Medical education reforms in grading systems and licensing examinations in the United States are transforming how student performance is assessed and how residency applicants are evaluated. Pass/fail grading in the preclinical years has been adopted at several U.S. medical schools over the last 20 years and has replaced tiered grading systems. A major milestone occurred in January 2022, when the United States Medical Licensing Examination (USMLE) Step 1 transitioned to a non-numeric pass/fail method of assessment.
One purpose of introducing these changes was to address concerns about the extreme pressure associated with numeric Step 1 scores. Critics claimed that a score-based culture negatively affected student well-being, encouraged strategic rather than meaningful learning, and raised concerns about fairness and equity.
However, researchers are now questioning whether these reforms have truly reduced assessment pressure or merely shifted it to later stages of training, particularly the clinical years and the USMLE Step 2 Clinical Knowledge (CK) examination. A narrative review analysing grading changes and assessment practices in undergraduate medical education synthesized empirical, survey-based, and conceptual research. The literature was identified through searches of PubMed/MEDLINE and Google Scholar, with the most recent update conducted in December 2025.
The review focused on four key topics: preclinical pass/fail grading systems, the transition of USMLE Step 1 to pass/fail reporting and its impact on residency selection, predictors and determinants of USMLE Step 2 CK performance, and variability, reliability, and fairness of actions in the clinical years of medical training. Evidence consistently indicates that pass/fail grading in preclinical education does not worsen performance on licensing examinations.
A national survey of allopathic medical schools in the United States found that pass/fail grading was not inferior to tiered grading when comparing mean USMLE Step 1 and Step 2 CK scores after adjusting for student characteristics. Other studies report similar findings: although pass/fail systems may lead to slightly lower performance on internal preclinical examinations, they do not significantly affect Step 1 results. Importantly, pass/fail grading has been associated with improved psychological well-being and higher learner satisfaction, without negatively affecting clerkship grades, Step 2 CK scores, or residency placement.
A more substantial change in the national evaluation system occurred when USMLE Step 1 adopted a pass/fail format in January 2022. Previously, Step 1 scores were widely used as a standardized metric in residency selection. Residence program directors’ surveys across a variety of specialties indicate that, following the reform, programs anticipate increasing their reliance on USMLE Step 2 CK scores, clerkship grades, and narrative assessments. Early evidence suggests that the transition to pass/fail scoring has redistributed academic pressure rather than reducing it.
Some studies have found that applicants whose Step 1 results were reported as pass/fail had slightly lower average CK scores in Step 2, and fewer traditional academic differences. Although adjusted analyses showed no independent association between the Step 1 reporting format and residency match outcomes. With Step 1 CK no longer providing a numeric score, Step 2 CK has become a more influential measure. Performance on this examination is strongly associated with the previous academic indicators, including earlier examination results and internal assessments.
Clerkship performance, especially scores on National Board of Medical Examiners (NBME) subject examinations, such as internal medicine, also explains a substantial portion of the variation in Step 2 CK scores. Additionally, the sequence of core clerkships may influence clinical learning experiences and examination performance.
Despite these developments, clinical-year assessment remains highly variable across institutions because of differences in grading cultures, evaluator bias, and contextual factors. Small differences in clinical evaluations can lead to large differences in honors designations and academic awards. clinical evaluation. Consequently, experts have recommended the adoption of more competency-based evaluation frameworks, improved transition-to-clerkship preparation, and greater use of longitudinal assessments.
Overall, current evidence suggests that pass/fail grading enhances student well-being. However, evaluation pressure has largely shifted toward USMLE Step 2 CK and clinical-year assessments, where challenges related to standardization and fairness continue to persist.
Reference: Khorsand Askari M, Wunderly K, Shabpiray H. Pass/Fail Grading and United States Medical Licensing Examination (USMLE) Step 1 Reform: Implications for Clinical-Year Assessment and USMLE Step 2 Clinical Knowledge (CK) Performance. Cureus. 2026;18(2):e103358. 2026. doi:10.7759/cureus.103358
