The Case to Abolish Medical School Grades

Competition in medical school and residency has been getting a bad rap. Systemic issues are being highlighted, USMLE Step 1 is becoming pass/fail, and some propose we abolish medical school grades entirely. Let’s separate the signal from the noise, and explore the reality of competition in the medical training system.

In recent years, there has been an increased focus on the competitive nature of medical school and its downsides. The line of thinking argues that high degrees of competition lead to increased stress, resulting in burnout and depression, which is the driving force of the mental health epidemic amongst medical trainees.

Many point to abolishing the numerical score for USMLE Step 1 as a big step in the right direction. They argue this should reduce the overwhelming stress students face given its importance in the residency selection process. Plus, the students who earned a seat in medical school have already proven themselves. They’re smart enough, so do we really need grades or scores at all?

The Scapegoat – Medical School Grades, USMLE Step 1, & Competition

What’s being pushed is an overly simplistic view of the problem with a half-baked solution. It’s addressing a symptom rather than the root cause.

First, the burnout and depression epidemic is the most important issue, but it’s not due to grades or USMLE Step 1. It’s something I deeply care about and is highly relevant to both doctors and patients alike – I’ve spoken about it many times and even created the #SaveOurDoctors initiative to raise awareness. But well-intentioned medical students and residents are pointing at USMLE Step 1, grades, and other downstream effects and not recognizing the root issue.

The problem isn’t actually grades or USMLE, but rather the culture of medicine. USMLE Step 1 becoming pass-fail doesn’t change anything in the big picture. Sure, you’re less stressed as a medical student about Step 1, but guess what, residencies still need cutoffs. Now they’ll be putting greater weight into USMLE Step 2CK, or perhaps clinical grades or shelf exam scores, and you’ll be more stressed about each of those. In making Step 1 pass/fail, you don’t fix the problem, you just shift it. We’re playing whack-a-mole.

I recently came across an article on KevinMD, written by a current medical student, putting forward the case to abolish medical school grades. The author argues that “grades feed competition which feeds students’ lack of self-worth, which threatens future doctors’ compassion for patients, and so on.” To me, this seems to be more of an issue with the author’s relationship to competition and self-worth rather than a logically sound argument of the relationship of competition to practicing medicine compassionately.

During the third and fourth year in medical school, also known as the clinical years, medical students receive most of their education through clinical rotations in the hospitals. As he explains, “when I was a third-year student completing core clerkships, I found myself approaching each of my patients as a determinant in ‘how I would do’ in a given clerkship. Imagine you are a patient, and your medical student front-line provider is sticking you with a butterfly needle three, maybe four times in desperate search for a flash because they want their resident to know how ‘competent’ they are.”

The goal in medical school is to learn extensively and become the best future doctor you can be. In focusing on this as your primary goal during your clinical rotations, you’ll end up getting favorable evaluations. If you find yourself so stressed about your grades that you’re sticking a patient four times to draw blood, you should first go back to basics and practice. And second, you should examine your relationship with your clerkship evaluations because maintaining this attitude will compound and become dangerous for both yourself and your patients the further along you go in medical training.

The issue with blaming grades or competition is that it lacks deeper thought on the second and third-order effects. By removing grades, how will medical schools ensure that their students are studying and learning to a sufficient capacity to become competent physicians? How will residency programs select between candidates?

Large swaths of society have been shifting toward the “everyone is a winner” philosophy. Sure, we’re all equally valuable as human beings, but that doesn’t mean we each have to be a winner in everything we apply ourselves in. Imagine if I raced Michael Phelps in the swimming pool and we both received equivalent blue ribbons because everyone’s a winner. It’s a slippery slope and dangerous way of thinking when people focus on equal outcome, as opposed to equal opportunity. The two are very different and should not be confused.

Life is competitive and life is hard. Trying to shield ourselves from this truth isn’t doing ourselves any favors. Just because losing doesn’t feel good doesn’t mean we must abolish losing altogether. There’s value in both winning and losing in the swimming pool, or in any competition, just as there is value in excelling or falling short in the classroom.

During my time in medical school, I worked my tail off. I didn’t relax as much as most of my classmates. I studied harder and spent less time relaxing and having fun because I wanted to get into something competitive like plastic surgery. One of my good friends, on the other hand, had decided on family medicine. Since the first day of class, he had also maintained that life is short and he didn’t want to sacrifice his work-life balance for getting higher grades in class or scoring higher on Step 1. We were two people with two different approaches to medical school — neither approach was right or wrong. We simply had two different priorities. By the end of medical school, I had stronger preclinical and clinical grades, a higher USMLE score, more publications, and I was a stronger residency candidate. Again, neither is right or wrong, it’s simply a tradeoff. He probably enjoyed medical school more and definitely had a less stressful and more balanced life, but I was a more compelling applicant for something like plastic surgery.

If you want to reduce competition, it needs to be less competitive to secure a residency position. To do that, we must open more residency positions. The greater the discrepancy there is between the number of medical school graduates and residency positions, the greater the degree of competition. Making USMLE pass/fail or abolishing grades doesn’t remove the fact that residencies need to rank and filter applicants for a limited number of positions.

Two Mentalities – Empowered vs Victim Mindsets

Life is hard, and life isn’t fair. There are two mindsets through which we can approach the current dialogue:

Option 1 is to point the finger at other people and systemic failures for your problems. You lament that if only X and Y were different, then you’d be successful or happy.

Option 2 is to be proactive, make the most of the situation, and even help move the needle and spark change in productive ways.

The student that subscribes to option 1 is dissatisfied with his academic performance and complains that grades cause him to be stressed. The student that subscribes to option 2 questions why he isn’t achieving the marks he desires and seeks out ways to improve his study strategies or test-taking skills.

The student with a victim-mindset seeks to quash discomfort and negativity in his life by changing the world around him without examining himself. The student with an empowered-mindset understands it is far more effective to improve and adapt himself first. Only then can he best assess the situation around him and begin working towards meaningful change.

We need more people who are willing to speak out against the cultural issues in medicine. Physicians are who we look to for guidance on how to live healthier lives, yet many physicians lead terribly imbalanced lives themselves. We can only do so much through our own efficiency and optimization, yet we continue to propagate an antiquated training culture that does more harm than good. Knowing what we know about sleep, why is it the norm to be sleep deprived beyond belief in medical school clerkship rotations and residency? By using loopholes like home call, residents are often expected to work for 30 hours straight or longer, and then expected to return back the next day after less than 18 hours off. And yes, I’ve had to do that more times than I would like to admit. Are grades really the issue, or are there bigger issues that deserve more attention?

On the other hand, we shouldn’t fool ourselves into thinking that all medical students or residents have the same priorities, same work ethic, or same level of mastery. Not everyone needs to work their tail off to be a great physician, but those who are willing to make the sacrifices and work harder will continue to outshine those who don’t, regardless of what metrics are used to assess residency candidacy.

Decide on what it is that you want to optimize for. For those that want to match into something hypercompetitive like dermatology or plastic surgery, yes, you’ll certainly have to work harder. But even if you’re going into something less competitive like pediatrics or family medicine but want to match at prestigious academic programs like UCSF or MGH, you’ll have to work harder than your colleagues who are perfectly content going to a community program. One isn’t better than the other – it all depends on your value system and what you prioritize.

Whatever you decide, my mission with Med School Insiders is to help you realize that dream. We’re in this to create a generation of happier, healthier, and more effective future doctors. And I’m not afraid to show you some tough love if you complain grades are evil and causing you to lose compassion for your future patients. Maybe you don’t want to be at the top of your class, but by honing your study strategies and time management, you’ll save a couple of hours every day which means you can explore other hobbies, or be a gunner and put that extra time into securing some publications. If you want to go into neurosurgery but don’t consider yourself the smartest, understand that it’s not about how smart you are, it’s about how intelligently you approach studying, time management, and effort allocation.

In summary, it’s important we question the medical training establishment and seek to improve it in meaningful ways. At the same time, we must be careful not to fall into a victim mentality and always maintain an empowered frame.