This commentary lays out reasons for and against medical school moving towards a pass/fail grading system. Advocates for pass/fail highlight multiple analyses that show no decline in exam scores across preclinical, clinical, or USMLE testing after switching to pass/fail. At the same time, residency programs appear almost indifferent to preclinical grades: in a 2024 survey of >1000 programs, preclinical performance ranked dead last among 22 selection factors. Proponents of tiered grading argue that pass/fail grading, while well-intentioned, has shifted—not reduced—student stress. With Step 1 also now pass/fail, Step 2 scores have become the sole standardized discriminator, and scores are creeping upward as pressure shifts into clerkship year. Tiered preclinical grading can offer early, specific feedback, help students calibrate study habits, and provide an avenue for differentiation—especially for learners without built-in advantages in the emerging “shadow economy” of research, connections, and extracurricular prestige. | Marwah, N Engl J Med 2025
