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Study: Clerkship Grading Varies 'Dramatically' at U.S. Medical Schools

One medical student describes rotation grading practices as “horrendously subjective.”

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M.D. students on rotation face a "dramatic variation in grading practices" at medical schools across the country, according to a new study from researchers at Brigham and Women's Hospital, a Harvard Medical School teaching affiliate. 

The study, "Variation and Imprecision of Clerkship Grading in U.S. Medical Schools," will appear in the August volume of the journal Academic Medicine. It examined 119 of the 123 accredited U.S. medical schools

U.S. medical schools have eight different grading systems, 27 "unique sets of descriptive terminology," and recognitions, such as "honors," often mean different things at different schools, according to the study. Researchers also discovered "extreme variability"—a range from 2 percent to 93 percent—in the number of students who earned a top grade for clerkships, another name for rotations. And nationally, fewer than 1 percent of students failed a required clerkship, the study found. 

The study demonstrates, for the first time, the "widespread heterogeneity and imprecision in grading systems and grade meaning" in the U.S. medical education system and serves as a "call for improvement," says Erik Alexander, the director of medical student education at Brigham and Women's and the lead author of the study. 

[Learn how to go to medical school for free.] 

"Current and future medical school applicants should consider these data as part of their application and decision process," Alexander says. "Globally, students should be concerned that this lack of consistent meaning to their evaluations ... may contribute to uncertainty or, perhaps, confusion, as to how their transcript is viewed elsewhere when applying for future training programs, or by their state medical licensure board." 

Medical students spend a lot of time and money learning the knowledge and skills of doctoring, yet the study indicates that medical school evaluations "may, at times, not transparently and accurately reflect students' individual attributes or accomplishments to the extent desired," Alexander says. 

That's why applicants should ask admissions officials at their prospective medical schools about their evaluation standards, particularly when it comes to clinical clerkships, Alexander adds. 

One way students can navigate confusing grading standards is to keep track of as many factual and easily documented achievements as possible—such as quality and quantity of patient interactions, sample patient notes (with patient information redacted), and senior physician evaluations—so that their résumés are easy to interpret, says Mike Moore, a fourth year medical student at Pacific Northwest University of Health Sciences in Yakima, Wash. PNWU officials assemble portfolios of student work for that purpose, and the school doesn't issue honors for rotations due to "honors inflation," Moore says. 

[Learn why med schools disavow classics programs' claim as road to M.D.'s.] 

But Moore doesn't think the Brigham and Women's study is anything new. 

"I'm not sure if it is anything that we do not already know," he says. "The 'grades' during clinical clerkships are horrendously subjective. They are typically oriented on personal interactions with a preceptor, and therefore not necessarily indicative of how well an individual student is doing in mastering the core clinical knowledge of being a physician." 

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