March 24, 2022

Should We Adopt a Two-tier Grading System in Health Professions Education? Benefits and Practical Considerations

by Mary Kathryn Vance, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Grades have long been a cornerstone of educational systems, giving students and educators a way to measure the achievement of learning objectives within courses. Grades were first instituted in the 1700s in Europe to assign a rank order among students. By the late 1800s, several American universities had adopted a grading system with “passing” rates ranging from 26-75%. Eventually, this transitioned to the tiered grading system we recognize today, where an A generally means the student has scored at least 90% on the assessment (or received >90% of available points in the course), a B means 80-90%, a C means someone scored in the 70s, and so forth. Grades typically are attached to a descriptor.  For instance, an A might signify an exceptional level of achievement, a B good but not outstanding level of performance, a C a fair level, and a D signifies significant performance deficiencies but still passing.1 While this is still the system widely employed by the majority of Doctor of Pharmacy programs in the United States, some programs have adopted a pass/fail or two-level grading system.

Several studies have shown that students in health professions programs, including pharmacy students, experience anxiety, depression, and stress at higher rates than their peers. This places students at a higher risk of developing burnout, which is characterized by exhaustion and a diminished sense of accomplishment.2,3 Moreover, multitiered grading systems can foster unhealthy competitive environments among students. Two-level grading systems have been proposed as a potential way to mitigate stress, reduce competition, and increase students’ well-being. A survey with nearly 1200 first- and second-year medical student respondents found that students in schools using grading scales with three or more categories had higher levels of stress, emotional exhaustion, and depersonalization when compared to students in schools using two-level grading systems. Students in schools with multi-tier grades were also more likely to have seriously considered dropping out of school.4 Another study conducted at Mayo Medical School compared students from classes before and after implementation of a two-level grading system. Students graded with the two-level system had less perceived stress and greater group cohesion than their multilevel peers.5

One concern that educators express about two-level grading systems is that they can negatively impact academic performance. Students’ motivation to learn the material might be decreased because they may not have to understand the concepts as deeply to get a passing grade. Some evidence suggests this concern is more theoretical than true. At the University of Virginia School of Medicine, the first two years of the curriculum were changed from graded to pass/fail. When student performance was compared before and after the change, no differences were observed in subsequent course grads, grades during clerkships, or scores on the United States Medical Licensing Examination (USMLE) Steps 1 and 2 Clinical Knowledge boards.6 Similar results were seen at the Mayo Medical School — there was no difference in USMLE Step 1 board scores before and after changing from a multilevel to a two-tier grading system.5

While they do not appear to reduce students’ achievement during school, two-level systems may better position students to become self-regulated learners. Health professionals are expected to engage in a process of continuous learning throughout their careers. This may be difficult for some students after transitioning from a system with strong extrinsic motivators (i.e. grades) to professional life where the individual must muster the internal motivation to figure out what, how, and when to learn. Helping students develop into self-regulated learners while still in school lays the foundation for this to continue throughout their careers and ultimately increases their knowledge and skills to provide better patient care.7

Another potential disadvantage of two-level systems is a decreased probability for students to match with residency programs. The American Society of Health-System Pharmacists (ASHP), the organization that is responsible for pharmacy residency program accreditation, will soon be requiring that all accredited pharmacy residency programs develop procedures on how to evaluate the academic performance of applicants from pass/fail (two-tier grading) institutions.8 There is still the potential that students from institutions that have two-tier grading systems could be seen as less desirable or competitive. However, this effect was not seen in a study that examined the effect pass/fail grading on advanced pharmacy practice experiences (APPEs) had on residency match rates at 100 pharmacy schools in the United States over the course of 3 years.9 Unadjusted analyses showed that there was no difference in match rates between students from schools with multilevel and two-level grading systems. After adjusting for potential confounders, two-level grading was actually associated with higher match rates during one of the three years.9 Similar rates of success in residency placement were also seen in the study conducted at the University of Virginia School of Medicine before and after their transition to a two-tier grading system.6

Despite the potential benefits, two-tier grading systems have not been widely implemented in pharmacy education and when it has been implemented, they are some inconsistencies. A study examining the implementation of two-tier grading systems within Doctor of Pharmacy programs found that the programs varied in the terminology used to describe student achievement levels, minimum pass levels, and whether a class rank or GPA was calculated, among other factors.10 This lack of uniformity leads to questions as to how best to implement two-tier grading systems.

Experiential courses such as introductory and advanced pharmacy practice experiences would seem to lend themselves well to a two-tier grading system. These types of courses tend to vary in their rigor and requirements based on the practice site. This can make interpreting and interpreting letter grades assigned to a student’s performance is already difficult. There are a variety of labels that could be used in a two-tier system, such as pass/fail, pass/no pass, or satisfactory/unsatisfactory. These labels haven’t been evaluated, but the connotations with “fail” and “unsatisfactory” would seem to be more negative than “no pass.”

Converting non-experiential courses to a two-level system is controversial. In schools where this has been done, numerical grades given to assignments and assessments are used to calculate a student’s class rank. This could allow high achievers to be rewarded and give residency programs a way to compare applicants. We clearly need additional studies about two-tier grading systems to determine their benefits and risks and how to best execute them.


  1. Cain J, Medina M, Romanelli F, Persky A. Deficiencies of Traditional Grading Systems and Recommendations for the Future. Am J Pharm Educ 2022; 86 (2): Article 8850.
  2. Brazeau CMLR, Shanafelt T, Durning SJ, et al. Distress Among Matriculating Medical Students Relative to the General Population. Academic Medicine. 2014;89(11):1520-1525.
  3. Geslani GP, Gaebelein CJ. Perceived Stress, Stressors, and Mental Distress Among Doctor of Pharmacy Students. Social Behavior and Personality: an international journal. 2013;41(9):1457-1468.
  4. Reed DA, Shanafelt TD, Satele DW, et al. Relationship of Pass/Fail Grading and Curriculum Structure With Well-Being Among Preclinical Medical Students: A Multi-Institutional Study. Academic Medicine. 2011;86(11):1367-1373.
  5. Rohe DE, Barrier PA, Clark MM, et al. The Benefits of Pass-Fail Grading on Stress, Mood, and Group Cohesion in Medical Students. Mayo Clinic Proceedings. 2006;81(11):1443-1448.
  6. Bloodgood RA, Short JG, Jackson JM, Martindale JR. A Change to Pass/Fail Grading in the First Two Years at One Medical School Results in Improved Psychological Well-Being. Academic Medicine. 2009;84(5):655-662.
  7. White CB, Fantone JC. Pass–fail grading: laying the foundation for self-regulated learning. Adv in Health Sci Educ. 2010;15(4):469-477.
  8. American Society of Health-System Pharmacists. (2021). ASHP Accreditation Standard for Prost Graduate Residency Programs Draft Guidance.
  9. Pincus K, Hammond AD, Reed BN, Feemster AA. Effect of Advanced Pharmacy Practice Experience Grading Scheme on Residency Match Rates. Am J Pharm Educ 2019; 83(4): Article 6735
  10. Spiess JP, Walcheske E, MacKinnon GE, MacKinnon KJ. Survey of Pass/Fail Grading Systems in US Doctor of Pharmacy Degree Programs. Am J Pharm Educ. 2022;86(1): April 8520.

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