Clerkship Grading, USMLE Step 1, and Student Distinction: A CERA Study

Background and Objectives: The 2022 transition of USMLE Step 1 scoring to pass/fail altered a key metric used by programs to select students to interview for residency. This study explores family medicine clerkship directors’ (FMCDs’) perceptions of how students now distinguish themselves, particularly in relation to clerkship grading methodologies. Methods: Ten questions were included in the 2024 Council of Academic Family Medicine Educational Research Alliance survey, distributed to 173 FMCDs. Items investigated perceptions of student distinction, stress, and grading practices. Statistical analyses included descriptive statistics, Kruskal-Wallis tests, and Wilcox signed-rank tests. Results: Of the 83 respondents (48% response rate), 59% reported using pass/fail grading in the preclerkship phase, while only 22% used pass/fail grading in the clerkship phase. A majority (58%) indicated no changes to clerkship grading systems post-2022, though 20% had changed and 22% were considering changes, predominantly toward less-tiered methodologies. Regarding the impact of Step 1 changes on the students’ ability to distinguish themselves, 37% perceived harm, 14% benefit, and 48% neutrality. Despite this finding, 78% of FMCDs perceived that students were more stressed about distinguishing themselves. No significant associations were found between grading methodology and perceptions of distinction or stress. Conclusions: FMCDs perceived increased student stress following the Step 1 pass/fail transition, yet largely believe that students still can distinguish themselves. Neither tiered nor pass/fail grading was viewed as a definitive solution. These findings underscore the need for standardized, competency-based assessment and clearer communication of distinguishing features in residency applications.