Medicine should have the same grading system as other academic disciplines
Photo: Einar Nilsen
Over the years, various grading systems have been used for university and university college exams. In 2003, a grading scale from A to F was introduced for most university disciplines in Norway, a scale which is widely used in other countries, including in medicine. In recent years, however, medical students in Oslo, Trondheim and Tromsø have only received the grades «pass» or «fail». In Oslo, these grades were introduced in 1996 along with the new study programme «Oslo 96», in which the key principles were academic integration, more in-depth learning and teaching that would promote student activity (1). In such programmes, pass/fail was considered to be the most suited grading system, emphasising insight, promoting collaboration and stimulating more informative feedback to the students (2). The students should be motivated by a desire to learn – not by the prospect of good grades at exams.
The discussion of grading systems has now re-emerged with the upcoming revision of the study programme for medicine at the University of Oslo (3). Many teachers would probably prefer a re-introduction of the grading scale. Among the students, opinion is divided, although the majority most likely would prefer the current system to continue (4).
Since 1996, many things have happened. Until recently, the allocation of hospital internships was decided by drawing of lots, but is now based on individual applications to the hospitals. Without a grading scale, the employers will have a scant basis for selecting the best applicants. Personal connections, for example parents who are doctors, could be the decisive factor for employment – this has already been reported to be a problem (5). Medicine as an academic discipline is increasingly characterised by internationalisation and globalisation. With a high and rising number of medical graduates, the labour market for doctors will grow tighter and more competitive. Hence, having a grade that exceeds a «pass» will gain in importance.
It has proven difficult to document an effect of problem-based learning and pass/fail exams on cooperation skills and clinical behaviour among doctors, as envisaged. Such things are not easily measured. Some studies from the USA indicate that pass/fail exams improve the well-being of students without any significant change in academic outcome, but the long-term effects have not been studied (6). Feedback from teachers in Oslo indicate that the academic level among medical students has declined in recent years, but this is also difficult to document. If this is true, it could have several causes. Many students appear to adapt to the minimum requirements to pass the examination – why work hard on your studies when this will not pay off in terms of better grades?
There are good arguments in favour of introducing a grading scale in medicine, like they have in Bergen and a large number of medical schools abroad. Good grades provide motivation to perform better, and this motivation is no less valuable than a genuine thirst for knowledge. Exams and grades have a great impact on the students’ learning behaviour, and this should be used to best advantage. A key factor is that new types of exams have made it possible to assess the students on a wider basis than knowledge only (7). Station exams based on objective, structured clinical examination (OSCE) test the students’ knowledge, application of knowledge, communication skills, clinical assessment skills and practical procedures. Their performance is assessed on the basis of pre-defined scoring templates, which restricts the need for discretionary judgement and reduces the scoring variation among the different teachers and examiners. Station exams produce far better test validity, and the grading becomes more reliable and consistent than in traditional types of exams. A grading scale would more easily reveal the students with research talents and provide them with the motivation to set out on this path.
Many of the arguments in favour of retaining a pass/fail grading system are relevant and legitimate. Two factors have been given little attention in the debate. A two-value grading system permits stricter requirements for obtaining a pass than what a more finely graded scale does (3). A pass/fail system is also less complicated for the teachers and the school administrators in terms of work – if a grading scale is introduced, one must expect more formal complaints from dissatisfied students, demanding a lot of work, time and resources.
The students are hungry for feedback on their academic performance. This is a recurring topic at meetings where the study programme is evaluated. We as teachers must improve our ability to provide constructive feedback on the students’ performance. Praise and advice must be provided continuously throughout the studies – on the students’ clinical examinations, writing skills, communication skills and oral statements made during small group sessions and clinical lectures. Errors made are not errors – they are golden opportunities for good learning. Grading scales for exams cannot replace such informal, continuous evaluation, but they will provide the students with well-founded, valid and reliable feedback on their academic performance.