Most U.S. medical schools use pass/fail grading, at least for part of the curriculum. About 56% of allopathic (MD) programs grade the entire preclinical period on a pass/fail basis, and many others use a hybrid system that starts pass/fail and shifts to letter or tiered grades later. But the full picture is more nuanced than a simple yes or no, especially since the USMLE Step 1 licensing exam also moved to pass/fail scoring in 2022.
How Preclinical Years Are Graded
The first two years of medical school, often called the preclinical years, focus on classroom-based sciences like anatomy, pharmacology, and pathology. Of 142 U.S. allopathic medical schools surveyed using admissions data, 79 (55.6%) use pass/fail grading for the entire preclinical curriculum. The remaining schools use some form of tiered grading, whether traditional letter grades (A through F), honors/pass/fail, or a similar multi-level system.
Some schools take a blended approach: pass/fail for the first year, then a more granular grading scale for the second year. Harvard Medical School, for example, uses a system built around satisfactory progress and unsatisfactory designations rather than traditional letter grades. The specific structure varies widely from school to school, so checking each program’s handbook or the AAMC’s Medical School Admissions Requirements database is the most reliable way to know what you’d be walking into.
Clinical Rotations Use Different Standards
The final two years of medical school look nothing like the first two. Students rotate through hospital departments like surgery, internal medicine, pediatrics, and psychiatry, and their evaluations become far more detailed. Even schools that are strictly pass/fail during preclinical years typically shift to a tiered system for clinical clerkships, using grades like honors, high pass, pass, and fail.
This distinction matters enormously for residency applications. In a national survey of residency program directors published in JAMA Network Open, clerkship grades ranked as the single most important applicant characteristic, both before and after Step 1 went pass/fail. Clinical performance is where schools draw the sharpest lines between students, and it’s where residency programs look hardest when comparing candidates.
USMLE Step 1 Is Now Pass/Fail
On January 26, 2022, the USMLE Step 1 exam officially transitioned from a three-digit numerical score to pass/fail reporting. Step 1 is the first of three licensing exams all medical students must pass, and for decades its score (typically ranging from the 190s to the 260s) functioned as a major sorting tool for residency applications. A 250 opened doors to competitive specialties like dermatology or orthopedic surgery. A 215 closed some of them.
The National Board of Medical Examiners made the change to reduce the outsized emphasis on a single exam score and encourage residency programs to evaluate applicants more holistically. In practice, this has shifted attention to other metrics. The same survey of program directors found that class rank moved from the fourth most important factor to the third after the transition. Step 2 CK, which still reports a numerical score, has also gained weight in residency decisions.
Pass/Fail Schools Still Rank Students
If you’re imagining that pass/fail grading means everyone is treated equally, the reality is more complicated. Schools communicate student performance to residency programs through a document called the Medical Student Performance Evaluation (MSPE), sometimes known as the dean’s letter. Even schools that officially don’t rank their students often use language that functions as a ranking system.
A study in Academic Medicine examined MSPEs from schools that claimed not to rank students and found that 45% of those schools included descriptive phrases in their summary paragraphs that strongly correlated with actual academic performance. One school, for instance, categorized every graduating student as an “outstanding,” “excellent,” or “very good” candidate for residency training. When researchers compared those labels against students’ clinical clerkship grades, eight schools showed strong statistical correlations between the descriptor and the student’s actual class standing. In other words, “outstanding” consistently meant top of the class, and “very good” consistently meant somewhere lower.
Three of the non-ranking schools even had special language reserved for top students only, like a citation noting the student was “recommended highly, a citation awarded to approximately one-third of the senior class.” So while the transcript might show a clean row of “pass” marks, the MSPE often tells residency programs exactly where a student fell relative to their peers.
What Happens if You Fail
Failing a course in a pass/fail system triggers a formal remediation process. The school designs an individualized plan that typically includes intensive tutoring, small-group work with faculty, study skills coaching, and repeated assessments. The goal is to get the student back on track, but the failure itself is documented and can appear on the transcript or in the MSPE.
Schools increasingly try to catch struggling students early. Programs that flag students at four, seven, and twelve months into preclinical training see higher rates of students engaging with support services and ultimately completing their coursework. When remediation does happen, it tends to involve structured sessions focused on evidence-based study strategies: practice testing, mixing different types of problems in study sessions rather than cramming one subject at a time, and having students write their own exam questions to deepen understanding.
A single failed course that’s successfully remediated won’t necessarily derail a medical career, but repeated failures or being placed on academic probation creates a serious obstacle for competitive residency applications. Professionalism concerns, more than knowledge gaps, are the strongest predictor of being placed on formal probation.
What This Means for Applicants
If you’re choosing between medical schools and one of your criteria is grading structure, pass/fail preclinical grading does reduce day-to-day pressure during those first two years. Students at pass/fail schools report lower stress around exams and more freedom to explore interests outside the tested curriculum. But it doesn’t eliminate competition. The system simply moves the pressure points: clinical rotations, Step 2 scores, research output, and extracurricular involvement all carry more weight when preclinical grades and Step 1 scores no longer differentiate candidates.
Residency program directors have adapted. They rely more heavily on clerkship honors, class rank (whether explicit or implied through MSPE language), letters of recommendation, and Step 2 performance. For students aiming at highly competitive specialties, excelling in third-year rotations and scoring well on Step 2 has become the primary path to standing out.