students should be graded? Share in the comments.
Forrest is a second-year medical student interested in rural medicine and how to best address the physician shortage in these areas, as well as being particularly interested in health policy and the way it is applied to different groups of people in the U.S.
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