Variation and Imprecision of Clerkship Grading in U.S. Medical Schools

PURPOSE: Despite standardized curricula and mandated accreditation, concern exists regarding the variability and imprecision of medical student evaluation. The authors set out to perform a complete review of clerkship evaluation in U.S. medical schools. METHOD: Clerkship evaluation data were obtained from all Association of American Medical Colleges-affiliated medical schools reporting enrollment during 2009-2010. Deidentified reports were analyzed to define the grading system and the percentage of each class within each grading tier. Inter- and intraschool grading variation was assessed in part by comparing the proportion of students receiving the top grade. RESULTS: Data were analyzed from 119 of 123 accredited medical schools. Dramatic variation was detected. Specifically, the authors documented eight different grading systems using 27 unique sets of descriptive terminology. Imprecision of grading was apparent. Institutions frequently used the same wording (e.g., "honors") to imply different meanings. The percentage of students awarded the top grade in any clerkship exhibited extreme variability (range 2%-93%) from school to school, as well as from clerkship to clerkship within the same school (range 18%-81%). Ninety-seven percent of all U.S. clerkship students were awarded one of the top three grades regardless of the number of grading tiers. Nationally, less than 1% of students failed any required clerkship. CONCLUSIONS: There exists great heterogeneity of grading systems and imprecision of grade meaning throughout the U.S. medical education system. Systematic changes seeking to increase consistency, transparency, and reliability of grade meaning are needed to improve the student evaluation process at the national level.