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Letters to the Editor

Can Change to Clerkship Assessment Practices Create a More Equitable Clerkship Grading Process?

Teherani, Arianne PhD; Hauer, Karen E. MD, PhD; Lucey, Catherine MD

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doi: 10.1097/ACM.0000000000002824
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To the Editor:

We implemented changes to our clerkship student assessment process aimed at creating equity for our underrepresented in medicine (UIM) medical students. The concept of “differential attainment” addresses how educational outcomes diverge for different demographic groups assessed in the same way. We recently reported differences in scores on assessments at our institution, the University of California, San Francisco, School of Medicine, a public, research-intensive health sciences university, that consistently favored not-underrepresented in medicine (not-UIM) students.1 These assessment differences narrowed throughout medical school. These small differences nonetheless produced what we called the “amplification cascade”—small differences in assessed performance that yield larger differences in grades and selection for awards.1 The amplification cascade creates inequities with serious consequences, such as diminished opportunities to compete for selective residency programs and enter academic careers. The amplification cascade raises questions about clerkship grading policies at our institution that also concern medical schools nationwide.

To address these inequities, leaders at our institution brainstormed countermeasures to differential attainment to prevent the amplification cascade. We focused on a coordinated and integrated system of change in our clerkship assessment methods starting in 2016. First, we introduced grading committees into all core clerkships to mitigate unchecked bias by single supervisors or clerkship directors. Second, we eliminated a threshold examination score to qualify for clerkship honors, a change subsequently endorsed in the literature. Third, we liberalized the honors cap per clerkship from 25% to 45% to provide more opportunities for all students to attain honors.

To determine whether there was greater equity in the number of honors received by UIM students, we examined 3 years preclerkship (N = 501) and 2 years postclerkship (N = 307) assessment countermeasure changes. Post changes, both UIM and not-UIM students received more honors. In the 3 years preceding clerkship assessment changes, UIM students earned on average 17% and not-UIM students earned 34% honors grades. In the 2 years since implementing our clerkship assessment changes, UIM students received on average approximately 32% and not-UIM students 46% honors grades (P = .001–.05). Although differences in attaining honors narrowed slightly postclerkship after assessment changes, the results were similar and smaller than expected. We continue to consider ongoing contributors to this discrepancy and strategies to optimize equity in medical student assessment.


None reported.

Arianne Teherani, PhD
Professor, Department of Medicine and Center for Faculty Educators, and director of program evaluation, University of California, San Francisco, School of Medicine, San Francisco, California; [email protected]; Twitter: @arianneteherani; ORCID:
Karen E. Hauer, MD, PhD
Professor, Department of Medicine, and associate dean for assessment, University of California, San Francisco, School of Medicine, San Francisco, California; ORCID:
Catherine Lucey, MD
Professor of medicine and vice dean for education, University of California, San Francisco, School of Medicine, San Francisco, California.


1. Teherani A, Hauer KE, Fernandez A, King TE Jr, Lucey C. How small differences in assessed clinical performance amplify to large differences in grades and awards: A cascade with serious consequences for students underrepresented in medicine. Acad Med. 2018;93:1286–1292.
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