By: Robert Englander
“If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.”- Albert Einstein
This quote serves as a constant reminder to me to make sure I understand a problem before attempting to solve it. So today, as I examine a solution-changing from a system with grades beyond pass/no pass (or pass/not yet as Carol Dweck1 would say) to a system of only pass/no pass (not yet), I want to start by trying to understand the issues for which this may be a solution. While the change may have effects on a variety of stakeholders, the key driver for this change is learners, and they will be the focus of my blog.
I would argue that four current issues are precipitating the grade debate: the paradigm shift to competency-based medical education (CBME) and criterion-referenced assessment; student burnout; bias in assessment; and learning theory.
The shift to CBME and criterion-referenced assessment
The paradigm shift from the Flexnerian model of structure/process education, the predominant model in medical education across the globe in the 20th century, to competency based medical education2 was catalyzed by the increasing evidence that physician education and training was not preparing physicians to meet the expanding needs of the public in the 21st century. CBME offered a solution and has been implemented in many jurisdictions across the globe. A result of this shift was a move from norm-referenced to criterion-referenced assessment3. This shift has been hard to make in medical education and training, as we are so used to a highly competitive admissions system for both medical school and residency that begs for ‘ranking’ of learners. The problem is, medical students and residents are not “normally distributed.” They may be normally distributed in their performance on MCATs or standardized licensing exams, but when it comes to demonstrating competence almost 100% of medical students and residents are perfectly capable of reaching the preset criteria! So, the very notion of criterion referenced assessment begs the whole need for grades—set the criteria, make it clear to the learner, and all will “pass” in time. In fact, early evidence in CBME4-5 suggests that the average time for completion will be shorter with a change from structure-process to CBME.
Reducing learner burnout
The second issue for which movement to a pass/fail (not yet) system may be at least a partial solution is the issue of learner burnout. Doctors have the highest levels of burnout of any profession and the origins of this burnout appear to be in medical school and training. In studies across the globe somewhere between a quarter and up to 40% of students report significant symptoms of burnout during some point of their medical school education, using validated scales. Additionally, the physical component of burnout, which often includes fatigue, is associated with decreased ability to learn and retain information. One of the few proven solutions to burnout in undergraduate medical education is going from a graded system to a pass/fail system.6
Mitigating bias in assessment
The third issue stimulating the grade debate is how grades play into bias in assessment. Evidence abounds that biases play a large role in assessment, form broad scale standardized tests to individual workplace-based assessments. McClintock et al present a practical approach to eliminating bias in assessment.7 One of the few mitigating strategies for this bias is the elimination of grades. Even those who use standardized tests, such as SHELF exams in the US, to try to provide “objectivity” to grades, are only substituting the bias in those tests for the bias in clinical performance assessments in arriving at a “grade” for a learner.
Finally, learning is enhanced by the elimination of grades. While some students argue that they are motivated to learn by grades, the learning from external motivators is fleeting, while internal motivation drives long term learning.8 In addition, no one is going to be giving them the “reward” of a high grade in practice. The elimination of grades is a great start to moving from the fixed mindset that grades induce to the growth mindset of continuous formative low stakes assessment.
So it seems to me there is compelling evidence to support the elimination of grades in medical education, and yet a good deal of resistance remains. Two groups drive that resistance: some students/learners themselves, and residency and fellowship program directors seeking ways to “rank” applicants to their programs. The former group is mostly led by those who have traditionally been motivated by grades and highly successful in distinguishing themselves with grades. To these learners, I say it’s time to move away from grades as an external reward and embrace internal motivators for learning, while also recognizing that some of your success has been at the expense of others for whom the grades represented a biased “ranking”. To program directors I say first that what predicts success at one program is likely quite different from what predicts success at another. The ideal would be to rank your applicants on factors that predict success in your program—and I am willing to wager that grades are not a top predictor!
In the end, I struggle to find any remaining compelling arguments to continue with grades in medical education and training, and compelling reasons outlined above to move towards a pass/no pass system. Perhaps ultimately we can work towards the system of pass/not yet introduced by Carol Dweck, as we partner with struggling learners to find better ways to enrich their education and training to find the path to “yet”.
About the author: Robert Englander, MD, MPH, is Associate Dean for Undergraduate Medical Education, at the University of MInnesota Medical School.
1. Dweck CS, The Power of Yet. https://www.youtube.com/watch?v=J-swZaKN2Ic
2. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: from Flexner to competencies. Acad Med. 2002 May; 77(5):361-7.
3. Pereira AG, Woods M, Olson APJ, van den Hoogenhof S, Duffy BL, Englander R. Criterion-Based Assessment in a Norm-Based World: How Can We Move Past Grades? Acad Med. 2018 Apr;93(4):560-564.
4. Nousiainen MT, Mironova P, Hynes M, Glover Takahashi S, Reznick R, Kraemer W, Alman B, Ferguson P; CBC Planning Committee. Eight-year outcomes of a competency-based residency training program in orthopedic surgery. Med Teach. 2018 Oct; 40(10):1042-1054.
5. Andrews JS, Bale JF Jr, Soep JB, Long M, Carraccio C, Englander R, Powell D; EPAC Study Group. Education in Pediatrics Across the Continuum (EPAC): First Steps Toward Realizing the Dream of Competency-Based Education. Acad Med. 2018 Mar;93(3):414-420.
6. Reed DA, Shanafelt TD, Satele DW, Power DV, Eacker A, Harper W, Moutier C, Durning S, Massie FS Jr, Thomas MR, Sloan JA, Dyrbye LN. Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: a multi-institutional study. Acad Med. 2011 Nov; 86(11):1367-73.
7. McClintock AH, Fainstad T, Jauregui J, Yarris LM. Countering Bias in Assessment. J Grad Med Educ. 2021; 13 (5): 725–726.
8. Center for Self-Determination Theory: http://selfdeterminationtheory.org/
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