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A Change to Pass/Fail Grading in the First Two Years at One Medical School Results in Improved Psychological Well-Being

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To measure the impact of a change in grading system in the first two years of medical school, from graded (A, B, C, D, F) to pass/fail, on medical students' academic performance, attendance, residency match, satisfaction, and psychological well-being. For both the graded and pass/fail classes, objective data were collected on academic performance in the first- and second-year courses, the clerkships, United States Medical Licensing Examination (USMLE) Steps 1 and 2 Clinical Knowledge (CK), and residency placement. Self-report data were collected using a Web survey (which included the Dupuy General Well-Being Schedule) administered each of the first four semesters of medical school. The study was conducted from 2002 to 2007 at the University of Virginia School of Medicine. The pass/fail class exhibited a significant increase in well-being during each of the first three semesters of medical school relative to the graded class, greater satisfaction with the quality of their medical education during the first four semesters of medical school, and greater satisfaction with their personal lives during the first three semesters of medical school. The graded and pass/fail classes showed no significant differences in performance in first- and second-year courses, grades in clerkships, scores on USMLE Step 1 and Step 2CK, success in residency placement, and attendance at academic activities. A change in grading from letter grades to pass/fail in the first two years of medical school conferred distinct advantages to medical students, in terms of improved psychological well-being and satisfaction, without any reduction in performance in courses or clerkships, USMLE test scores, success in residency placement, or level of attendance.
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Students’ Academic Performance
A Change to Pass/Fail Grading in the First Two
Years at One Medical School Results in
Improved Psychological Well-Being
Robert A. Bloodgood, PhD, Jerry G. Short, PhD, John M. Jackson, MS,
and James R. Martindale, PhD
Abstract
Purpose
To measure the impact of a change in
grading system in the first two years of
medical school, from graded (A, B, C, D,
F) to pass/fail, on medical students’
academic performance, attendance,
residency match, satisfaction, and
psychological well-being.
Method
For both the graded and pass/fail classes,
objective data were collected on
academic performance in the first- and
second-year courses, the clerkships,
United States Medical Licensing
Examination (USMLE) Steps 1 and 2
Clinical Knowledge (CK), and residency
placement. Self-report data were
collected using a Web survey (which
included the Dupuy General Well-Being
Schedule) administered each of the first
four semesters of medical school. The
study was conducted from 2002 to 2007
at the University of Virginia School of
Medicine.
Results
The pass/fail class exhibited a significant
increase in well-being during each of the
first three semesters of medical school
relative to the graded class, greater
satisfaction with the quality of their
medical education during the first four
semesters of medical school, and greater
satisfaction with their personal lives
during the first three semesters of
medical school. The graded and pass/fail
classes showed no significant differences
in performance in first- and second-year
courses, grades in clerkships, scores on
USMLE Step 1 and Step 2CK, success in
residency placement, and attendance at
academic activities.
Conclusions
A change in grading from letter grades
to pass/fail in the first two years of
medical school conferred distinct
advantages to medical students, in terms
of improved psychological well-being
and satisfaction, without any reduction
in performance in courses or clerkships,
USMLE test scores, success in residency
placement, or level of attendance.
Acad Med. 2009; 84:655–662.
Editor’s Note: Commentaries on this article appear
on pages 545 and 548.
In recent years, U.S. medical schools
have used a variety of grading systems,
particularly in the first two years of
medical school. The most recent data
available from the Association of American
Medical Colleges Web site (http://services.
aamc.org/currdir/section1/grading1.cfm)
show the following breakdown of the
grading systems used by medical schools
for the required basic sciences portion of
the curriculum: two intervals (usually
pass/fail) 40 schools, three intervals
(usually pass/fail/honors) 35 schools,
four intervals (usually pass/fail/honors/
high honors) 32 schools, and five
intervals (usually A, B, C, D, F) 26
schools. These data suggest that there is
currently no consensus on the most
appropriate grading system in the early
years of medical school. In addition,
there are few useful data available to
guide decision making in this area.
1–5
Medical school is inherently stressful.
6–8
The principal attraction in moving
toward a pass/fail grading system lies in
the expectation that it will improve
students’ psychological well-being
(reduce stress and anxiety), decrease
competitiveness, and promote
cooperative learning. However, for
medical schools contemplating a change
from a traditional graded (A, B, C, D, F)
system to a pass/fail system, concerns
may include (1) a decline in attendance
at scheduled educational activities,
(2) a decline in academic performance,
(3) a decline in United States Medical
Licensing Examination (USMLE) Step 1
scores, and (4) reduced success in
residency placement.
A University of Virginia School of
Medicine faculty committee examined
the literature on medical student
grading systems (and its relationship
to academic performance), medical
student well-being, and residency
placement. The committee surveyed
current medical students and faculty
regarding their preferences for grading
systems and gathered data on grading
policies at other medical schools. Based
on these preliminary measures, in the
spring of 2002, the decision was made
to switch from a five-interval (A, B, C,
D, F) to a two-interval (pass/fail)
grading system for each individual
course in the first two years of medical
Dr. Bloodgood is professor of cell biology,
University of Virginia School of Medicine,
Charlottesville, Virginia.
Dr. Short is associate dean for medical education
support and professor of medical education, University
of Virginia School of Medicine, Charlottesville, Virginia,
and professor of education, Curry School of Education,
University of Virginia, Charlottesville, Virginia.
Mr. Jackson is director of educational technology
and assistant professor of medical education, University
of Virginia School of Medicine, Charlottesville, Virginia.
Dr. Martindale is assistant professor of medical
education, University of Virginia School of Medicine,
Charlottesville, Virginia.
Correspondence should be addressed to Dr.
Bloodgood, Department of Cell Biology, University
of Virginia School of Medicine, P.O. Box 800732,
Charlottesville, VA 22908-0732; telephone: (434)
924-1739; fax: (434) 982-3912; e-mail: (rab4m@
virginia.edu).
Supplement digital content is available for this
article. (http://links.lww.com/A1172)
Academic Medicine, Vol. 84, No. 5 / May 2009 655
school. The change in grading system
was introduced with the class of 2007
(the class entering medical school in
the fall of 2003).
The faculty committee that recommended
the switch to pass/fail grading
hypothesized that the change from a
graded to a pass/fail system would result
in no change in attendance at scheduled
academic activities, no change in
academic performance in courses and
clerkships, no change in performance on
USMLE Step 1 and Step 2 Clinical
Knowledge (CK) exams, and no change
in residency placement success. However,
it was predicted that this change in
grading system would improve students’
well-being, increase satisfaction with
their medical education, and affect their
time utilization (e.g., allow more “risk
taking” in terms of time allocation to
activities not directly related to the
medical curriculum). A comprehensive
assessment of the impact of the change in
the grading system at the University of
Virginia School of Medicine has been
conducted, the results of which we report
here. R.A.B. cochaired the grading study
committee, designed the study, collected
the data, and wrote the paper. J.G.S. was
a member of the grading study
committee and assisted in study design
and data analysis. J.M.J. designed the
online survey tool and assisted in data
collection and processing. J.R.M. did all
of the statistical analysis of the data.
Method
Our protocol involved the comparison of
two medical school classes at the University
of Virginia School of Medicine: the class of
2006 (n 141), the last class under the
five-interval grading system in the first
two years of medical school, and the class
of 2007 (n 140), the first class under
the pass/fail grading system in the first
two years of medical school. The medical
curriculum experienced by these two
classes (to be referred to as the graded
and pass/fail classes) was essentially
identical; both classes took the same array
of courses (eight courses in year 1 and six
courses in year 2). Both classes
experienced a five-interval grading
system in the clerkships and a pass/fail
grading system in the fourth-year
electives portion of the curriculum.
Grades on individual clerkships reflect a
combination of (1) evaluations by clinical
preceptors (faculty and residents) and (2)
the score on the National Board of
Medical Examiners “shelf exam.” The
clerkships do not use a fixed distribution
for the assignment of letter grades. No
change in clerkship grading procedures
occurred between the graded and pass/
fail classes.
While the class of 2007 studied under a
pass/fail grading system at the level of
each individual course, cumulative
honors were awarded to 20% of the
medical class at the end of the second
year; honors were calculated by a simple
average of all percentage scores in
all courses. The committee that
recommended a change to pass/fail
grading did not include any
recommendation for cumulative honors;
this was added by the dean of the school
of medicine as a compromise to gain
the support of a small minority of
department chairs who wanted a means
to recognize superior performance
(presumably for the purpose of residency
placement). The course directors
maintained percentage scores for course
performance for each student (a blend
of exam scores, quiz scores, and lab
performance scores that varied for each
course) even when only “P” or “F” grades
were awarded to students.
We collected students’ course
performances, USMLE Step 1 scores,
clerkship grades, USMLE Step 2CK
scores, and residency program quality
measures from existing databases. Self-
report data were collected by means of a
Web-based survey (survey available as
supplemental Appendix online,
(http://links.lww.com/A1172), which we
administered to the two classes once each
semester for the first four semesters of
medical school; the surveys were
administered to all 141 members of the
graded class and to all 140 members of
the pass/fail class. Each class received the
surveys at the same time in the semester,
and each administration fell at least two
weeks away from any vacation period or
exam period; each survey was available
on the Web for one week. The survey was
completely deidentified, and there were
no incentives provided to medical
students for completing the surveys. The
response rate on these voluntary surveys
varied with administration from 44%
(n 62) to 75% (n 103); the subset of
students completing the survey varied
with administration. The survey
contained the complete Dupuy Schedule
of General Well-Being
9
as well as
additional questions on satisfaction with
medical school, satisfaction with personal
life, attendance at scheduled academic
activities, and time utilization. The
Dupuy Schedule, developed by Harold J.
Dupuy, has been widely used in clinical
studies and has been well validated,
9–11
although we are not aware of its
previously having been used in
undergraduate medical education. It uses
18 questions that gather data on anxiety,
depression, positive well-being, self-
control, vitality, and general health.
9
As
part of a larger Web-based survey, this
instrument was administered to both the
graded and pass/fail classes in each of the
first four semesters of medical school. It
was administered at approximately the
same time in each semester for each class,
and the administration of the survey fell
at least two weeks away from any
vacation period or exam period. The
Likert questions on the Dupuy Schedule
were assigned numeric scores, and a
cumulative Dupuy Schedule score
(maximum of 124 points) was calculated
for each student for each administration
of the survey. Dupuy Schedule subscores
were calculated as indicated in Exhibit
5.12 in Dupuy et al.
9
IRB approval for
this study was obtained before the
commencement of any data collection
and was renewed annually.
Statistical analyses
Initial demographics for both classes were
calculated and included number of
students in each class, mean age, mean
undergraduate grade point average, mean
MCAT scores for the Biology, Physics,
and Verbal Reasoning sections, gender,
minority status, proportion of students
who were University of Virginia
undergraduates, and the percentage who
were Virginia residents. Two-sample
independent ttests were used to compare
the two classes on mean MCAT Biology,
Physics, and Verbal Reasoning test
components. Chi-square tests of
independence were used to look at the
association between class and gender,
minority status, percentage of class,
attendance at the University of Virginia
for undergraduate degree, and Virginia
residency status.
Mean overall course grades were analyzed
by class and by gender within class.
Students’ Academic Performance
Academic Medicine, Vol. 84, No. 5 / May 2009656
Means and standard deviations were
calculated for each of the three group
comparisons, and a two-sample
independent ttest was used to look for
statistically significant mean differences
between the overall graded and pass/fail
class performances, as well as between the
graded and pass/fail class performances
for males only and for females only.
Overall measures of medical student well-
being obtained from the Dupuy Schedule
were compared for the graded and pass/
fail classes. Means and standard
deviations were computed, and mean
group comparisons were addressed for
statistical significance by the use of two-
group independent ttests. Additionally,
overall mean group comparisons were
made for each class, broken down by
gender. Comparisons were made for each
of the first four semesters in medical
school. The Dupuy Schedule was also
broken down into its individual subscale
components (anxiety, depression,
positive well-being, self-control, vitality,
and general health), and mean group
comparisons were made for each subscale
for the graded versus pass/fail classes for
each of the first four semesters of medical
school. Means and standard deviations
were computed, and mean group
comparisons were made using two-group
independent ttests.
Mean board certification exam pass
rates were compared for the residency
programs to which the graded and pass/
fail classes matched. Five-year average
pass rates for individual residency
training programs in internal medicine,
family medicine, pediatrics, and general
surgery were obtained from the
appropriate academy Web sites. These
were the only residency programs for
which board certification exam rates are
available at the level of individual
training programs, and hence our
conclusions about residency placement
success must be qualified as applying
only to these four types of residency
programs (representing about half of
our medical graduates). Means and
standard deviations were calculated,
and a two-group independent ttest was
used to look for mean group
differences.
Cohen effect sizes as well as 95%
confidence intervals were calculated for
all mean differences. An a priori alpha
level of .05 was used for all inferential tests.
To control for inflated type I error rates due
to multiple significance tests, a Bonferroni
correction procedure was applied to each
set of significance tests. All statistical
analyses were performed using SPSS
version 13 (SPSS Inc., Chicago, Illinois).
Results
Comparison of the characteristics of the
graded and pass/fail medical classes
The characteristics of the two University
of Virginia medical school classes (class
of 2006 and class of 2007) used in this
study are shown in Table 1. They were
well matched with the exception of
gender composition; the graded class had
38% male and 62% female students, and
the pass/fail class had 54% male and 46%
female students, a statistically significant
difference (P.024). Because of this
gender disparity between the graded and
pass/fail classes, all across-class
comparisons were performed three ways:
male and female combined, only male,
and only female.
Academic performance
Performance in medical school courses
for the first two years of the curriculum is
shown in Table 2. Even though the class
of 2007 was under a pass/fail grading
system in each course, course directors
calculated percentage scores for each
student for each course on the basis of
performance in exams, quizzes,
laboratories, etc. Students were aware of
these percentage scores. For each student
in each of the two classes, we averaged all
of the individual course scores for the
first two years of medical school to
generate an individual mean; from these
individual student means, we generated a
class mean. There was no statistically
significant difference between the two
classes in terms of academic performance
on all first- and second-year courses
combined, even when the data were
broken down by gender (Table 2). When
course performance in first- and second-
year courses was analyzed separately,
there were still no significant differences
in academic performance between the
graded and pass/fail classes (P.651 for
all first-year courses and P.397 for all
second-year courses).
Performance in clinical clerkships did not
differ between the graded and pass/fail
classes. For both classes, the clinical
clerkships used letter grades, including
plus and minus; two different schemes
for converting letter grades to numeric
scores were compared. One scheme is
used by this medical school for the
selection of medical students for
membership in Alpha Omega Alpha, the
national medical honor society, and is
based on a 13-point scale (A⫹⫽13, A
12, A⫺⫽11, etc.). The mean clerkship
grade was 10.59 for the graded class and
10.69 for the pass/fail class (P.165).
The other scheme is a four-point scale in
which an A (A,A,A) is worth four
points,aB(B,B,B) is worth three
points, etc. The mean clerkship grade was
3.54 for the graded class and 3.57 for the
pass/fail class (P.426).
Table 1
Demographic Characteristics of Two Medical School Classes, From a Study of
Graded Versus Pass/Fail Grading Systems, University of Virginia Medical School,
2007
Characteristic
Class of 2006:
Five intervals
(A, B, C, D, F)
Class of 2007:
Two intervals
(pass/fail) Pvalue
Students in the class (no.) 141 140
.........................................................................................................................................................................................................
Age (mean years/months) 22/4 22/4
.........................................................................................................................................................................................................
Undergraduate GPA (points) 3.66 3.70 .150
.........................................................................................................................................................................................................
MCAT score—biology (points) 10.73 10.83 .549
.........................................................................................................................................................................................................
MCAT score—physics (points) 10.75 10.94 .267
.........................................................................................................................................................................................................
MCAT score—verbal reasoning (points) 10.22 10.31 .587
.........................................................................................................................................................................................................
Male (%) 38 54 .024
.........................................................................................................................................................................................................
Female (%) 62 46 .024
.........................................................................................................................................................................................................
Underrepresented minorities (%) 5.1 5.7 .770
.........................................................................................................................................................................................................
University of Virginia undergrads (%) 26.1 25.7 .990
.........................................................................................................................................................................................................
Virginia residents (%) 62.3 65.7 .570
Students’ Academic Performance
Academic Medicine, Vol. 84, No. 5 / May 2009 657
USMLE scores
In terms of first-time performance on
USMLE Step 1 (a measure of academic
performance in the first two years of
the curriculum), the pass/fail class
performed as well as the graded class.
The graded class had a mean of 222
(20), and the pass/fail class had a
mean of 226 (21), out of a possible
260. The comparable national means
for those two years were 216 (24) and
218 (23). A two-tailed ttest showed
no statistically significant difference
(P.101) between the two classes. On
the USMLE Step 2CK exam, the pass/
fail class again performed as well as the
graded class. The graded class had a
mean of 231 (21), and the pass/fail
class had a mean of 236 (21), out of a
possible 260. The comparable national
means for those two years were 221 (24)
and 225 (24). A two-tailed ttest showed
no statistically significant difference (P
.060) between the two classes.
Residency placement success
Given the importance of the residency
match, the concern that a change in
medical school grading in the first two
years of medical school from a graded to
a pass/fail system might have a negative
impact on residency placement, and the
absence of any useful measure (other
than percent of total medical students in
a class who match to any residency
program) for accessing the overall quality
of the residency programs to which a
group of students matches, we examined
a number of possible measures (including
various medical school rankings). The
most relevant and objective measure that
we could identify for the quality of
individual residency programs was based
on the board certification pass rates (five-
year averages) for the residents in the
specific residency programs to which the
medical students in this study matched.
These scores are available for all residency
programs in internal medicine, family
medicine, pediatrics, and general surgery
on the respective board Web sites. For
these four categories of residency
programs combined, there was no
significant difference in the mean board
certification pass rates for the residency
Table 3
Comparison of Medical Student Well-Being Between Graded and Pass/Fail
Medical School Classes, From a Study of Graded Versus Pass/Fail Grading
Systems, University of Virginia Medical School, 2007
Students Semester
Graded class Pass/fail class
95% CI ES
PvalueNo.
Dupuy
Schedule
score* SD No.
Dupuy
Schedule
score* SD
All
...................................................................................................................................................................................................................................................................................................................
1 81 80.56 16.40 103 91.46 14.46 15.37 to 6.43 .122 .001
...................................................................................................................................................................................................................................................................................................................
2 106 85.74 15.29 96 91.97 17.73 10.78 to 1.68 .376 .008
...................................................................................................................................................................................................................................................................................................................
3 62 77.56 14.79 101 87.13 16.64 14.62 to 4.52 .607 .001
...................................................................................................................................................................................................................................................................................................................
4 88 77.74 15.13 100 79.02 18.89 6.22 to 3.66 .074 .610
Female
...................................................................................................................................................................................................................................................................................................................
1 47 77.51 14.67 48 91.44 14.28 19.75 to 8.11 .962 .001
...................................................................................................................................................................................................................................................................................................................
2 63 82.37 14.43 48 90.52 19.47 14.45 to 1.85 .475 .013
...................................................................................................................................................................................................................................................................................................................
3 36 75.25 14.61 48 84.58 14.77 15.68 to 2.98 .635 .005
...................................................................................................................................................................................................................................................................................................................
4 50 76.42 15.16 48 74.73 19.11 5.13 to 8.51 .098 .628
Male
...................................................................................................................................................................................................................................................................................................................
1 34 84.79 17.91 55 91.47 14.75 13.53 to 0.17 .407 .059
...................................................................................................................................................................................................................................................................................................................
2 43 90.67 15.32 48 93.42 15.87 9.18 to 3.68 .176 .405
...................................................................................................................................................................................................................................................................................................................
3 26 80.77 14.72 53 89.43 17.99 16.64 to 0.68 .526 .037
...................................................................................................................................................................................................................................................................................................................
4 38 79.47 15.12 52 82.98 17.97 10.55 to 3.53 .211 .332
* The Dupuy Schedule of General Well-Being is a 124-point scale that measures anxiety, depression, positive well-
being, self-control, vitality, and general health. In all cases, a larger number denotes improved well-being.
ES indicates Cohen effect size.
Table 2
Student Academic Performance Data by Gender, From Study of Graded Versus
Pass/Fail Grading Systems, University of Virginia Medical School, 2007
Students No. Mean (SD) 95% CI ES* Pvalue
All 1.38 to 0.744 .071 .558
.........................................................................................................................................................................................................
Graded 137 87.14 (4.46)
.........................................................................................................................................................................................................
Pass/fail 138 87.46 (4.47)
Male 1.72 to 1.43 .032 .959
.........................................................................................................................................................................................................
Graded 53 88.06 (4.82)
.........................................................................................................................................................................................................
Pass/fail 74 88.02 (4.19)
Female 1.59 to 1.33 .028 .738
.........................................................................................................................................................................................................
Graded 84 86.56 (4.13)
.........................................................................................................................................................................................................
Pass/fail 64 86.81 (4.72)
* ES indicates Cohen effect size.
Students’ Academic Performance
Academic Medicine, Vol. 84, No. 5 / May 2009658
programs to which the medical students
in the graded and pass/fail classes were
matched (Table 5).
Psychological well-being
Table 3 shows the mean Dupuy Schedule
scores for each class for each of the four
administrations. The pass/fail class
exhibited a statistically significant
increase in well-being (P.01)
compared with the graded class for the
first three semesters of medical school.
Although the pass/fail class still exhibited
a higher level of well-being than the
graded class in the fourth semester of
medical school, the difference was not
statistically significant. When the data
were broken down by gender, the same
pattern of greater well-being in the pass/
fail class relative to the graded class for
the first three semesters of medical school
was observed for male and female
medical students. This effect was
statistically significant for females in the
first three semesters of medical school (P
.05) but statistically significant for males
only in the third semester (P.05).
Because the Dupuy Schedule assigns
questions to six different categories
(anxiety, depression, positive well-being,
self-control, vitality, and general heath),
we calculated subscores for these six
criteria for each student in each class for
each administration of the survey (Table
4). For the first three semesters of
medical school, the pass/fail class
exhibited higher scores on all six
subscores relative to the graded class. For
all subscores, higher scores represented a
better state of well-being (i.e., less
anxiety, less depression, more positive
well-being, more self-control, more
vitality, and better general health). Table
4 shows that, in semester 1, the
improvement in well-being status for the
pass/fail class was statistically significant
for all six subscore categories. For
semesters 2 and 3, the improvement in
well-being for the pass/fail class was
statistically significant for four of the six
categories (anxiety, depression, positive
well-being, and vitality). For semester 4,
there were no statistically significant
differences between the two classes for
any of the subscores.
Cumulative honors and stress
There was one somewhat unusual feature
of the grading system experienced by the
pass/fail class: the awarding of cumulative
honors in the basic sciences at the end of
the first four semesters of medical school.
Although every individual course used a
straight pass/fail grading system,
individual student performances in the
entire array of first- and second-year
courses were averaged, and the top 20%
of the class received cumulative honors.
Anecdotal discussion with medical
students under the pass/fail grading
system suggested that many students
chose a strategy early in medical school
either to work actively toward achieving
the cumulative honors or to ignore the
cumulative honors component of the
pass/fail grading system. This stimulated
a separate survey (dealing only with
cumulative honors) of the pass/fail class,
which was administered after completion
of the first two years of medical school.
Of those medical students who felt they
had made a conscious decision to seek
cumulative honors, 70% felt that this
decision resulted in greater stress, 30%
felt this decision had no effect on level of
stress, and 0% felt that this decision
resulted in lower stress during the first
four semesters of medical school. Of
those who felt that they had made a
conscious decision to not seek cumulative
honors, 0% felt that this decision resulted
in greater stress, 8% felt that this decision
had no effect on perceived stress, and
92% felt that this decision resulted in
lower stress.
Satisfaction, attendance, and time
utilization
The major survey instrument used in this
study, besides the Dupuy Schedule, also
gathered self-reported data from the
medical students on satisfaction with
medical school, satisfaction with personal
life, attendance at scheduled academic
events, and time utilization. The pass/fail
class exhibited a statistically significant
increase (P.05) in “satisfaction with
the quality of my medical education” for
each of the first four semesters of medical
school relative to the graded class,
although this effect was more robust in
the first year of medical school than in
the second year. The pass/fail class also
exhibited a statistically significant
increase (P.05) in “current satisfaction
with my personal life during the last
month” for the first three semesters of
medical school relative to the graded
class; this effect disappeared in the fourth
semester of medical school, as did the
increased well-being (based on Dupuy
Schedule) shown in Tables 3 and 4. There
Table 4
Comparison of Dupuy Schedule Subscores Between Graded and Pass/Fail (P/F)
Classes, From a Study of Graded Versus Pass/Fail Grading Systems, University of
Virginia Medical School, 2007*
Semester 1 Semester 2 Semester 3 Semester 4
Subscore
Graded
(n 82)
P/F
(n 103) Pvalue
Graded
(n 107)
P/F
(n 96) Pvalue
Graded
(n 62)
P/F
(n 102) Pvalue
Graded
(n 88)
P/F
(n 100) Pvalue
Anxiety 15.98 18.14 .002
17.65 19.01 .048
14.55 17.02 .001
14.20 14.08 .858
...................................................................................................................................................................................................................................................................................................................
Depression 15.89 17.62 .001
§
16.65 17.61 .049
15.08 16.92 .001
15.35 15.56 .705
...................................................................................................................................................................................................................................................................................................................
Positive well-being 11.02 13.02 .001
§
12.20 13.09 .030
10.74 12.37 .001
§
10.40 10.59 .674
...................................................................................................................................................................................................................................................................................................................
Self-control 14.12 15.51 .001
§
14.45 15.10 .126 14.40 15.13 .078 14.42 14.61 .632
...................................................................................................................................................................................................................................................................................................................
Vitality 12.15 14.60 .001
§
13.31 15.16 .001
11.95 14.10 .001
§
12.06 12.88 .111
...................................................................................................................................................................................................................................................................................................................
General health 11.48 12.56 .016
11.24 11.99 .152 10.84 11.25 .472 11.31 11.30 .989
* The Dupuy Schedule of General Well-Being is a 124-point scale that measures anxiety, depression, positive well-
being, self-control, vitality, and general health.
P.05.
P.01.
§
P.001.
Students’ Academic Performance
Academic Medicine, Vol. 84, No. 5 / May 2009 659
were no statistically significant changes in
self-reported attendance at scheduled
academic events or in self-reported time
utilization (voluntary clinical activities,
independent scholarly activities,
community service activities, exercise-
related activities, and leisure activities
other than exercise) between the two
classes during the first four semesters of
medical school.
Discussion
The literature on medical education
contains very few useful data that address
the effects of the grading system in the
early years of medical school on factors
such as course performance, USMLE
scores, time utilization, attendance,
residency placement success,
psychological well-being, satisfaction
with medical education, and
competitiveness among students. This
leaves medical schools with little basis for
making informed decisions about
choosing or changing their grading
systems.
Our study has demonstrated that a
change from a five-interval (A, B, C, D,
F) to a two-interval (pass/fail) grading
system in the first two years of medical
school at the University of Virginia
School of Medicine was not associated
with a decline in students’ academic
performance (course performance in the
first two years of the curriculum, USMLE
Step 1 scores, clerkship grades, or
USMLE Step 2 CK scores). This is
consistent with previous data from the
University of Michigan Medical School
showing that a change from a four-
interval (honors, high pass, pass, fail) to a
two-interval (pass/fail) grading system in
the first year of medical school resulted
in no statistically significant change in
performance in the first-year gross
anatomy course.
2
This was also the case
for the gross anatomy course in the
present study. On the other hand, when
the Mayo Medical School switched from
a five-interval (A, B, C, D, F) to a three-
interval (pass, marginal pass, fail) grading
system in the first year of medical school
only, a statistically significant decrease in
performance on written exams occurred
in the first-year gross anatomy course.
4
Robins et al,
2
when comparing medical
student performance in basic science
courses at the University of Michigan
under a four-interval (honors, high pass,
pass, fail) versus a two-interval (pass/fail)
grading system, found that medical
students’ performance on their last
course examination correlated with the
average of all previous examinations in
that particular course, suggesting that the
students did not “slack off” at the end of
a course, even when already assured a
passing grade based on their performance
on the previous exams. Supporting this,
we found no change in students’ self-
reported lecture attendance between the
graded and pass/fail classes for any of the
first four semesters of medical school.
Rohe et al
5
found no statistically
significant change in USMLE Step 1
scores when comparing a five-interval
and a three-interval grading system at the
Mayo Medical School. When looking at
the credentials of applicants to the
Northwestern University internal
medicine residency program, Hughes et
al
12
found that average USMLE Step 1
scores for students from schools with a
two-interval (pass/fail) grading system
exceeded those of students from schools
with either five-interval (A, B, C, D, F) or
three-interval (high pass, pass, fail)
grading systems.
The data from the current study indicate
that the major benefit to be derived from
a change from a five-interval (A, B, C, D,
F) to a two-interval (pass/fail) grading
system in the first two years of the
medical school curriculum lies in the area
of psychological well-being. Using the
Dupuy Schedule,
9
which has questions
that address anxiety, depression, positive
well-being, self-control, vitality, and
general health, we observed that the
change to a pass/fail grading system
resulted in a statistically significant
improvement in students’ well-being
(mean cumulative Dupuy Schedule
score) for each of the first three semesters
of medical school (Table 3). When the
data were broken down by gender, we
again saw the same pattern of increased
well-being for each of the first three
semesters of medical school for both
males and females. For females, this
increase was statistically significant for
semesters 1 through 3; for males, this
increase was statistically significant only
for semester 3. It is interesting to note
that the switch to the pass/fail system was
associated with a greater increase in well-
being among females than among males
in the first year (first two semesters).
When the Dupuy Schedule well-being
data were broken down by subscore, the
change to pass/fail resulted in an increase
in well-being for all subscores for each of
the first three semesters (Table 4). For
semester 1, these increases in well-being
were significant for all subscores; for
semesters 2 and 3, the increases were
significant for anxiety, depression,
positive well-being, and vitality. Just as
the cumulative Dupuy scores showed no
significant change (with change in
grading system) in the fourth semester,
the same applied to all six of the
subscores.
The pass/fail grading system
implemented by the University of
Virginia School of Medicine effective
with the class of 2007 had one unusual
component: cumulative honors awarded
to 20% of the class based on overall
academic performance in the first two
years of the curriculum. Whereas Dupuy
Schedule data showed a significant
decrease in stress associated with the
switch to pass/fail grading, a separate
survey of the class of 2007 on the impact
of cumulative honors suggests that those
Table 5
Residency Placement Success Judged by the Board Certification Pass Rates for
Individual Residency Programs to Which the Medical Students Matched, From a
Study of Graded Versus Pass/Fail Grading Systems, University of Virginia
Medical School, 2007
95% CI
Graded class
(n 63)
Pass/fail class
(n 52) ES
Pvalue
Board exam pass
rates for residency
programs (%)*
3.87 to 3.57 .014 .937
.........................................................................................................................................................................................................
Mean (SD) 90.34 10.66 90.49 9.45
.........................................................................................................................................................................................................
Range 59–100 59–100
* Programs were in internal medicine, family medicine, pediatrics, and general surgery.
ES indicates Cohen effect size.
Students’ Academic Performance
Academic Medicine, Vol. 84, No. 5 / May 2009660
students who consciously chose to seek
cumulative honors experienced greater
stress relative to those students who
consciously choose to not pursue
cumulative honors. These data suggest
that the greater well-being associated
with a change to pass/fail grading that we
have documented for the first three
semesters of medical school might have
been even greater had there not been the
cumulative honors component of the
pass/fail grading system. After two classes
under the pass/fail grading system, we
dropped the cumulative honors
component, with the support of the
medical students.
The greater well-being associated with a
switch to pass/fail grading documented in
the present study is consistent with other
recent data. Rohe et al
5
studied the effect
of a change in grading system from a five-
interval (A, B, C, D, F) to a three-interval
(pass/marginal pass/fail) system in the
first year only at the Mayo Medical
School. At the end of the first year, the
students on the three-interval grading
system exhibited less stress, better overall
mood, and greater group cohesion; these
levels of stress and group cohesion
continued through the second year of the
curriculum, even though a five-interval
grading system was used. Rohe et al
5
found no correlation between test anxiety
and the grading system in their study,
even though examinations are considered
by medical students to be among the
greatest sources of stress in medical
school.
8,13,14
Robins et al
2
cited student
survey responses suggesting that a switch
from a four-interval (honors, high pass,
pass, fail) to a two-interval (pass/fail)
grading system at the University of
Michigan eased anxiety and reduced
competition while encouraging student
cooperation. Numerous comments on
the open-ended question in the survey we
used indicated that students in the pass/
fail class felt that pass/fail grading
reduced competition among medical
students as well as stress on individual
medical students.
It is of interest to consider why the
benefit of greater well-being associated
with a change from a graded to a pass/fail
system disappeared in the fourth
semester of medical school. It should be
noted that the fourth semester of medical
school showed the lowest level of well-
being for the pass/fail class, a level
comparable with both the third and
fourth semesters of medical school for
the graded class. The fourth semester
showed declines in students’ self-reported
lecture attendance for both the pass/fail
and graded classes (data not shown).
Survey data from our medical students
suggest that the impending USMLE Step
1 exam, coupled with cumulative course
examinations, was responsible for both
the decline in well-being (increased
stress) and the decreased lecture
attendance, since decreased lecture
attendance freed up time to study for
USMLE Step 1 and the cumulative course
exams, which are used primarily at the
end of the second year of the curriculum.
This is consistent with the literature:
Kidson and Hornblow
13
reported that the
examinations marking the end of
preclinical training at Monash University
in Australia were rated by the majority of
medical students as having provoked
extremely high anxiety. Rosenthal et al
8
found that entry into medical school and
the point just before the end of the
second-year exams were the most
stressful times during the first 30 months
at the University of Tennessee College of
Medicine. Clark and Zeldow
15
showed
that depressive symptoms in medical
students were highest at the end of the
second year of medical school.
For each of the first four semesters of
medical school, medical students in the
pass/fail class rated their current level of
satisfaction with the quality of their
medical education higher than did the
students in the graded class. This is
consistent with observations of Robins et
al,
2
who found that medical students at
the University of Michigan Medical
School on a two-interval (pass/fail)
grading system in the first year of medical
school were more satisfied with their
evaluation and examination system and
the learning environment than were
students on a three-interval (honors,
pass, fail) grading system. We found that
the switch to a pass/fail grading system
was associated with greater satisfaction
with personal life for the first three
semesters of medical school.
One of the areas of major concern when
considering any change in grading system
in a medical school is the possible impact
on residency placement success. As far as
we are aware, the only measures of
success in the residency match that have
been used by medical schools, by the
National Residency Match Program, and
in other research studies are the
percentage of the total class that matched
to any residency program, the percentage
of students who matched to their first
choice, or the percentage of students who
matched to one of their first three
choices. The present study is the first to
quantitate residency placement “success”
for a medical class using an objective
measure (board certification pass rates)
to assess the quality of the residency
programs to which the medical students
in the class were matched. Using this
measure, there was no statistically
significant difference in residency
placement success between the graded
and the pass/fail classes. There is
considerable literature that suggests that
grades in the first two years of medical
school are not given much weight in the
residency selection process.
16–19
A
somewhat separate issue is whether
medical students from medical schools
with pass/fail grading systems suffer any
competitive disadvantage in residency
selection; the literature in this area is
somewhat confusing because of
differences in terms of which portion of
medical school was pass/fail in the
different studies (often not indicated).
Tardiff
20
found that 73% of residency
directors did not give preference to
students from either graded or pass/fail
schools. However, there were differences
across specialties in the percentage of
residency directors who gave preference
to students from graded schools, ranging
from a low of 6% in psychiatry programs
to a high of 42% in surgery programs.
Hughes et al
12
studied the selection of
internal medicine residents at
Northwestern University and found that
“the overall impact of the grading system
as a factor in the selection of residents
seems to be minimal.”
Although it is not a formal part of this
study, we feel that we would be remiss
not to comment on the potential impact
of a change to pass/fail grading on
medical admissions. In the years just
before the change to pass/fail grading,
surveys of students who rejected offers of
admission to the University of Virginia
School of Medicine often cited the
grading system as a factor in their
decision. In a prematriculation survey of
the medical class entering in the fall of
2007 (under a pass/fail system, after we
had eliminated cumulative honors), 81%
said that the grading system was
somewhat to very important in their
Students’ Academic Performance
Academic Medicine, Vol. 84, No. 5 / May 2009 661
decision to accept the offer of admission
from the University of Virginia School of
Medicine.
In summary, our findings have shown
that a change from a five-interval (A, B,
C, D, F) to a two-interval (pass/fail)
grading system at the University of
Virginia School of Medicine did not
result in any decline in academic
performance (on first- and second-year
courses, clerkships, and USMLE Step 1
and Step 2CK), attendance at scheduled
academic activities, or residency
placement success (as measured by the
quality of the residency programs to
which students were matched). This
change to a pass/fail grading system was
accompanied by a statistically significant
improvement in psychological factors
related to anxiety, depression, positive
well-being, self-control, vitality, and
general health in the first three semesters
of medical school. These data on
performance and psychological well-
being are nicely reflected in one student
survey comment that the pass/fail system
“directly influences my stress level
without compromising my effort level.”
The students in the pass/fail class
reported increased satisfaction with the
quality of their medical education in their
first four semesters of medical school and
with their personal life in their first three
semesters of medical school.
Possible limitations of the current study
include the facts that (1) survey response
rates were lower for the graded class than
the pass/fail class for three of the four
semesters assessed, (2) the conclusion of
similar success in the residency match for
the graded and pass/fail classes is based
on a portion of the study sample because
data are available only for certain types of
residency programs, (3) the graded and
pass/fail classes differed in gender ratio,
(4) knowledge of the grading system
before entry into medical school may
have altered the composition of the
graded and pass/fail classes in some
manner, (5) we do not know whether the
two medical classes used in this study
entered medical school with the same or
a different average level of psychological
well-being, (6) medical students were
aware that a research study on the effects
of grading was under way, and (7) the
results of the study can best be
generalized to medical schools with a
similar student body and similar
curriculum.
This study provides useful information
for medical schools contemplating a
change in grading system in the early
years of medical school from a graded (A,
B, C, D, F) to a pass/fail grading system as
to the probable impact on medical
student performance, attendance,
residency placement, satisfaction with
medical school, and psychological well-
being. Similarly, it provides reassurance
for medical schools that have already
chosen to make such a change.
Acknowledgments
The authors thank Allison Innes (Office of
Student Affairs), Beth Bailey (Office of
Admissions), and Randolph Canterbury
(Office of Admissions) for providing data, and
Addeane Caelleigh for valuable comments on
the manuscript. Alfred F. Connors (currently
at Case Western Reserve University)
recommended the use of the Dupuy General
Well-Being Schedule for analyzing the effects
of the change in grading system on
psychological factors. Michael F. Rein
suggested the use of the board certification
exam pass rates as a measure of residency
program quality.
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The prevalence of distress among medical students continues to rise. Studies have shown that stressrelated to examinations – test anxiety (TA) – is the most frequently reported source of distress. Research on the relationship between TA and assessment modalities is thus critical for determining the potential ramifications of this problem. This study aimed to explore assessment modalities that aggravate TA among medical students in a Malaysian medical school. A cross-sectional study was conducted among medical students at the School of Medical Sciences (SMS) of Universiti Sains Malaysia (USM). Students rated TA for each assessment modality used in the school. Each modality was scored from 1 to 10, with 1 indicating no TA and 10 representing extreme TA. Forty-five students participated in the study. The group was divided almost equally in terms of sex. The assessment modalities that provoked the most TA were the objective structured clinical examination (OSCE), the short case, the short essay question (SEQ) and the long case, with mean scores of 7.9, 7.8, 7.7 and 7.7, respectively. The case write-up, the problem-based learning (PBL) assessment, the multiple true-false (MTF) questions and the Simplified Thematic Engagement of Professionalism Scale (STEPS) were the assessment methods that induced the least TA, with mean scores of 5.1, 5.0, 4.4 and 4.0, respectively. This study found that the worst assessment modalities in terms of TA were the OSCE, the short and long cases, and the short essay question, while the case write-up, the PBL assessment, the MTF questions, and the STEPS induced the least TA. Most students reported that memorisation difficulties and facing examiners were the most common causes of TA. Remedial measures include examiner training on how to deal with examinees during assessments, evaluating the distribution of marks according to assessment modality and student training focused on study skills and exam preparation.
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