“The Grade Debate: Evidence, Knowledge Gaps, and Perspectives on Clerkship Assessment Across the UME to GME Continuum” is an Alliance for Academic Internal Medicine (AAIM) Perspectives article that was originally published in the April 2023 issue of The American Journal of Medicine.
Introduction
Core clerkships are typically a medical student’s first fully immersive clinical experiences where they learn to work in teams and contribute to patient care across specialties. Assessment of student clinical performance in the core clerkships can serve many purposes, including providing feedback that guides learning, ensuring achievement of competencies defined by each medical school, and determining readiness for advancement in the curriculum. With the increasingly competitive nature of the residency match, the purpose of assessment for determining grades may supersede the initially intended purposes for both students and educators. Although most core clerkships use multi-tiered rather than binary pass/fail grading systems (henceforth referred to as “tiered” and “pass/fail” for simplicity), prior studies have raised concerns about how bias, lack of fairness, imprecision, and variability in clerkship grading across institutions can negatively affect students and threaten the accuracy of this information to inform residency selection.
In response to these concerns, some medical schools in the United States have transitioned to pass/fail grading in the core clerkships. Data from the 2018 Clerkship Directors in Internal Medicine survey indicated that most medical schools use tiered grades, and only 4.6% had adopted a pass/fail grading system in their internal medicine clerkship.
Association of American Medical Colleges (AAMC) data from 2021 indicated that 16% of medical schools had adopted a pass/fail system across all required clinical clerkships, suggesting a potential trend toward pass/fail clerkship grading, with the caveat that the COVID-19 pandemic may have spurred temporary changes.
Clarity on the best practices for clerkship assessment and grading is particularly important within the context of the change in the reporting of the US Medical Licensing Examination (USMLE) Step 1 to pass/fail, continued residency application inflation, and virtual interviewing for residency positions. Data are lacking with regard to views on grading across the continuum from undergraduate medical education (UME) to graduate medical education (GME) to inform a unified approach. This paper describes the current state of knowledge about clerkship grading and examines perspectives from medical educators within internal medicine, spanning the UME to GME spectrum. We aim to generate dialogue and identify workable approaches to address this ongoing challenge in assessment and grading …
— Katherine R. Schafer, MD, Lonika Sood, MBBS, MHPE, Christopher J. King, MD, Irene Alexandraki, MD, MPH, Paul Aronowitz, MD, Margot Cohen, MD, MSEd, Katherine Chretien, MD, Amit Pahwa, MD, SFHM, E Shen, PhD, Donna Williams, MD, Karen E. Hauer, MD, PhD
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