Title The Pass/Fail Grading System Increases Student Satisfaction and Alleviates Stress Without Decreasing Performance
Clinical Question Among health professions education students, does a pass/fail system for reporting student performance, in comparison to a traditional letter grade (A, B, C, D, F), produce better student outcomes as measured by group cohesion, exam scores, and student satisfaction?
Clinical Bottom Line For health profession students, a pass/fail system for reporting student performance levels was found to better foster cohesive learning, as evidenced by a reduction in student competition and stress levels, without showing a significant difference in exam performance as compared to the traditional letter-grading system. This is supported by cohort studies performed in various medical schools in which the pass/fail system was implemented and found to be superior to traditional grading for group cohesion, exam scores, and student satisfaction by a statistically significant margin. The pass/fail system has been adopted by many medical schools looking to eliminate a discriminatory (i.e., assigns students to A, B, C and D pass levels) performance reporting system in an effort to improve student retention and enhance the learning environment.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
20012686White/2010Second Year Medical StudentsProspective Cohort Study
Key resultsIn this study, two different groups of second-year medical students at the same university who were graded on either a traditional letter (A,B, C, D, F) or pass/fail system (2004/2005 and 2005/2006 respectively) had their performance recorded based on: grades on second year examinations, performance on USMLE Step 1, performance on USMLE Step 2, student satisfaction, and residency placement. The study found a statistically significant difference in 3 out of the 11 curriculum sequences (curricular blocks devoted to organ systems) between the two years (statistical significance was defined as p < .0045). Performance declined upon switching to a pass/fail system in: Cardiology (90.4% in 2004/2005 and 90.3% in 2005/2006, p = .000) and Reproduction (93.9% in 2004/2005, 89.1% in 2005/2006, p = .000). Performance improved on the Renal sequence (89.4% in 2004/2005 and 92.2% in 2005/2006, p = .000). There was no statistically significant difference in performance between the letter grade and P/F cohorts for the other 7 sequences. There were no statistically significant differences in performance between the letter grade and P/F cohorts on the USMLE Step 1 (p = .628) or on USMLE Step 2 (p = .377). When asked about satisfaction with the grading system, students rated traditional grading in year two as 2.96 on a 5-point Likert scale, (5 being most satisfied), while pass/fail students rated that system as 4.64. The investigators also reported that pass-fail students perceived that they had more free time to devote to activities outside of school, with their responses on several inquiry questions ranging from 3.07 to 3.43 on a 4 point scale where 4 = strongly agree. Lastly, there was no statistically significant difference in residency placement between the two classes, either in average rank by residency program directors (p = .817) or number of class members placing in a Top 15 program (p = .814).
17120399Rohe/2006First and Second Year Medical StudentsProspective Cohort Study
Key resultsThe Mayo Medical School altered first-year course grading from the traditional 5-interval grading system (A, B, C, D, F) to a 2-interval pass-fail system for the class of 2006. Students from the previous class of 2005, who were graded using the traditional system, were then compared to students from the class of 2006 at the end of the first and second years on: performance on the USMLE Step 1 (end of 2nd year), perceived stress scale, profile of mood states, perceived cohesion scale, and test anxiety inventory. Results showed that students who were graded with the pass-fail system had a statistically significant lower perceived stress (p = .01) and greater group cohesion (p = .02). They also had a better mood median than the letter-graded group, although this value was not statistically significant. No significant difference was found between the two groups in anxiety during test-taking or performance on the USMLE Step 1 board scores.
24256070Jacobs/2014First year medical studentsProspective Cohort Study
Key resultsThis two-year study follows the effect of changing from the traditional grading system to a distinction/pass/fail system (D/P/F) on first-year medical student exam performance and self-perceived stress levels. At the end of the academic year, first-year medical students were administered a Perceived Stress Scale-10 (PSS-10). Stress measured by the PSS-10 was significantly lower in the student group who were assessed using the D/P/F grading system, while analysis of qualitative responses showed a shift in sources of stress away from competition among peers. There was no statistically significant difference in overall exam performance between the D/P/F and letter-grade groups.
Evidence Search pass[All Fields] AND fail[All Fields] AND grades[All Fields]
Comments on
The Evidence
Validity: All three studies used a large population of students (n > 100) exposed to the same curriculum at the schools they were attending each year that the data was collected. White (2010) and Rohe (2006) provided p-values and exact quantitative values for all statistically analyzed data. There was no reportable or observable bias in any of the studies. Perspective: Overall I found the evidence to be pertinent to assessment and performance reporting in dental school. The evidence was definitely compelling as insight into why more medical schools are moving away from the traditional letter grading system in favor of a pass/fail approach, which appears to foster more cohesion and lower stress without any change in standard measures of academic performance, and notably, no impact on students’ ability to get into residency programs.
Applicability These studies, while exclusively performed in medical schools, could be applied to other health professions education schools, including dental. The evidence might be of interest for schools seeking a way to combat unusually high stress levels, poor peer-interaction, or negative rapport/low satisfaction within their student population.
Specialty (General Dentistry) (Interprofessional CATs)
Keywords grades, performance, dental school, medical school, student performance
ID# 2695
Date of submission 03/31/2014
E-mail malagayo@livemail.uthscsa.edu
Author Marii Malagayo
Co-author(s) e-mail
Faculty mentor William Hendricson
Faculty mentor e-mail hendricson@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
Comments and Evidence-Based Updates on the CAT
None available