Pass/Fail, Honors or Letter Grades? Understanding Medical School Grading in 2027

Grades may feel like one of the biggest concerns when comparing medical schools, but the system is not the same everywhere. One school may use pass/fail grading throughout the preclinical years, while another may award honors or letter grades during clerkships.

No grading system automatically produces better doctors or guarantees stronger residency outcomes. What matters is understanding how your school evaluates performance, how those results appear on your transcript and which learning environment helps you perform at your best.

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What Grading Systems Do Medical Schools Use?

Most medical schools use one of four approaches:

• Pass/fail
• Tiered pass/fail
• Traditional letter grades
• A hybrid system combining different approaches

The AAMC’s guide to what students can expect in medical school confirms that grading varies considerably. Some schools use pass/fail, others use honors/pass/fail or letter grades, and many change systems between the preclinical and clinical phases.

Pass/Fail Grading

Under a true pass/fail system, students receive one of two results:

• Pass
• Fail

Students must meet a defined academic standard, but those who pass are not separated into additional grade categories.

This system is most common during the preclinical phase, when students study subjects such as anatomy, physiology, pathology, pharmacology and biochemistry.

Potential advantages

• May reduce unnecessary competition
• Encourages collaboration
• Allows students to focus on understanding rather than small grade differences
• Can create more time for research, service and personal wellbeing
• Aligns with the pass/fail format of USMLE Step 1

Potential drawbacks

• Students may find it harder to judge their performance relative to classmates
• Residency programs receive less academic differentiation
• Other measures may carry greater weight
• Some students may feel less externally motivated

Pass/fail does not mean that the curriculum is easy. Students still need to meet competency standards, complete examinations and remediate unsuccessful coursework.

Tiered Pass/Fail Grading

Tiered systems divide passing performance into several categories, commonly:

• Honors
• High Pass
• Pass
• Fail

Some schools use different names, such as Outstanding, Excellent, Satisfactory and Unsatisfactory.

Tiered grading is especially common during clinical clerkships because it allows schools to recognize different levels of performance without using traditional letter grades.

A clerkship grade may consider:

• Clinical evaluations
• Subject examinations
• Patient presentations
• Professionalism
• Clinical reasoning
• Written assignments
• Attendance
• Participation

Students should ask how much each component contributes to the final result. At some schools, standardized examinations carry considerable weight. At others, clinical evaluations have a larger influence.

Traditional Letter Grades

Traditional systems use grades such as:

• A
• B
• C
• D
• F

Some medical schools calculate a GPA, while others record letter grades without producing a traditional cumulative average.

Potential advantages

• Provides clear performance categories
• May motivate students who prefer structured academic targets
• Gives residency programs another way to compare applicants
• Is familiar to most students
  
  

Potential drawbacks

• Can increase stress and competition
• Small score differences may produce different final grades
• Students may focus on grades rather than mastery
• Curves can make performance dependent on classmates

Letter grades may appeal to students who perform well under clearly defined academic competition, but they can feel unnecessarily intense to students who thrive in collaborative environments.

Hybrid Grading Systems

Many medical schools use a hybrid approach.

A common structure is:

 
This approach allows students to focus on foundational learning during the early years while giving residency programs more detailed information about clinical performance later.

Some schools also use competency-based assessment, where students are evaluated according to their progress in areas such as patient care, medical knowledge, communication, professionalism and teamwork. The AAMC notes that a small number of schools use systems focused primarily on progression across defined competencies.

Why Did Medical Schools Move Toward Pass/Fail?

One reason is the growing recognition that intense academic competition can affect student wellbeing and discourage collaboration.

Pass/fail grading may allow students to:

• Share study resources more openly
• Support classmates
• Focus on long-term understanding
• Explore research and community service
• Seek help without feeling that every small weakness will affect class rank

The shift also reflects broader changes in medical education, including competency-based assessment and the move of USMLE Step 1 to pass/fail reporting, which took effect for examinations administered on or after January 26, 2022.

However, removing grades does not remove evaluation. Clinical performance, Step 2 CK, recommendations, research, interviews and the Medical Student Performance Evaluation may become more important when preclinical grades offer limited differentiation.

How Does Grading Affect Residency Applications?

Residency programs do not evaluate medical school grades in isolation.

The NRMP Program Director Survey examines the factors programs use when selecting applicants for interviews and creating rank lists. These factors extend beyond grades and include clinical performance, examinations, recommendations, professionalism, experiences and interview impressions.

Residency reviewers may consider:

• Core clerkship performance
• Specialty-specific rotations
• USMLE Step 2 CK
• Letters of recommendation
• Medical Student Performance Evaluation
• Research and scholarly work
• Professionalism
• Personal statement
• Interview performance
• Alignment with the program

The NRMP has also highlighted the growing use of holistic review, in which program directors consider applicant experiences and attributes alongside academic measures.

Does Pass/Fail Hurt Your Residency Chances?

Not automatically. Residency programs are accustomed to reviewing applicants from schools with different grading systems. Medical schools explain their assessment methods in the transcript and Medical Student Performance Evaluation so that reviewers can interpret student performance in context.

A pass/fail student can still build a strong residency application through:

• Excellent clerkship evaluations
• Strong specialty electives
• A competitive Step 2 CK result
• Meaningful recommendations
• Research where relevant
• Leadership and service
• Strong interview performance

The impact may be more noticeable in competitive specialties because programs need ways to distinguish between many academically strong applicants. Even then, the grading system itself matters less than how effectively you perform within it.

Why Clinical Grades Can Feel Subjective

Clinical clerkships are evaluated differently from classroom courses.

Your grade may depend partly on observations from residents, attending physicians and other members of the healthcare team. This can introduce variation because students may work with different supervisors, patient volumes and clinical cases.

Clinical advisors often recommend asking for feedback throughout a rotation rather than waiting until the final evaluation.

Useful questions include:

• What am I doing well?
• Where am I performing below expectations?
• How can I improve my patient presentations?
• Am I demonstrating appropriate clinical reasoning?
• What should I focus on before the end of the rotation?

Documenting feedback and acting on it can improve both performance and professional growth.

What Does Remediation Mean?

Remediation occurs when a student does not initially meet the requirements of a course, examination or clinical rotation and must complete additional work.

This might involve:

• Repeating an examination
• Completing additional assignments
• Repeating part of a course
• Repeating a clinical rotation
• Participating in academic support

The way remediation appears on a transcript varies by school. Applicants should ask whether both the original result and the successful remediation are recorded.

One unsuccessful assessment does not necessarily prevent a student from progressing or matching into residency. However, repeated academic or professionalism concerns may require a clear explanation and evidence of improvement.

How to Compare Grading Systems Between Medical Schools

Before choosing a medical school, ask:

• Is preclinical grading true pass/fail?
• Are passing students internally ranked?
• Are clerkships graded or pass/fail?
• How are honors awarded?
• Is there a class rank?
• Does the school use Alpha Omega Alpha membership?
• How are clinical evaluations standardized?
• How does remediation appear on the transcript?
• What information appears in the MSPE?
• Are electives graded differently from core rotations?

The AAMC Medical School Admission Requirements database includes curriculum information that can help applicants compare individual schools.

The AAMC is also reviewing how the MSPE should evolve as grading systems become increasingly varied, partly because residency programs need clearer and more consistent information about applicants.

Which Medical School Grading System Is Best?

There is no universally best system.

A true pass/fail curriculum may suit you when you value:

• Collaboration
• Lower academic competition
• Flexibility
• Mastery-focused learning

A tiered or letter-grade system may suit you when you prefer:

• Clear performance targets
• Frequent academic differentiation
• Competitive motivation
• A direct way to demonstrate strong performance

Also consider whether a school is transparent about assessment. A program described as pass/fail may still use internal rankings or performance categories in recommendation documents.

When speaking with current students, ask how the system operates in practice, not only what the website calls it.

Do Not Choose a School Based on Grading Alone

Grading matters, but it should be considered alongside:

• Curriculum
• Clinical training sites
• Student support
• Cost
• Location
• Mentorship
• Research
• Residency outcomes
• School culture

A pass/fail school may still have a stressful environment. A school with graded clerkships may have supportive faculty and strong collaboration.

The better question is: Will this school’s complete learning environment help me grow and perform well?

How Clinical Experience Can Prepare You

Students who enter medical school with meaningful clinical exposure may feel more comfortable with patient communication, hospital routines and multidisciplinary teamwork.

Through Go-Elective’s Medical Internships Abroad, participants gain supervised exposure to healthcare settings while exploring the realities of clinical learning.

Our participants often tell us that observing ward rounds, professional communication and teamwork helped make the transition from classroom learning to clinical environments feel less unfamiliar.

These experiences do not replace medical school training, but they can help students develop maturity, cultural awareness and a clearer understanding of the profession.

Conclusion

Medical schools use pass/fail, tiered pass/fail, letter grades and hybrid systems. Each approach has strengths and limitations.

Pass/fail grading may encourage collaboration and reduce competition, while tiered or traditional systems provide clearer academic differentiation. Residency programs understand that schools assess students differently and evaluate grades alongside clinical performance, Step 2 CK, recommendations, experiences and interviews.

When comparing medical schools, look beyond the name of the grading system. Ask how students are ranked, how clerkships are assessed, how feedback is provided and how results are communicated to residency programs.

The best system is the one in which you can learn effectively, remain supported and demonstrate consistent growth.

Frequently Asked Questions

#1. Are most medical schools pass/fail?

Many medical schools use pass/fail during at least part of the curriculum, particularly the preclinical phase. Others use tiered pass/fail, letter grades or a hybrid system.

#2. Does pass/fail grading make medical school easier?

No. Students must still meet rigorous academic and clinical standards. Pass/fail changes how performance is reported, not necessarily how difficult the curriculum is.

#3. Do residency programs prefer letter grades?

Residency programs review applicants from many grading systems. They use transcripts alongside clinical evaluations, Step 2 CK, recommendations, the MSPE, experiences and interviews.

#4. What is tiered pass/fail grading?

Tiered pass/fail separates passing performance into categories such as Honors, High Pass and Pass, with Fail for students who do not meet requirements.

#5. Can you match into a competitive specialty from a pass/fail school?

Yes. Strong clinical performance, specialty electives, Step 2 CK, recommendations, research and interview performance can help distinguish an applicant.

#6. How can I find a medical school’s grading system?

Review its official curriculum page and the AAMC MSAR database. Ask admissions or current students when the information is unclear.

Article Details

Categories

Recent Articles , Med Schools, Pre-health,

Author: Tatina Himes

Date Published: Aug 26, 2026