The subject of whether pass/fail grading affects chances of matching into residency among medical students is grounded in over four decades of research. To understand how grading systems work, read what is a passing grade in college, then in this article we will compare how medical schools apply it differently.
The rapid changing trends in medical school landscape bring about complexity, making it challenging to give a yes/no answer. In this article, we debunk what other studies have found and draw a conclusion on whether it truly affects or not.
Research Findings on Pass/Fail and Residency Matching
The concern that pass/fail grading disadvantages students in the residency match is not new. It dates back to at least the 1970s and has been debated in medical education circles since then. A systematic literature review by Spring et al(2011) examined 1980-2010 available research on the topic and found no statistical difference.
Across the nine studies they reviewed, students from pass/fail grading systems performed comparably to their letter-graded peers on objective measures including USMLE Step 1 and Step 2 scores, pre-clinical grade point averages, clerkship performance, and quality of residency programmes obtained.
While it was discovered that students from pass/fail schools perform just as well objectively, some residency programme directors have historically preferred applicants from tiered grading systems. Dietrick et al. (1991) surveyed 302 US general surgery programme directors and found that 81% believed that a student's ability to compete for a residency position was adversely influenced by pass/fail evaluation.
Similarly, Provan and Cuttress (1995) found that 66% of programme directors in Ontario felt that students from pass/fail schools would be at a disadvantage compared to those from letter-graded or numeric grading systems.
This is the reason the debate persists and the problem has never been about student performance but information availability.
The USMLE Step 1 Change
In january 2022, the USMLE Step 1 examination transitioned from a three-digit numerical score to a simple pass/fail outcome. For decades, Step 1 had served as the most important screening tool for residency programme directors.
According to the 2021 NRMP Programme Director Survey, 86.2% of programme directors listed the Step 1 score as an important factor in deciding who to interview thus making it the most endorsed academic criterion in the entire selection process.
With that numerical anchor removed, the landscape of residency selection changed fundamentally for every medical student and not just those at pass/fail schools.
What Programme Directors Are Now Prioritising
Research conducted in the wake of the Step 1 change found that 88.4% of programme directors reported that binary Step 1 scoring would increase the emphasis placed on USMLE Step 2 Clinical Knowledge scores.
83.6% stated they would require Step 2 results at the time of application. More than half also indicated that medical school reputation would become a more significant factor in their evaluations.
This shift means that students from pass/fail grading systems are no longer uniquely disadvantaged by the absence of numerical data. Every applicant now faces the same situation regarding Step 1.
What distinguishes candidates now includes Step 2 Clinical Knowledge scores, clerkship grades, letters of recommendation, research productivity, honour society membership, and interpersonal skills assessed during interviews. For students at pass/fail schools, this leveled playing field represents an opportunity rather than a liability.
The Rise of Research and Holistic Review
Research productivity increases significantly among applicants, with more abstracts, presentations, and publications being submitted. Programme directors in that specialty increasingly prioritised holistic factors such as interpersonal skills, faculty interactions, and letters of recommendation — trends consistent with what is being reported across other competitive specialties.
For students in pass/fail programmes, this matters. The time freed from grade competition — time that research consistently shows pass/fail students use for extracurricular engagement, volunteering, and research may now translate directly into a stronger, more competitive residency application.
Significance of The Wellbeing Dividend
One dimension of the pass/fail debate that is often underappreciated in conversations about residency matching is student wellbeing. It is tempting to treat this as a personal benefit divorced from professional outcomes. But the evidence suggests they are closely connected.
The Spring et al. (2011) review found that all four studies examining wellbeing in the context of pass/fail grading reported improvements in at least some measured areas — including reduced stress and anxiety, improved satisfaction with the learning environment, better overall mood, and greater group cohesion among students. Some studies also found that switching to pass/fail grading in the first two years of medical school significantly improved psychological wellbeing without any decline in academic performance, residency placements, or board scores.
Burnout, Collaboration, and the Making of a Better Doctor
To prepare for a successful career in the medical field, students in med and nursing programs spend more study hours above average of other students in other courses. As a result, burnout is common among these learners.
Medical student distress is well documented. Dyrbye, Thomas and Shanafelt (2006) conducted a systematic review of depression, anxiety, and psychological distress among US and Canadian medical students, their findings confirm that rates of distress among medical students significantly exceed those of the general population. Consequences include reduced empathy, academic dishonesty, impaired clinical performance, and in severe cases, substance abuse and suicide.
Pass/fail grading, by reducing the pressure to perform for a grade rather than to learn for mastery, has been shown to foster greater collaboration and intrinsic motivation (White and Fantone, 2010). These are not incidental benefits. They support the development of the professional character that residency programme directors and ultimately patients need from the next generation of physicians.
Many studies have concluded that pass/fail grading systems and collaborative learning approaches appear protective for student wellness. The Association of American Medical Colleges (AAMC) has similarly recommended that medical schools consider pass/fail grading as part of a broader set of mental health support strategies for students.
Conclusion on Pass/Fail Grading System
The honest answer, drawn from the evidence, is: not as much as historically feared, and in the current landscape, possibly not at all. The objective research does not support the idea that pass/fail grading reduces academic performance or undermines residency outcomes. Where the concern had genuine merit — in the subjective preferences of individual programme directors for numerical differentiation — the playing field has been substantially levelled by the 2022 Step 1 change.
What matters now is how you build your application in the absence of traditional numerical differentiators. Strong Step 2 Clinical Knowledge scores, meaningful research contributions, excellent clerkship performance, and compelling letters of recommendation carry more weight than ever. The same principles that make a strong college admission essay — communicating who you are beyond your grades — apply equally when crafting your residency personal statement. Students in pass/fail programmes who use the reduced competitive pressure wisely — investing time in clinical experience, research, and genuine professional development — may find themselves better positioned for residency than those who spent pre-clinical years optimising for a single score.
The question was never really whether your grading system defines you. It was always what you do with the time and freedom it gives you.
References
- Spring, L., Robillard, D., Gehlbach, L., & Moore Simas, T.A. (2011). Impact of pass/fail grading on medical students' well-being and academic outcomes. Medical Education, 45(9), 867–877. https://doi.org/10.1111/j.1365-2923.2011.03989.x
- Bloodgood, R.A., Short, J.G., Jackson, J.M., & Martindale, J.R. (2009). A change to pass/fail grading in the first two years at one medical school results in improved psychological well-being. Academic Medicine, 84(5), 655–662.
- Dietrick, J.A., Weaver, M.T., & Merrick, H.W. (1991). Pass/fail grading: a disadvantage for students applying for residency. American Journal of Surgery, 162(1), 63–66.
- Provan, J.L., & Cuttress, L. (1995). Preferences of programme directors for evaluation of candidates for postgraduate training. CMAJ, 153(7), 919–923.
- Dyrbye, L.N., Thomas, M.R., & Shanafelt, T.D. (2006). Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Academic Medicine, 81(4), 354–373.
- Dyrbye, L.N., Thomas, M.R., & Shanafelt, T.D. (2005). Medical student distress: causes, consequences, and proposed solutions. Mayo Clinic Proceedings, 80(12), 1613–1622.
- White, C.B., & Fantone, J.C. (2010). Pass-fail grading: laying the foundation for self-regulated learning. Advances in Health Sciences Education, 15(4), 469–477.
- Kamath, P., et al. (2024). Navigating the transition: the impact of Step/Level 1 pass/fail grading on dermatology residency match outcomes. SKIN: The Journal of Cutaneous Medicine. https://doi.org/10.25251/skin.3389
- Patel, R., et al. (2023). The US residency selection process after the USMLE Step 1 pass/fail change. JMIR Medical Education. https://doi.org/10.2196/37069
- Gaddis, M., et al. (2021). Impact of pass/fail USMLE Step 1 scoring on the internal medicine residency application process. PMC8342724. Academic Medicine.
- Robbins, J.B., et al. (2022). Student wellness trends and interventions in medical education: a narrative review. Humanities and Social Sciences Communications, 9, 92. https://doi.org/10.1038/s41599-022-01105-8
- AAMC. (2022). Destigmatizing mental health care for medical students. Retrieved from https://www.aamc.org
- NRMP. (2021). Results of the 2021 NRMP Programme Director Survey. National Resident Matching Programme, Washington, DC.
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