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What does “Honors” mean? Depends where you go to school. Variation and Imprecision of Clerkship Grading in US Medical Schools. Alexander EK et al. Academic Medicine 2012;87(8):1-7

Reviewed by Patricia Kavanagh

What was the study question?
To what extent is there variability and imprecision in clerkship grading in U.S. medical schools?

How was the study done?
Researchers from Brigham and Women's Hospital in Boston, MA collected grading data from all U.S accredited medical schools for the year 2009-2010 for six core third year clerkships: medicine, surgery, pediatrics, obstetrics/gynecology, psychiatry and family medicine. Data were abstracted from the Medical Student Performance Evaluation (formerly known as the Dean's letter) provided by each medical school or through personal communication (n=1). The type of grading system for each school and distribution of grades for each clerkship were compiled.

What were the results?
Data were collected from 119/123 (97%) of medical schools, and 110/119 provided the grading distribution by clerkship. Among these schools eight grading systems, using 27 different sets of terminology, were identified, ranging from 2 to 11- tiers, with the 4-tier system most commonly used (63/119). Both letter (e.g. A) and descriptive (e.g. Honors) systems were used. Within the descriptive system, the same word had different meanings across institutions. For example, "Honors" was the top grade at some schools, but reflected second-tier grading at others (below "High Honors"). In the same way, a grade of "B" indicates the second highest grade at some schools and the third or fourth highest at others. Ninety-seven percent of students received one of the top three grades and less than 1% failed a required clerkship. Excluding schools using the pass-fail system, 30/113 (27%) had 2 or more clerkships in which the percentage of students receiving the top grade differed by more than 30%.

What are the implications of these findings?
Over the last century, curriculum and training methods have become increasingly standardized yet significant variation of assessment methods persist within and across U.S. medical schools. We have all heard medical students' concerns about their grades, and these results support their claims that grading methods are inconsistent. Furthermore, this variation complicates the work of intern selection committees as they determine the strengths and weaknesses of each student.

Editor's note: This study represents an ambitious initiative that has started a meaningful conversation about grading. The authors wonder why the LCME - which mandates that certain areas of the curriculum be standardized - does not recommend a single, consistent grading system. Argue Durning and Hemmer in an insightful commentary in the same issue of Academic Medicine (2012;87:1002-1004.), "we do not believe that stricter regulatory restrictions are the a good answer… We believe that what is needed is more credible and transparent interpretation of what grades mean, not inflexible regulatory grade distributions." Durning and Hemmer also distinguish between normative and criterion-based grading systems and argue that there is nothing wrong - and perhaps something very right and good - with most students achieving a high grade in a criterion-based grading system. (SLB)

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