Impact of Grade Inquiries and Appeals on Clerkship Directors

Grade inquiries and appeals are time-consuming, unpleasant, and often confrontational occurrences in higher education, ¹ with the term “dreaded” being a commonly used descriptor; ² and medical school clerkships are no exception. The Liaison Committee on Medical Education Standard 9.9 requires a formal process for students to be allowed to inquire about and/or appeal grades based on error, discrimination, or bias. ³ “Grade inquiries” refer to requests for clarification or more information, without explicit requests for a grade change. “Grade appeals” refer to requests for a grade change. Recently published studies in internal medicine cited a rate of clerkship grade inquiries of 8% and an appeals rate of 3% (range 0%–20%). ⁴ Psychiatry clerkships found an appeals rate of 4.5% (range 0%–17%). ⁵ Both studies found that clerkships with honors/high pass/pass/fail schemas had higher appeal rates than those with pass/fail schemas. These rates in family medicine clerkships are unknown, but records for one clerkship suggested that they may be higher than these cited and that they have increased in the last few years (author’s personal data). ⁶ A survey of internal medical clerkship directors (CDs) found a 14% rate of grade appeals, which resulted in an actual grade change approximately 0.4% of the time. ⁴

Several factors likely contribute to students seeking grade inquiries and/or appeals. The information age allows medical students to access a massive body of medical information, with a resultant flattening of the traditionally perceived hierarchies of knowledge. ² Simultaneously, intense pressure to perform well in clerkships may be the result of changes in grading policy for the first 2 years of medical school and the change to pass/fail for United States Licensing Examination Step 1 exams. ⁵ Because students have fewer objective data points for residency program directors to review, the assumption is that program directors place greater weight on clerkship grades in determining candidacy for interviews. Grade inflation may create an expectation of high grades for clerkship students, ^{7, 8} with resultant disappointment and grade appeals when the highest grade is not achieved. 

Grade appeals are time-consuming, with a formal grade appeal taking 2 to 3 hours. ⁴ Among internal medicine CDs, grade appeals were specifically named as one factor contributing to a high rate of burnout. ⁹ At many institutions, unsuccessful grade appeals at the departmental CD level may be escalated to a higher level (eg, medical school administration, including dean staff); the escalation creates the potential for the CD’s decision to be overturned, which may cause resentment due to a lack of perceived support for the CD. In addition, grade appeals can negatively impact volunteer community preceptors with an additional time burden and a dissatisfying sense of self-doubt when they are asked to give additional information and/or reconsider their grades of students when an appeal occurs.

Our survey sought to establish the rate of grade inquiries and appeals in family medicine clerkships, to determine whether CDs perceive these rates to be increasing, and to determine whether grade appeals or inquiries contribute to CD burnout or to changes in grading criteria.

Data were gathered and analyzed as part of the 2024 Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) survey of family medicine clerkship directors. CAFM is a joint initiative of four major academic family medicine organizations, including Society of Teachers of Family Medicine, North American Primary Care Research Group, Association of Departments of Family Medicine, and Association of Family Medicine Residency Directors. ¹⁰ The methodology of the CERA clerkship director survey has previously been described in detail. ¹¹

The survey was emailed to 179 clerkship directors in June and July 2024. Invitations to participate included a personalized letter signed by CAFM organization presidents and a link to the survey via SurveyMonkey. Nonrespondents received five weekly requests and one final request 2 days before closing the survey. One survey was sent to a residency program, which was subsequently deleted from the pool. Five undeliverable email addresses were removed from the pool, yielding a final pool size of 173 survey recipients (158 in the United States and 15 in Canada). The project was approved by the American Academy of Family Physicians Institutional Review Board in April 2024.

Demographic questions included gender, race, underrepresented in medicine status, years as clerkship director, years since residency graduation, and full-time equivalent (FTE) for clerkship director role. The introduction to this section of the survey defined the terms as follows:

Participants reported the percentage of students who initiated informal inquiries and formal grade appeals in the last year. Participants indicated whether informal inquiries and formal grade appeals had increased in the last 3 years (Likert scales from 1=strongly disagree to 5=strongly agree). Participants were asked whether they felt supported in their decisions as a clerkship director if the students appealed to a higher level (Likert-type scale, 1=very unsupported to 5=very supported). General burnout was one question with a 1 to 5 response choice: “Overall, based on your definition of burnout, how would you rate your level of burnout?” Higher scores indicated greater burnout. Grade appeal related burnout was measured by asking, “How often does dealing with grade inquiries and formal grade appeals together contribute to your feeling of burnout as a clerkship director?” Response choices ranged from 1 (never) to 6 (a few times a week) with higher scores indicating greater burnout. Participants indicated whether grade appeals made them feel like leaving their role as clerkship director (Likert scale from 1=strongly disagree to 5=strongly agree). Participants were asked whether they had modified clerkship grading criteria in the last 3 years to avoid grade appeals. The final draft of survey questions was modified following pilot testing.

Descriptive statistics summarized study variables. Spearman rank order correlations determined associations between informal grade appeals, formal grade appeals, and changes in grade appeals and the burnout questions. Independent sample t tests determined associations between grade appeals and changing grading criteria.

Of 173 surveys, 91 were returned for an overall 53% response rate. Most clerkship directors were female (58.4%), White (72.5%); 9.1% of respondents identified as underrepresented in medicine. The respondents averaged 17.8 (SD=11.2) years since residency graduation, 7.0 (SD=5.8) years as clerkship director, and 0.30 FTE (SD=0.14) as clerkship director. Five CDs had missing data for the grade appeals questions and were not included in subsequent analyses. Descriptive statistics for the grade appeals questions and burnout measures are shown in Table 1 and Table 2.

Spearman rank order correlations showed that an increase in grade appeals was associated with general burnout, grade appeal related burnout, and wanting to give up their CD role. The percentage of students initiating grade appeals was associated with general burnout, grade appeal related burnout, and wanting to give up their CD role. The more support clerkship directors felt they received from administration about their grading decisions, the less general burnout they felt. (Table 3). The t tests showed that the percentage of students and an increase in students initiating grade appeals was associated with clerkship directors changing grading criteria to reduce the frequency of grade appeals (Table 4). Years since residency graduation, years as clerkship director, and FTE for clerkship director role were not associated with any of the burnout measures (Table 5).

Extensive literature exists regarding burnout among academic physicians and their intention to leave academic medicine. ¹² To date, research has not examined the impact of grade inquiries and appeals on burnout in CDs. Our study results demonstrate that grade appeals may have important effects on CD well-being and behavior. Family medicine CDs reported a 5.8% rate of grade inquiries and a 2.9% rate of formal grade appeals, somewhat consistent with previous data in internal medicine and psychiatry. CDs who reported higher rates of grade inquiries were more likely than their peers to modify grading criteria to avoid grade appeals. Some CDs perceived the rate of grade appeals to be increasing; those who did were significantly more likely than their peers to report burnout and to want to resign as CD because of grade appeals.

These phenomena are not unique to family medicine. Internal medicine CDs also have reported a high level of burnout and cited frustrations with grading and assessment as major contributors to burnout. Of the internal medicine CDs who reported considering resignation, 40% cited grade conflicts as a factor. ⁹ Given that high levels of burnout are associated with lower physician leader effectiveness ¹³ and intention to leave their current job, ¹² finding ways to reduce burnout and support CDs in their roles is imperative.

Whether a CD feels supported in their decisions regarding grade appeals strongly impacts their well-being. CDs who felt less supported in their decisions about grade appeals were significantly more likely to report burnout or to want to resign from that role. Similar findings have been documented across academic medicine. In a large survey of academic physicians, those who felt supported in their leadership roles had lower intention to leave academic medicine than those who did not feel supported. ¹² Excessive turnover in academic medicine has a devastating financial and academic impact on faculty. ¹⁴ Deans and other medical school leadership should seek ways to support CDs and minimize burnout.

Previous reviews of burnout among academic physicians have noted that junior faculty, women, and underrepresented minorities are disproportionately affected by burnout. ¹⁴ Our study, which was limited to family medicine CDs, did not find this phenomenon. Possibly the impact of seniority, gender, or race are not as strong among family medicine CDs as they are among other departments of academic medicine.

Our survey had several limitations. First, we used the term “grade inquiries” to define informal contests (discussions about grade calculations or seeking further information) and “grade appeals” to define formal contests (those having a goal of changing grades) ubiquitously. However, we recognize and honor the variability in process and protocols across medical schools. Second, we assumed that both grade inquiries and appeals were based on students’ perceptions of subjective clinical evaluations rather than exam scores or other largely objective measures. In addition, CD reports of grade inquiries may be subject to recall bias.

Third, we found a negative correlation between CD decision and support from medical school administration, but we did not inquire about the details of why CDs did or did not feel supported. In addition, burnout was self-reported. Due to space limitations, we were not able to include a validated scale to measure burnout. Lastly, respondents had wide variability in years of service as a CD, but we did not assess the relationship between time in role and burnout relative to factors outside of grade inquiries and appeals. We recognize that additional stressors exist outside of grading issues, but limitations on the allowed number of questions in the survey prevented further inquiry into these issues.

Future research can include surveying medical school administration and deans on their perceptions of grade inquiries and appeals relative to burnout in CDs and relative to how that impacts deans and administrators. In addition, future surveys can inquire about student reasoning for grade appeals, which may help CDs design grading criteria that are perceived by students as fair and transparent. Future surveys may investigate and disseminate effective strategies medical schools can use to manage grade inquiries and appeals.