Monday, January 23rd, 2017


Slavena Salve Nissan

Within our first 5 months, the Mount Sinai Class of 2020 has taken 5 exams and 16 quizzes as well as participated in 4 table conferences (group-based anatomy lab evaluations). Each of these assessments has been administered under the pass/fail system now used at many medical schools around the country. At Mount Sinai, this system is in place for the first two years, with passing being a 70 or two standard deviations below the mean (whichever is lower).

Simply put, I think that this is one of the best things that has happened to medical education in recent memory.

Like many of my classmates, before medical school, I had always strived for a 90+. I took deep pride in my grades and in doing “well.” But this constant chasing of high grades could be very tiring, too. One bad exam grade meant that I had to make sure that I did stellar on the next exam so that I could still get an A in the class.

But now, in these first two years of medical school, that pressure is gone. There are no A’s or B’s or C’s. A 99 on an exam will give you the same grade as a 70. So maybe now you’re thinking that medical school is easy, and I must not need to work as hard as I used to. Not at all. I’m working as hard as ever, and I am as committed to my education as I’ve ever been. But for the first time in a long time, I’m also ok with not getting a 90+.

At Mount Sinai, we start medical school with a course called “Structures,” which covers anatomy, histology, and embryology. It is a whirlwind of a course that teaches us a whole lot in just 9 weeks. From the beginning, I embraced the pass/fail system fully and just focused on learning as much as I could without the added pressure of the 90+ goal hanging over my head. I can’t imagine the additional stress I would have been under if I was obsessing over every point instead of truly taking the time to understand the important concepts and clinical correlates. I like to put it this way: I prepared for each assessment as well as I always have but also told myself that it was ok not to be perfect if I was having a bad day or just wasn’t in love with the material (it’s impossible to like everything). It seems contradictory, but this approach has actually worked really well for me. My focus in my preparation has been to make sure that I don’t have any significant gaps in my knowledge. It has not been to fight for every point because I needed to get an A instead of a B+.

During our second course, “MCG” (molecular biology, cell biology, and genetics/genomics), I got an exam score that would have made me very happy in my undergrad days. As I sat looking at my results on the computer screen, I felt that familiar high of doing well, but it dissipated quickly. That score just didn’t mean as much to me as it would have 2 years ago, and I think that’s because the pass/fail system has given me the freedom to not associate my sense of fulfillment with a number.

What keeps me feeling fulfilled and motivated is reflecting on how much we already know about the human body after these first months.

The same goes for getting exam results that would have once had me terrified of putting my final grade in jeopardy. After that “stellar” exam score, I got a not-so-stellar one and found myself staring at the screen again, this time in disappointment. But like that high before, the disappointment dissipated just as quickly. I accepted it and moved on because at the end of the day, a pass is a pass. My job is to figure out if I feel like I have a good enough grip on the material to go forward and just had a rough time with the questions or if I need to adjust my study habits and review the material more closely when I’m studying for my Step 1 exam.

This system also eliminates the sense of competition that is so rampant in our community starting in our pre-medical years all the way through residency and beyond. I’m grateful that we can live without that in these two years. It allows for a more collaborative environment. But I will tell you a funny story. After our first exam, I was quite happy with my score (one that I previously wouldn’t have considered as “enough”). But the week after the exam, I overheard someone telling his friend that he had gotten a very high score on the exam, and I felt a pang of jealousy. It turns out that he was just trying to trick his friend, but it was a good reminder for me of how deeply ingrained this terrible habit of comparing ourselves to others is. As students, we have to fight this instinct if we truly want to make for a friendlier environment.

A pass/fail system also allows us to spend more time doing extracurricular activities. I’m always wowed by what my classmates are able to accomplish so early on in their training just because we don’t have the pressure of a GPA looming over our heads. We also have optional recorded lectures, which allow for a flexibility that just didn’t exist in most of our undergraduate institutions. Whether it’s involvement in global health, basic/clinical research, medical humanities, or advocacy work, Mount Sinai students are doing some great things.

Because the pass/fail system covers only the first two years, I do worry about the rest of my time in medical school. I think about Step 1 and think back to the difficulty of the months prior to the MCAT exam. It’s important that I have a healthy approach to Step exam preparation because I don’t want to do well at the cost of being miserable. Also, most of the third year clerkships are currently graded on an honors/high pass/pass/conditional pass/fail basis. I don’t want to have that insidious feeling of comparing myself to my fellow third years during each rotation all year long. I just know that doing so would make for a terrible year. My hope is that by having these two years of just learning and focusing on myself, I’ll be less likely to go down that path.

At the end of the day, exams will always be nerve-wracking experiences. I’ve taken more than I can count, and I still feel like vomiting before every single one of them. But having a pass/fail pre-clinical curriculum just makes things significantly less intimidating and puts the focus on what’s most important: learning the material that will become the basis of our clinical practice. In 30 years, I probably won’t remember any of these grades. But I hope to still remember how incredible it felt to hold a human lung in my hand, my first nervous interactions with standardized patients, and maybe even that DNA is missing a hydroxyl group at the 2’ position (maybe).

About Slavena Salve Nissan

Nissan, Slavena Salve HeadshotSlavena Salve Nissan moved to Brooklyn, New York from Baku, Azerbaijan when she was 6-years-old and comes from an ethnic minority known as the Mountain Jews. She graduated with a major in biology from the Macaulay Honors College at Hunter College in 2015 and after graduation, worked as a medical receptionist. She’s currently a medical student at the Icahn School of Medicine at Mount Sinai where she’s continuing to explore the intricacies of her two passions: healthcare and art.

You can find her poetry, photography, and thoughts on social media @slavenareina on Instagram and Twitter.

5 thoughts on “P/F

  1. Wow, this piece is incredible! I’m currently working on a proposal for my medical school to adopt this grading system for the very reasons you’ve mentioned. The literature that supports the change is helpful, but it’s the student insights that are truly valuable when evaluating such a decision. Thank you so much for sharing this story.

  2. Great article. First of all, I do agree with all that was said. I am just curious wether your school has only Pass / Fail or does it have Honors as well? That is how my school works, anything above 70 is pass and anything above 90 is Honors. In this scenario there is still some competition due to the fact that some schools have the Alpha Omega Alpha society and for that purpose grades do matter. Is your school like that ?

    Based on the F/P/H (Fail/Pass/Honor) system those who wish to just pass can focus on that BUT also those who wish to excel and achieve prestige cna still do that chasing that H, so everybody is happy.

    1. Just to ADD. By no means I meant that does who “Just” pass do not want to excel. Just passing is hard enough. For some specialties and programs having titles and big names (AOA) does some how matter.

    2. For our first two years, we have a purely pass/fail system. For our third year, we have an honors/high pass/pass/conditional pass/fail system. We have the Alpha Omega Alpha society at our school too, but I believe the grade qualifications for that are solely based on third year clerkship grades.

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