# Two-Tiered Grading in Required Clerkships: Understanding the Why and Results of Making This Change

## TL;DR

Medical schools are switching to two-tiered grading in clinical clerkships to improve grading fairness and student well-being, with mixed evidence on broader impacts.

## Contribution

This study identifies the motivations and outcomes of adopting two-tiered grading in clinical clerkships based on survey responses from medical school leaders.

## Key findings

- Most schools switched to two-tiered grading due to concerns about grade reliability and student well-being.
- Student satisfaction and well-being improved after the switch, but residency outcomes remained unchanged.
- Few institutions tracked other potential impacts of the grading change.

## Abstract

Background

Clinical clerkship grading has a significant and lasting impact on medical students. Recently, there has been a trend towards schools transitioning from multi-tiered to two-tiered grading in the clinical clerkships.

Objective

The goal of this study was to explore the motivation and impact of shifting to two-tiered grading in the required clinical clerkships.

Methods

The authors designed a survey to explore the motivations and impacts of using a two-tiered grading system and disseminated it to educational leaders at institutions that have transitioned from multi-tiered grading, identified through data from the Association of American Medical Colleges (AAMC).

Results

Of the 20 schools identified as utilizing two-tiered grading, curricular leaders at 11 finished the survey, and two additional schools partially completed the survey. Their responses were based on their interpretation of their own institution-specific data. Respondents noted the reliability and validity of grades and student well-being as the most important reasons for switching to a two-tiered system. After implementing two-tiered grading, student well-being and satisfaction with the grading process trended towards improvement at most institutions. Student match rate, number of students in the supplemental match, and number of residency interviews did not change. Other domains cited as reasons for the change to two-tiered grading were not tracked by institutions.

Conclusions

This study suggests that the most common motivation for transitioning to two-tiered grading for the clinical clerkship is concern about grading validity and reliability. While student well-being and satisfaction with grading trended towards improvement after changing to two-tiered grading, there was no formal monitoring by institutions of the other drivers for implementing two-tiered grading which limits further conclusions.