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Letters to the Editor

In Reply to Greenberg

Williams, Winter MD1; Estrada, Carlos A. MD, MS2; Zinski, Anne PhD3

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doi: 10.1097/ACM.0000000000004233
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We thank Greenberg for the thoughtful comments on our article and agree with the sentiment that clinical performance should be “the sine qua non for determining excellence” among clinical trainees. For the clerkship sample discussed in our article, clinical performance was weighted as 70% of the clerkship grade, with the remaining 30% determined by scores on the subject examinations of the National Board of Medical Examiners. Despite the potential for subjectivity in clinical performance assessment, we believe that the assessment of medical knowledge and clinical competency using multiple-choice questions should not be the chief determinant of clinical grades at our institution. Additionally, in a prior Academic Medicine article, 1 clinical faculty reported placing value on factors other than medical knowledge when determining clerkship grades.

As the Step 1 exam of the United States Medical Licensing Examination becomes pass/fail and the Step 2 Clinical Skills examination is discontinued, there is a terrific opportunity for schools to collaborate and reconsider their approaches to clinical grading, particularly given the extreme variation between and even within schools. 2 Rather than decreasing the weight of clinical performance in grading, however, we view this as a chance to enhance performance assessment through improved tools for measuring performance in the clinical setting, as well as through novel ways of weighting comprehensive modes of assessment. These include input from patients, peers, and other health professions personnel, as well as from standardized patients and faculty in an objective structured clinical exam setting.

Finally, we agree with Greenberg that faculty training is essential, as well as input, cooperation, and buy-in from clinical educators and administrators within both undergraduate and graduate medical education. Only by pursuing shared models of essential clinical skills across the continuum of medical education can we develop and assess trainees’ performances in ways that will best prepare them to provide excellent patient care as medical graduates.


1. Herrera LN, Khodadadi R, Schmit E, et al. Which student characteristics are most important in determining clinical honors in clerkships? A teaching ward attending perspective. Acad Med. 2019; 94:1581–1588
2. Alexander EK, Osman NY, Walling JL, Mitchell VG. Variation and imprecision of clerkship grading in U.S. medical schools. Acad Med. 2012; 87:1070–1076
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