Relationship of Pass/Fail Grading and Curriculum Structure With Well-Being Among Preclinical Medical Students: A Multi-Institutional Study

Reed, Darcy A. MD, MPH; Shanafelt, Tait D. MD; Satele, Daniel W.; Power, David V. MD, MPH; Eacker, Anne MD; Harper, William MD; Moutier, Christine MD; Durning, Steven MD; Massie, F. Stanford Jr MD; Thomas, Matthew R. MD; Sloan, Jeff A. PhD; Dyrbye, Liselotte N. MD, MHPE

doi: 10.1097/ACM.0b013e3182305d81
Learners' Well-Being

Purpose: Psychological distress is common among medical students. Curriculum structure and grading scales are modifiable learning environment factors that may influence student well-being. The authors sought to examine relationships among curriculum structures, grading scales, and student well-being.

Method: The authors surveyed 2,056 first- and second-year medical students at seven U.S. medical schools in 2007. They used the Perceived Stress Scale, Maslach Burnout Inventory, and Medical Outcomes Study Short Form (SF-8) to measure stress, burnout, and quality of life, respectively. They measured curriculum structure using hours spent in didactic, clinical, and testing experiences. Grading scales were categorized as two categories (pass/fail) versus three or more categories (e.g., honors/pass/fail).

Results: Of the 2,056 students, 1,192 (58%) responded. In multivariate analyses, students in schools using grading scales with three or more categories had higher levels of stress (beta 2.65; 95% CI 1.54–3.76, P < .0001), emotional exhaustion (beta 5.35; 95% CI 3.34–7.37, P < .0001), and depersonalization (beta 1.36; 95% CI 0.53–2.19, P = .001) and were more likely to have burnout (OR 2.17; 95% CI 1.41–3.35, P = .0005) and to have seriously considered dropping out of school (OR 2.24; 95% CI 1.54–3.27, P < .0001) compared with students in schools using pass/fail grading. There were no relationships between time spent in didactic and clinical experiences and well-being.

Conclusions: How students are evaluated has a greater impact than other aspects of curriculum structure on their well-being. Curricular reform intended to enhance student well-being should incorporate pass/fail grading.

Dr. Reed is assistant professor, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

Dr. Shanafelt is associate professor, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

Mr. Satele is statistician, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

Dr. Power is associate professor of family medicine, University of Minnesota Medical School, Minneapolis, Minnesota.

Dr. Eacker is assistant professor of medicine, University of Washington School of Medicine, Seattle, Washington.

Dr. Harper is associate professor of medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois.

Dr. Moutier is associate professor of medicine, University of California, San Diego, School of Medicine, La Jolla, California.

Dr. Durning is professor of medicine and pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

Dr. Massie is associate professor of medicine, University of Alabama School of Medicine, Birmingham, Alabama.

Dr. Thomas is assistant professor, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

Dr. Sloan is professor of oncology, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota.

Dr. Dyrbye is associate professor of medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

Please see the end of this article for information about the authors.

Correspondence should be addressed to Dr. Reed, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55901; telephone: (507) 284-6391; fax: (507) 266-0038; e-mail: reed.darcy@mayo.edu.

First published online September 26, 2011

© 2011 Association of American Medical Colleges