Grading in medical school looks different from college — and it varies widely from school to school. This page describes national patterns only; for any specific school, check that school's own student handbook or admissions materials.
National patterns, not school specifics. Every U.S. medical school sets its own grading policy. This page deliberately describes only broad national patterns. No school-specific or program-specific grading data appears here — for any school you're considering, check that school's own published materials.
Most U.S. medical schools now grade the first year or two — the classroom-based, preclinical phase — as simply pass/fail. This is a deliberate trend: pass/fail preclinical grading is associated with lower student stress and better well-being, and it reflects a shared understanding that the basic-science years are about building competence, not ranking students. A pass/fail transcript means residency program directors see your clinical-year performance and board scores instead of your first-year grades — which shifts what matters, as described below.
That said, some schools retain tiered grading (such as honors/pass/fail) in the preclinical years, and a small number still use letter grades. The school's policy will be in its student handbook and is fair game to ask about on interview day.
Once students enter clerkships — the hospital and clinic rotations of the third year — most schools switch to tiered grading. The most common scale is honors / high pass / pass / fail, though schools use many variations: some use honors / pass / fail, others add finer tiers or use letter grades.
Clinical grades are where differences between students show up on paper, because they're the grades residency programs read most closely. Clerkship grades typically combine several components: evaluations from residents and attending physicians, a standardized subject exam (often called a shelf exam) at the end of the rotation, and sometimes OSCEs or other assessments. The weighting varies by school — another reason to read the individual school's policy.
Some schools rank students within their class; others do not, or rank only for internal purposes. Rank matters because it feeds into honors-society eligibility and because some residency applications ask about it. Schools that don't rank typically say so in the MSPE (the dean's letter sent to residency programs), and program directors are accustomed to both systems.
Alpha Omega Alpha (AOA) is the national medical honor society, and election to it is a long-standing marker of distinction in the residency application. Each school's AOA chapter sets its own election criteria — typically a combination of academic performance, leadership, service, and professionalism — and elects only a fraction of the class, usually in the final year. Other societies, such as the Gold Humanism Honor Society, recognize different qualities (humanism in patient care, for example). Because criteria and class percentages are set chapter by chapter, they vary from school to school.