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Old School Grading in Post Graduate Education.

By Chris Rangel MD ⋅ October 5, 2005 ⋅  Email this post ⋅  Print this post ⋅ Post a comment

The ABC grading system stands for ArBitrary Crap!

I was saddened to see that my ‘ol alma mater the University of Texas Southwestern Medical School at Dallas is still using the crusty “ABCDF” grading system. Someone who identified themselves as a first year Southwestern medical student posted a message online (via Enrico) that makes it clear that this grading system is still a stress point at UTSW.

“At a lunchtime meeting today with the first year medical students at UT Southwestern, Dean Gilman announced that a new, heretofore unannounced grading paradigm would be in effect for this year’s incoming medical students. The dean explained that the objective of this change is to create a wider distribution of grades among students.

The details of the plan were not revealed, however, Dean Gilman stated that he discourages the testing of minutiae as a way to achieve a spread in grades. When questioned, the dean also disapproved of using normalized distributions as a way to achieve grade spread, in spite of the fact that at least one professor has specifically stated such.”

Translation; UTSW students get far too many “A’s” and no, that’s not because the grading is easy. UTSW medical students are on average very intelligent, very motivated, and excellent studiers and test takers (which does not explain how I got into UTSW). So the majority of grades in many classes would be A’s without the use of such gimmicks like adding a few super-hard “minutiae” questions to tests or mandatory grade distributions. Even then the difference between an A and a C student could be literally a scant few missed questions on a single test.

“When students raised the issue that the new paradigm will introduce an element of unwanted competition between colleagues, the dean encouraged them to cultivate a class personality of cooperation. After all, he explained, the practice of medicine is a team sport.”

Obviously such ABC grading systems are at odds with what should be a very cooperative and harmonious learning experience to enter into a profession that requires a lot of communication and cooperation among peers. It doesn’t help to foster a sense of “team sport” when you tell a group of naturally very competitive individuals that no matter how well they do not everyone will be able to get an A.

“Notably, when students at the meeting pointed out that they might have made different admissions decisions had it been known that a new, competitive grading paradigm would be implemented this year, the details of which have not been specified, the dean admonished them, ‘Life’s a bitch, and then you die.’”

So far I have not confirmed that this meeting actually occurred or that interim medical school dean Dr. Alfred Gilman (who shared the 1994 Nobel Prize in Physiology/Medicine) uttered those confidence inspiring words. Yet the problem of the ABC grading system in unnecessarily creating an atmosphere of stress and competition remains at UTSW.

The alternative to a four or five interval traditional “ABC” grading system is a basic Pass/Fail system. There has been a great amount of debate about this since the 1960’s when data started to come out that showed little correlation between grades (ABC or D) and job performance. However, in the last few years, 17 of the 23 top rated medical schools in the US had switched to a pass/fail or honors/pass/fail system. Only four of these schools still use the old ABCDF system including UTSW.

In 2002 Johns Hopkins Medical School switched to a pass/fail system. It was a decision I applauded and which others criticized. Among the concerns about changing to a Pass/Fail system are;

1. Students would “slack off” and do only what is necessary to “get by” in a Pass/Fail system: There is no evidence that this occurs. Several studies (FAQ #3) have found that there is no difference in test performance of medical students in changing from a traditional to a Pass/Fail grading system.
2. Board scores will fall: Harvard Medical School switched to Pass/Fail in the early 70s but changed back to the old ABC system when board scores for it’s students fell. However they found that this was due to drastic curriculum changes at the time and the system was again changed to Pass/Fail in the mid 80’s and has remained such ever since. Harvard remains the most elite of elite medical schools even with a Pass/Fail grading system! Though less studied, there is no evidence that a Pass/Fail system would result in decreasing medical board scores (FAQ #6).
3. A Pass/Fail system would hurt student’s chances of getting into highly competitive residency programs: Multiple studies (FAQ # 11) have found that residency program directors consistently rank medical school preclinical grades (during the first two years) as among the least important factors in evaluating applicants. The most important factors include board scores, third year clinical clerkship grades, and medical school reputation. This last part is important. If you are good enough to get into a good medical school then why should your medical school grades matter as long as you pass the requirements of the classes and clerkships?

Opponents of a Pass/Fail system (or some derivation thereof) in medical school appear to have three general areas from which they draw their arguments.

1. The ABCDF system is traditional: This is the same hollow argument as that of your grandfather who tells you that when he was your age he had to walk 20 miles to school, barefoot, in the snow, uphill both ways! This is not a good argument for a profession that regularly sees ground breaking studies come out that fundamentally change the way we practice medicine.
2. The elitist argument: This is the idea that a Pass/Fail school is somehow inferior academically to other schools. Considering the fact that 17 out of the 23 top ranked medical schools (including Harvard and Yale) use some form of the Pass/Fail system, this argument makes one look like an idiot rather than an elitist.
3. The macho/wimp argument: This is the idea that a Pass/Fail system yields to the wimpy liberal ideals of cooperation, diversity, tree hugging, self-taught-Montessori style medical education and that the ABCDF system is a take no prisoners, boot camp, survival of the fittest system that separates the men from the boys. The practice of medicine is a cooperative rather then a competitive system. Physicians are not fortune 500 company executives locked in an ultimate episode of survivor. Students who savor such a system should consider looking elsewhere to satisfy their need for competition.

My ultimate argument is simple. Medical schools have extremely high admission standards and extremely high pass/fail requirements in all classes and clerkships. After so much hard work and sacrifice to get into medical school it is ridiculous and insulting for medical students to have to compete in a grading system that further sub-divides their efforts into being the best of the best (A), the middle of the best (B), or the worst of the best (C) when such distinctions are very close to each other and have little if any baring on how good a physician they become or what residency the get into. The ABCDF system exists only because it is traditional, it serves to feed egos, and it’s macho in a traditionally macho profession.