Grading Policies

The grading and remediation policies by curriculum phase. 

General Principles

Students will be granted a score of either Pass or Fail for each course during the Foundations of Medicine Phase (Phase 1). Percent scores will be maintained for each student in order to determine scholarships and AOA nominations, and for writing the MSPE letter. Students will have access to their final grade of Pass or Fail for each course and their percent performance on assessments in order to guide students in their progress and performance compared to their peers.

To determine a student’s percent score, a composite score consisting of all available points for a course will be determined. The total amount of available points for a course will arise from assessments within three domains (see below) and each course is expected to incorporate assessment in all three components to arrive at the composite score.

Example Assessments

• Medical Knowledge Exams (MK): Multiple-choice, short-answer, and essay examinations and quizzes; written assignments
• Application Exams (APP): OSCE; patient interviewing; physical diagnosis; procedural skills; lab activities 
• Collaborative & Independent Learning (CIL): Small-group engagement rubrics, reflection rubric, multiple quizzes as completion (e.g., five 10-point quizzes=5 points total), etc. 

Guidelines for a grade of Pass

• The minimum passing score in each block is calculated on a rolling basis annually, set at the average of final block scores that were 2.5 standard deviations below the mean for the preceding three years. This minimum passing score will be published in the syllabus and described during block orientation.
• Students who have an overall composite score at or above this published score will receive a grade of Pass for the course.
• Students who have an overall composite score below the published score will have de-identified assessment data reviewed by the Grading Committee who will determine the final grade for each of these students.
• The Grading Committee cannot increase the minimum passing composite score to one greater than the published cutoff score.

Grading Committee

This Committee, a subcommittee of the COM Curriculum Committee, will consist of five COM general faculty members without administrative educational roles in Phase 1 who have requisite understanding of the COM program objectives. Members are appointed by the Associate Dean for Medical Education for a two-year term, renewable twice. The Chair of the Committee will be the Phase 1 Director or designee and is a non-voting member. The block directors may attend Committee meetings as non-voting members for advisory purposes. Any Grading Committee member who serves in a formal leadership role for the course (e.g. Block Director), including the committee chair, must recuse themselves from relevant discussions.

The Grading Committee will recommend a grade of Pass (P) or Fail (F). For students receiving a Fail, the Grading Committee will identify which of the assessments fell below their standards. See remediation plan for further details.

In the process of determining grades, the Grading Committee will review available assessment data including but not limited to the overall performance of the class and de-identified composite and component data of individual performances of those students that do not meet or exceed the passing score published in the syllabus. The Grading Committee may also consider any contextual factors related to a specific course (e.g., standard deviations from mean, extenuating circumstances related to the administration of the course or an assessment) to help determine the appropriate minimum passing score. Grades determined by the Grading Committee will be sent to the Associate Dean for Medical Education (or designee) for validation and only in exceptional circumstances (e.g. mathematical error) will the grade(s) be modified. After validation, grades will be reported to students by the Office of Medical Education within 7-10 days of the completion of the course. 

Remediation

All students with a Fail will be contacted by e-mail from the Associate Dean for Medical Education or designee at the time of grade posting with a description of the assessment(s) to be retaken. Students will contact the Assessment Coordinator within 10 business days following grade receipt to discuss the logistics of retaking designated assessment(s). Note: students receiving a grade of Fail will be required to re-register for the block and pay tuition for the remediation per SEC guidelines. Note: the "Fail" grade for the first attempt, even if successfully remediated, will remain on the student's transcript. 

• Phase 1 – Semester 1 and Semester 2: Remediation needs to be completed by July 10 nearest the end of that academic year. Students may complete during winter and spring breaks if agreeable to the block director.
• Phase 1 – Semester 3: Remediation needs to be completed by the beginning of the Acute Care and Clinical Transitions Block.

The Grading Committee determines the remediation plan for a specific component(s) entailing retaking the same or comparable assessments to those taken previously in the above domain(s) demonstrating weakness. Students are not allowed to review examinations after the deadline described in the Exam Review Policy.

To determine the outcome of remediation, the results of remedial assessment(s) will replace the original one(s) and the student’s final grade for the block will be recalculated following completion of all activities designated by the Grading Committee. If this new grade is above the final minimum passing score for the block, the student will receive a Pass. If below the minimum passing score, the results will be reviewed by the Grading Committee for determination of the Final Grade.

Students who fail block remediations will be referred to the Student Evaluation Committee for action (see SEC guidelines). 

Approved by the Curriculum Committee: August 10, 2018
Approved by the Curriculum Committee: August 28, 2018
Modified by the Office of Medical Education and the Office of Admissions and Student Affairs: April 29, 2019
Approved by the Curriculum Committee: July 23, 2019
Modified by the Office of Medical Education: August 6, 2019
Approved by the Curriculum Committee: March 22, 2022
Approved by the Curriculum Committee: July 25, 2023 

Class of 2025 Phase 2 Grading Policy

Overall grades in the six core clerkships are determined by a combination of clinical performance, NBME Subject Exam score, OSCE score (if applicable), professionalism, attendance, and other assignments.  The contribution of each item to the final grade and minimum requirements to receive a Pass on the clerkship will be provided to students at orientation for each clerkship. Students who meet the minimum requirements for Pass are guaranteed a grade of Pass or higher. Each clerkship assigns Honors to the top 20%, High Pass to the next 30%, and the remaining students are eligible for Pass.

A grade of fail may be received for one of the following reasons:  final cumulative grade below the passing threshold, repeated instances of unprofessional behavior, failing performance on NBME shelf examinations, or unexcused absences.  Find additional details on criteria for failing performance in each area in the Fail Criteria for Core Clerkships.

The Acute Care and Clinical Transitions Block is a pass/fail event and will not be factored into class rank. A final course grade of 80% is required to pass.

Grading data must be communicated to the students no later than 6 weeks after the conclusion of the course or clerkship.

Overall grades in the six core clerkships are determined by a combination of clinical performance, NBME Subject Exam score, OSCE score (if applicable), professionalism, attendance, and other assignments. The contribution of each item to the final grade and minimum requirements to receive a Pass on the clerkship will be provided to students at orientation for each clerkship. Students who meet the minimum requirements for Pass are guaranteed a grade of Pass or higher. Each clerkship assigns Honors to the top 20%, High Pass to the next 30%, and the remaining students are eligible for Pass.

The Acute Care and Clinical Transitions Block is a pass/fail event and will not be factored into class rank. A final course grade of 80% and attendance per the Phase 2 attendance/absence policy is required to pass.

Grading data must be communicated to the students no later than 6 weeks after the conclusion of the course or clerkship.

Class of 2026 & Beyond Phase 2 Grading Policy

Overall grades in the six core clerkships are determined by a combination of clinical performance, NBME Subject Exam score, OSCE score (if applicable), professionalism, attendance, and other assignments.  The contribution of each item to the final grade and minimum requirements to receive a Pass on the clerkship will be provided to students at orientation for each clerkship. Students who meet the minimum requirements for Pass are guaranteed a grade of Pass or higher. Each clerkship assigns Honors to the top 20%, High Pass to the next 30%, and the remaining students are eligible for Pass.

The Acute Care and Clinical Transitions Block is a pass/fail event and will not be factored into class rank. A final course grade of 80% and attendance per the Phase 2 attendance/absence policy is required to pass.

Grading data must be communicated to the students no later than 6 weeks after the conclusion of the course or clerkship.

Pass/Fail Criteria for Core Clerkships

Overview of Clerkship Grades

The final grades in core clinical clerkships are determined by the Clerkship Director and/or a Clerkship Grading committee. Clerkship final grades are comprised of multiple grading components including clinical performance, NBME Subject Exam score, OSCE score, professionalism, attendance and other assignments.  Grades from clerkships include Honors, High Pass, Pass and Fail.  There are no marginal grades in Phase 2. 

Students may be at risk for a failing final grade based on the cumulative grade components as noted in detail below. The cumulative grade is comprised of weighted components defined by each clerkship in their syllabus. Thus, it is possible to be at risk for a fail without having a markedly poor performance in any one individual component of the grade. 

Students can also fail a clerkship based on discrete criteria for professionalism, attendance, OSCE, or NBME performance as noted below. These elements are critical components for future physician performance, thus a student will fail the clerkship if these criteria are met regardless of a cumulative passing grade.   

Final Cumulative Clerkship Grade

Any student with a final cumulative clerkship grade at or below the scores listed is at risk for failing the clerkship. The criteria listed below are based on historical student performance data for each clerkship and meet the minimum competency threshold for training determined by each clerkship. 

For any student with an at-risk final grade, the clerkship director and/or grading committee will review performance evaluations and exam scores and determine the final grade. 

Please note that each clerkship has individualized weighting of grade components and different scoring systems.  For full details see Canvas, clerkship syllabi, and orientation materials. 

• Internal Medicine
  • Cumulative Grade Passing Threshold: 170
  • Cumulative Grade Full Points: 20
• Obstetrics and Gynecology
  • Cumulative Grade Passing Threshold: 52
  • Cumulative Grade Full Points: 100
• Psychiatry
  • Cumulative Grade Passing Threshold: 50
  • Cumulative Grade Full Points: 100
• Surgery
  • Cumulative Grade Passing Threshold: 65
  • Cumulative Grade Full Points: 100
• Pediatrics
  • Cumulative Grade Passing Threshold: 68
  • Cumulative Grade Full Points: 100
• Family Medicine
  • Cumulative Grade Passing Threshold: 175
  • Cumulative Grade Full Points: 250

Note: The NBME exam and OSCE can comprise a significant portion of the cumulative grade for clerkships. Retakes of the NBME exam and OSCE are only allowed if the student fails the exam on the first attempt. See the NBME/OSCE Fail criteria below for full details on when retaking the NBME/OSCE exam is allowed. 

Professionalism Fail Criteria

Professional behavior is an essential element of a successful physician.  Any unprofessional behavior by students will be reviewed and discussed with clerkship leadership and a Professionalism Evaluation Form will be completed and forwarded to the Office of Student Affairs.

Fail

• Greater than or equal to 3 episodes of non-egregious unprofessional behavior
• One episode of egregious unprofessional behavior

Domains of Unprofessional Behavior

Assessments of professional behavior can be made in the following domains.  While this list is not comprehensive, it does emphasize the areas of professionalism that are most commonly the cause of concern or deficiency.  Unprofessional behavior by students in the domains noted with an asterisk (*) have a statistically significant association with state medical board discipline in the future as a practicing physician.   

1. Poor reliability and responsibility^1*,3*,4  or poor commitment²
   1. Late or absent⁵
   2. Missed deadlines⁵
   3. Unreliable⁵
2. Poor initiative and motivation^1*,3*
3. Immaturity^1,3
4. Poor relationships with students, faculty, staff^1,3*,4 OR poor working relationships²
   1. Falsifying data⁵
   2. Impaired communication with team⁵
5. Poor relationships with patients or patient families^1,3,4
6. Lack of self-improvement and adaptability^1*,3*,4 OR lack of response to instruction²
   1. Arrogant⁵
   2. Hostile⁵
   3. Defensive⁵

Citations

1. Teherani A, Hodgson CS, Banach M, Papadakis MA. “Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board.”  Acad Med. 2005 Oct;80(10 Suppl):S17-20.
2. PA Hemmer, R Hawkins, J L Jackson, L N Pangaro.  “Assessing how well three evaluation methods detect deficiencies in medical students' professionalism in two settings of an internal medicine clerkship. “  Acad Med.  2000 Feb;75(2): 167-73.
3. Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, Veloski JJ, Hodgson CS.  “Disciplinary action by medical boards and prior behavior in medical school.”   N Engl J Med. 2005 Dec 22;353(25):2673-82.
4. Papadakis MA, Osborn EH, Cooke M, Healy K.  “A strategy for the detection and evaluation of unprofessional behavior in medical students. University of California, San Francisco School of Medicine Clinical Clerkships Operation Committee.”  Acad Med. 1999 Sep;74(9):980-90.
5. Ziring D, Danoff D, Grosseman S, Langer D, Esposito A, Jan MK, Rosenzweig S, Novack D. “How Do Medical Schools Identify and Remediate Professionalism Lapses in Medical Students? A Study of U.S. and Canadian Medical Schools.”  Acad Med. 2015 Jul;90(7):913-20.

Assessment and Remediation

• A Professionalism Evaluation Form may be completed by the clerkship director/associate clerkship director for any episodes of unprofessional behavior.
• Any student who is at risk of meeting the fail criteria for professionalism shall have a Professionalism Evaluation Form completed by the clerkship director.  This evaluation will be discussed with the student in a face-to-face meeting and a professionalism action plan will be developed.  This professional remediation plan will be forwarded to the Student Affairs office for review.    
• Any student who demonstrates unprofessional behavior across clerkships will meet with the student Affairs Office and the Student Evaluation Committee.   

NBME/OSCE Score Fail Criteria

NBME

Performance on standardized board examinations is utilized to demonstrate baseline medical knowledge in the core clerkships.  Subject exams fail criteria will be based upon percentile ranking and will utilize the time-adjusted score for the student’s cohort group. Fail criteria align with recommended passing performance standards determined by national experts in each field. 

Fail

• Less than or equal to 1^st percentile (or the lowest reported percentile for the quartile on the NMBE score report)

Assessment and Remediation

• The percentile score is determined from the raw score by using the NBME score report.  The NBME score report from the year prior to the start of Phase 2 will be used for all the phase.
• The percentile score will also be adjusted as the student progresses through Phase 2 by using the quartiles in the NBME score report.  The table below describes which quartile is used per clerkship cohort to determine the percentile from raw score.  The quartile will be determined for all students by the clerkship cohort they are scheduled to take, no adjustment will be made for off cycle cohorts.   

Determining NBME Percentile Score by Quartile

• NBME Quartile 1
  • Clerkship Cohort: Internal Medicine 1, Psychiatry/OBGYN 1-2, Pediatrics/Surgery/Family Medicine 1
• NBME Quartile 2
  • Clerkship Cohort: Internal Medicine 2, Psychiatry/OBGYN 3-4, Pediatrics/Surgery/Family Medicine 2-3
• NBME Quartile 3
  • Clerkship Cohort: Internal Medicine 3, Psychiatry/OBGYN 5-6, Pediatrics/Surgery/Family Medicine 4
• NMBE Quartile 4
  • Clerkship Cohort: Internal Medicine 4, Psychiatry/OBGYN 7-8, Pediatrics/Surgery/Family Medicine 5-6

• Student with a failing or borderline performance on the NBME test will be notified by the clerkship director. 
• Students with a failing performance on the NBME exam may retake the exam one time.  The retake of the NBME exam must be completed by May 31 after the completion of Phase 2.  Students are encouraged to discuss timing of the NBME retake with the Clerkship Directors, Academic Advisors and/or Student Affairs. 
• The high score of the two exams will be used to determine the final grade.  The highest final grade a student can receive after a retake of the NBME exam is a pass. 
• Retake of the NBME exam is only allowed for a failing performance.  This policy is consistent with the retake policies of Step exams and board certification tests. 
• Any students with a score approximately 10^th percentile performance or lower will be referred to the Director of Academic Advising/Student Affairs. 

OSCE

The following clerkships have OSCE exams as part of the cumulative grade.  Fail criteria for the OSCE are listed below. Retake allowed if fail criteria met on first attempt. 

• Internal Medicine
  • OSCE Fail Criteria: Failure of a high impact case OR cumulative score below 80 AND > 2.5 standard deviations below the class mean. 
• Surgery
  • OSCE Fail Criteria: Overall score 65% or lower
• Pediatrics
  • OSCE Fail Criteria: Overall score of 72% or lower
• Obstetrics and Gynecology
  • OSCE Fail Criteria: Overall score of 69% or lower
• Family Medicine
  • OSCE Fail Criteria: Overall score of 74% or lower
• Psychiatry
  • OSCE Fail Criteria: Overall score 60% or lower AND > 2.5 standard deviations below the class mean. 

• Student with a failing or borderline performance on the OSCE will be notified by the clerkship director. 
• Students with a failing performance on the OSCE exam may retake the exam one time.  The retake of the OSCE exam must be completed by May 31 after the completion of Phase 2.  Students are encouraged to discuss timing of the OSCE retake with the Clerkship Directors, Academic Advisors and/or Student Affairs. 
• The high score of the two exams will be used to determine the final grade.  The highest final grade a student can receive after a retake of the OSCE exam is a pass. 
• Retake of the NBME exam is only allowed for a failing performance. 

Attendance Fail Criteria

Attendance along with full participation in clerkship and clinical activities is expected of all students.  Please reference the Attendance Policy for any questions related to the definition of excused or unexcused absences.

Fail

• 2 or more unexcused days

Assessment and Remediation

• Significant tardiness or failure to participate in clerkship activities may be considered an unexcused absence by faculty or clerkship directors.
• Make-up of activities missed due to both excused and unexcused absences is at the discretion of the clerkship director. Missed clinical experiences can be made up over weekends, breaks or holidays. Coordination with other clerkships and rotations is expected to appropriately schedule make-up experience without impacting future clinical experiences.
• Students are expected to communicate proactively with clerkship administrators about absences whenever possible.
• If you have a chronic condition that may cause absences during clinical rotations, a proactive discussion with the ADA office or your personal physician is recommended.
• Documentation of multiple unexcused absences may be a part of your final clerkship narrative and will result in the completion of the Professionalism Evaluation Form.  Multiple unexcused absences or a pattern of unexcused absences over several clerkships may result in a referral to the Student Evaluation Committee. 

Overall

• A failing performance for professionalism, NBME/OSCE score or attendance criteria results in a final failing grade overall.
• Overall clerkship performance comprised of multiple graded components such as clinical performance, OSCE (if applicable) and NBME below the passing threshold will place the student at risk for a final failing grade.
• Students who receive a final grade of fail will be required to remediate the course.

Reviewed and Approved by the Phase 2 Committee: December 14, 2021
Reviewed and Approved by the Curriculum Committee: January 25, 2022
Approved by the Curriculum Committee: March 22, 2022
Reviewed and Approved by the Phase 2 Committee: March 12, 2024
Approved by the Curriculum Committee: March 26, 2024

Curriculum Enhancement Seminars (CES): Pass/Fail (Successful completion of all components)

Residency Preparatory Course (RPC): Pass/Fail (Successful completion of all components)

Elective Rotations: Honors/High Pass/Pass/Marginal/Fail or Pass/Fail - Discretion of Sponsoring Department and as designated in the UNMC course catalog.

Grades for all rotations are to be posted within three weeks (21 days) of the completion of the rotation.

Approved by the Curriculum Committee: January 26, 2021
Modified by the OME: March 22, 2022
Modified by the OME: May 30, 2023
Approved by the Curriculum Committee: July 25, 2023