Grading Systems Used in Medical Schools

Traditional Grading

Traditional grading in medical school refers to letter grades. A+ is the best, F is for “fail,” and so on. This lettered grading system is historically the most common system — most undergrad colleges still use traditional grading — so you’re probably used to it by now.

This traditional system ranks students’ performance. Many institutions want students to focus on learning in their first or second year, and so there is no class ranking through GPA. Many med schools incorporate letter grading or tiered P/F (both of which rank students) in clerkship years.

In medical school, traditional grading is sometimes used in the pre-clerkship years and occasionally through all four years of medical school. If it’s used, it’s most often used in the final two academic years of med school.

Letter grading typically follows a 4-point GPA scale, where each grade contributes to a score that gets thrown into your GPA:

• A+ = 4.0
• A = 4.0
• A- = 3.7
• B+ = 3.3
• B = 3.0
• B- = 2.7
• C+ = 2.3
• C = 2.0
• C- = 1.7
• D+ = 1.3
• D = 1.0
• F = 0.0

Pros

Traditional letter grading:

• Clearly ranks med students.
• Incentivizes students to do well on coursework.
• Is easy to understand since it’s used in most high schools and undergrads.
• Is beneficial for residency programs, as some prefer a GPA based on four years of letter grading. 

Cons

Traditional letter grading systems:

• Can lead to increased stress and anxiety.
• Emphasize incremental improvements instead of overall understanding.
• May reduce collaboration and increase competition between students.
• Include curves, and they can be unfair.

Examples of Schools That Use Traditional Grading

Below are a couple of med schools that utilize the traditional letter grading system:

• University of Maryland School of Medicine
• University of Missouri Kansas City School of Medicine

Pass/Fail Systems

A true pass/fail grading system is when you are given a “pass” or “fail” at the end of the course – no letter grades.

A lot of institutions are switching over to a pure pass/fail system, but many schools are using tiered pass/fail grading, which is just an expanded P/F grading system. Tiered P/F grading typically uses the following scale:

• Honors (H)
• High Pass (HP)
• Pass (P)
• Fail (F)

If you retake a class you failed and then pass it, you may get a remediated pass. Remediation impacts your official transcript.

According to the Association of American Medical Colleges (AAMC), most medical schools have used some form of pass/fail grading system since 2016.

Pros

Pros of pass/fail grading include:

• Reduced stress.
• Encouraging collaboration instead of competition.
• A focus on mastery instead of incremental final grade improvements.
• Alignment with USMLE Step 1 pass/fail change and its influence.

Cons

The pass/fail system:

• May not adequately prepare students for the rigors of clinical rotation years.
• Could potentially impact the overall quality of physician training.
• Will grow reliance on other metrics (Step 2 CK scores, clerkship evaluations, research) in the absence of traditional GPA.
• May present difficulties for residency programs to differentiate candidates.

Examples of Schools Utilizing Pass/Fail

Here are a few schools that use a pure pass/fail grading system:

• UCSF School of Medicine
• University of California, Los Angeles Geffen School of Medicine
• Jacobs School of Medicine

A majority of U.S. medical schools use a tiered pass/fail system for at least two years of their curriculum:

• Yale School of Medicine
• SUNY Upstate Medical University
• New York University Long Island School of Medicine

Hybrid Approaches

Some schools may use a hybrid approach to grading. For example, they may use letter grading in elective classes, pass/fail for preclinical grading, and tiered P/F in third and fourth years.

The most common hybrid approach I’ve seen is this:

• Pre-clinical (years 1-2): Pure pass/fail
• Clinical (years 3-4): Tiered pass/fail, which produces a similar GPA to traditional letter grading

Generally, the advantage of this hybrid approach is that you prioritize comprehension in the early years and encourage incremental academic performance improvement in later years, in which students are ranked. This is what residencies prefer.

Some medical schools that use this hybrid approach include:

• Stanford University School of Medicine
• University of Chicago Pritzker School of Medicine
• University of California San Diego School of Medicine
• Renaissance School of Medicine at Stony Brook
• New York Medical College
• University of Rochester

Impacts on Residency Applications

As pass/fail systems are becoming more common, you should understand how residency programs evaluate your course grades.

Residency programs may find it harder to assess the relative strengths of students from P/F systems, especially in healthcare specialties with a high number of applicants or a low number of open positions.

However, pass/fail systems can encourage students to focus on developing strong patient care and clinical skills, which are highly valued in residency.

How your pass/fail grades appear to residencies truly depends on the specialty you want to pursue.

• For more competitive specialties, like dermatology and neurosurgery, pass/fail can make it slightly more difficult for you to stand out above the crowd.
• For less competitive specialties, like family medicine and pediatrics, pass/fail shouldn’t hurt your chances of getting into a good residency.

The good news is that residency competitiveness tends to be based on factors like your Step 2 CK score and your research/publication history. If you’re going for a competitive residency and are concerned about P/F system impacts to your residency prospects, aim to score high on Step 2 CK and do plenty of relevant research.

Read Next: Medical School vs. Residency: What to Expect 

Which Grading System Is Best?

There is no single “best” medical school grading system, as each has potential benefits and drawbacks.

Different students are stressed or relieved by different approaches. Prioritize your mental well-being in terms of which grading style you think will cause the least amount of anxiety.

Also, if you can look ahead far enough to residency, research how your ideal residency program views different grading systems. 

The optimal grading system depends on your individual needs and the specific context of your medical school and future residency program.

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