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The Successful Match: Clerkship Grades

Created July 1, 2007 by Samir P. Desai, MD, and Rajani Katta, MD
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Which of the following is the most important academic criterion used by program directors to select residents?

A) USMLE step 1 score
B) USMLE step 2 CK score
C) Pre-clinical course grades
D) Third-year clerkship grades
E)Membership in Alpha Omega Alpha (AOA)

In our own surveys, we have found that students almost always answer this question incorrectly. Students generally base their answer on information gathered from classmates, upperclassmen, residents, and discussion forums, among others. These are all useful sources of information. The ideal way to answer this question, though, would be to discuss it with those individuals directly involved in the residency selection process—in particular, program directors in your chosen field. Ideally, this should be done early in your medical school education. With this knowledge in hand, you can make the most of your opportunities, placing yourself in a position to succeed and match with the specialty or program of your choice.

Fortunately, others have done this work and published their findings. A survey of approximately 800 program directors was performed by Dr. Wagoner, the former dean of students at the University of Chicago Pritzker School of Medicine. These program directors represented 14 specialties, and were surveyed about the importance of various academic criteria used in the selection of residents.1 Dr. Wagoner and her colleagues learned that grades in required clerkships are the most important academic criteria used to select residents.

At most schools, required or core clerkships include internal medicine, pediatrics, psychiatry, surgery, obstetrics/gynecology, and family medicine.Most medical students are surprised to learn that grades in required clerkships are ranked higher in importance than USMLE scores. In our inaugural column, we presented data from a survey showing that 44% of students from three U.S. medical schools perceived required third-year clerkship grades as moderately, mildly, or not at all important in the residency selection process.2

While many reasons exist for this disconnect between the perceived and actual importance of clerkship grades, we know that this can impact students’ efforts and attitudes during rotations.

As this article goes to press, we recognize that thousands of students across the country have begun, or are about to begin, their third year of medical school. Put simply, your performance this academic year can make or break your chances of a successful match.

  • Grades in required clerkships are the most important academic criteria used to select residents.
  • “Number of honors clerkship grades” was the second most important academic criteria used to select residents in the most competitive specialties.
  • Clerkship grades are the major determinant of class rank. The most competitive specialties rate class rank among the three most important selection criteria.
  • Clerkship grades are a major factor used by schools in electing students to the Alpha Omega Alpha Honor Medical Society (AOA). Election to AOA is highly valued by many competitive specialties. In some programs, and in some specialties such as dermatology, membership in AOA is used as a screening tool to determine which applicants are even considered for interviews.
  • Comments made by attending physicians on the clerkship evaluation form find their way, often verbatim, into the Medical Student Performance Evaluation (MSPE). The MSPE, formerly known as the Dean’s letter, is often scrutinized closely by residency programs.
  • Clerkship performance and grades are important in securing strong letters of recommendation. In competitive residencies where many applicants have excelled academically, letters of recommendation take on additional importance.

We present one final question: Which of the following is the most important academic criterion used by ophthalmology program directors to select residents?

A) USMLE step 1 score
B) Alpha Omega Alpha
C) USMLE step 2 CK score
D) Grades in required third-year clerkships
E) Grades in the ophthalmology clerkship

If you selected choice D, congratulations. The correct answer is indeed “grades in required third-year clerkships.” In the Wagoner study, 46 ophthalmology program directors were surveyed. Grades in required clerkships and the number of honors grades were ranked higher in importance than grades from ophthalmology electives.

Is this finding surprising? In our experience, all students recognize the importance of grades in their chosen specialty. However, fewer understand the overall importance of grades in required clerkships. A review of various discussion forums reinforces this finding.

In our next column, we’ll discuss the transition between the basic science and clinical years of medical school: what makes the transition such a challenge, and can be done to excel?


1. Wagoner NE, Suriano JR. Program directors’ responses to a survey on variables used to select residents in a time of change. Acad Med 1999; 74(1):51-8.

2.Brandenburg S, Kruzick T, Lin CT, Robinson A, and Adams LJ. Residency selection criteria: what medical students perceive as important. Med Educ Online 2005; 10:17.


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  1. Dr. Abroad says:

    Most third year students these days have the importance of third year clerkship grades drummed into them. But realistically, how good are clerkship grades, which are often subjective, in determining who will be a better doctor or resident? Obviously, there are many residency programs which have residents that only passed their required clerkships. Some students feel that clerkship grades are more or less a popularity contest. While they are one important factor, there are many more important factors that should be considered besides this.

  2. firefly says:

    I understand your opinion Dr. Abroad but frankly, at this point, there are no other things that need to be considered. Throughout our schooling, we always used this excuse to get out of poor grades, SAT, and MCAT scores. I would agree that a 25 on the MCAT really can’t determine the quality of medicine that someone would practice. But now you are doing exactly what medicine is all about – you are practicing it via interaction with patients. This should be the most important aspect of your application – if you can’t show your ability to integrate your book knowledge of medicine with those that it will be primarily applied to, what should you be judged on? This is the final test and one that every doctor should pass with flying colors.

  3. kraphtymac says:

    That’s interesting firefly… your last sentence referring to grades on 3rd-year clerkships is “This is the final test and one that every doctor should pass with flying colors”. This is interesting, because I think almost EVERY school out there (with the exception of a few strictly Pass/Fail schools), grades students as Honors, Near Honors, or Pass (or letter grade) by PERCENTAGE. Our school, for instance, splits it up as 15% honor, 15% near honor, and the rest pass/fail. So not every student can “pass with flying colors”, by which I assume you mean honor/near honor in the context of your reply. Nice argument though.

  4. pedro says:

    I am curious to know how percentage scores are looked upon. My school and others report these raw numbers on our transcripts. We do not have honors/near honors/pass/etc..

  5. Steve says:

    This is the most ridiculous thing I have heard so far in terms of residencies! Third year rotation grades are more important than Step 1 and Step 2? Give me a break! Grades in rotations are SO subjective that it’s not even funny. Most everywhere the grade depends on one person,the chairman or director of the department, and his/her perception of you.

  6. Adam says:

    I agree with Steve’s post. Difference between Step 1&2 versus clinical evaluations.

    1.)USMLE is not racist and holds Asians to a higher standard. Articles have started to surface on this.
    2.)USMLE doesn’t care about your social networking skills or better put, how good you BS and kiss up.

  7. Student says:

    This is complete misinformation. USMLE is the only equalizing factor that is not biased in anyway. A common complaint among 3rd years is subjective clincal evals which varies a lot. Any knowledgable student knows in competitive residences step I, publications are more important than 3rd year evals.

    Where the heck do you get this type of information anyways???

  8. a reader says:

    What happens if you go to a school that uses P/F for third year, doesn’t rank, and doesn’t offer AOA? I assume in that case that USMLE scores would be the most important, since all of the other categories don’t even exist!

  9. Anonymous says:

    I think that everyone would agree there is a subjective component to third year clerkships grades, and it largely depends on factors outside of being a good doctor. To think that a third year clerkship is a final test of being a doctor is ridiculous to the point of absurdity. I have seen many a good students slammed on clerkship evaluations for apparently political reasons. Whereas students who struggle on the usmle step 1, 2, and objective measures of tests can grease their way past attendings and clerkship directors is sad. I agree with what the above poster said, USMLE Steps 1 and 2 are more objective. Students who are praised on a clinical clerkship often start bashing other students who didn’t get an Honors or High Pass, believing that they have somehow made the cut when really they may just have figured out how to please the attending without doing any work.

  10. Samir Desai says:

    Thanks for commenting on the column. I’ve been responding to some of these issues in the discussion thread for this article. Feel free to join in.

  11. AC says:

    I am completely mystified by what I have read in the above column. First of all, I bought Dr Desai’s book about how not to screw up, and some of the advice he gave actually screwed me on my clerkships. For example, the advice to “ask what is necessary to get honors” really ruined my relationship with the attending in family medicine. From then on he thought of me as just another gunner for honors. I think whoever read’s Dr Desai’s column ought to take his advice with a BIG grain of salt.

  12. medschoolfool says:

    I don’t buy this article. Either it is false, put together from selective data, or the program directors can’t admit openly what criterion they care most about. As subjective as 3rd year marks are, there is no way they put more value in those than they do in the USMLE or COMLEX. I suppose it makes them sound more concerned about clinical education, though, if they send the message to do well on ALL your core clerkships rather than on just 1 exam. If they reported any differently I’m sure that would open a whole other can of worms.

  13. Samir Desai says:

    Dear AC,

    I’m sorry about your experience but the advice you have received was not from me. In fact, if you go to and use the search inside the book feature (for the book – 250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them), you won’t find any such advice. Just put in the word “honors” and you’ll see eight pages of the book in which the word “honors” appears. You can access each one of those pages. Nowhere on those pages do I make that specific statement.

    I am an advocate of speaking with the attending at some point during the first few days of the rotation to get a sense of his expectations. If you don’t know your attending’s expectations, how can you possibly meet them? That’s why I recommend this meeting. Now, in this meeting, I would not recommend asking the attending “what is necessary to get honors.”

  14. Student says:

    My school has standard grading system during clerkships (A, B, C, F). Are A’s seen to carry the same weight as Honors?

  15. olliemctuffy says:

    I think people need to realize that it’s hard to extrapolate from a standardized test how good of a doc someone will be. It’s probably a little easier to tell based on how someone does in rotations based on clinical practice. While there may be grade inflation, docs in specific fields, especially those involved with education, tend to know one another and may well be discussing students. There is also grade inflation on standardized tests, ie those who can afford the review courses will inflate their scores, those who buy qbank or uworld will probably score better than those who just rely on reviewing old notes or 1st aid. These things cost money and not everyone can afford them. Therefore, board scores must be taken with a grain of salt.

  16. Dr. Abroad says:

    I would hope that all medical students could afford to buy good review materials, there are alot out there that are better than usmleworld and qbank. I know many people who used didn’t use either who did well. I really don’t think third year grades measure clinical practice, how many prescriptions or treatment plans did you generate all on your own as a third year? Third year is frantic with some students switching clinical sites every couple weeks. I think the students who study the hardest do very well on the steps, not based on which resources you use, but some might not known how important they are. . .the steps, especially step 2 deal with clinical scenarios and management questions which do pertain very well to the practice of medicine.

  17. Lydia says:

    You guys have thoroughly confused me. I am about to start my 3rd year and I have no clue what I am supposed to do now.

  18. Dr. Abroad says:

    Sorry! Didn’t mean to confuse you. I think the issue is that how to do well on a third year clerkship varies *alot* from institution to institution, the best advice you can get is from fourth years at your institution, if they are willling or care about helping third years, alot of times they are too busy. Third year is very political year that is very disorganized at alot of places, however, of course all students try to do very well in third year to get a competitive residency or to get a residency in a certain geographical area or just to become the best they can be. I would take with a grain of salt all of the hype as the posters of this article are selling a book, and benefit by enlarging the importance of third year as much as possible to scare students into buying their book and learning all the inside secrets. What they don’t tell you is that expectations and requirements vary alot by school, and you are best served being peer advised by upperclassmen, period.

  19. PS says:

    All Dr. Desai is saying is that rotations are important. He’s not saying that the USMLE is not important. Before third year, our dean said the same thing. He even referenced the same Wagoner article that the doc talks about.

    What I’m taking from this is that both are important. Do as well as you can on the boards. Ditto for rotations. To me, it’s not that confusing.

  20. Nate says:

    This is just bogus, especially with regards to the optho data. The early match specialties have offered interviews before dean’s letters are even ready. Offers no doubt based on LORs, away rotations, CV’s and board scores. That is way more info than you need to make a decision. Third year was there for me to learn to take care of patients, not to impress attendings/residents of varying comittment and quality.

  21. Dr. Abroad says:

    Although some clerkships are really great, others are more an abusive situation where some attending feels that they have a right to kick you around and treat you however they want, to the point of crying yourself to sleep some nights . . . Deans at medical schools have agendas as well, not the least of which is keeping complaints and concerns to a minimum, one way of doing this is impressing into students minds the power that attendings have over them by overinflatting the importance of third year clerk grades. . .less you complain. Most medical students today work harder than in the past because of decreased hours of work residents can put into the hospital AND increased patients loads, I felt like a resident on some rotations in terms of workload, more and more third years are employees that have no rights and less and less like students.

  22. Dr. Abroad says:

    As for not taking enough loans out to get the right books, get real, you are a medical student, your first priority should be getting good material to pass usmle, and do well. Studies show that those who take fancy board prep courses do worse anyhow. The medical student that cares most about learning medicine well will get the higher board score. Third year grades reward something else entirely.

  23. Samir Desai says:

    In reading your comments, I understand your concerns and respect your opinions. Again, it is my hope that through this column we can discuss some important issues as they relate to the residency match.

    Let me say that, as a student, I too felt that the clerkship grading system was unfair. The present system needs to be improved. I believe we are all in agreement on this issue.

    From your comments, I have gathered that because there is so much subjectivity in the clerkship grading process, people can’t believe that PDs/programs would place such emphasis on clerkship grades.

    Please understand that I am simply passing along to you information that was gathered from two surveys. Again, the Wagoner survey involved nearly 800 program directors representing 14 specialties. This is not my personal opinion but the thoughts of many people who are involved in the residency selection process.

    As an advisor at Baylor, I want to do everything I can to help my advisees match with the specialty or program of their choice. To help them make informed decisions, I do my best to review the literature and discuss issues with PDs/members of residency selection committees. I pass along this information to my students, encourage them to review the original work, and draw their own conclusions.

    It is my hope that these columns stimulate you to think about these issues, discuss them more in-depth with your own advisors, and use the information to help you develop a strategy – a strategy that will help you reach your professional goals.

    In closing, please join us in the discussion thread (about this column) under clinical rotations. I have addressed some of your issues there and would be happy to discuss this further.

    Happy fourth of July to you all,

    Samir Desai

  24. Arun Ivaturi says:

    Dear Drs. Desai and Katta:

    Thank you for a very valuable and timely appraisal of the medical student election to residency process.

    Needless to say, I, along with other medicine aspirants, do need a drumming in of these facts.

    There are those who prefer standardized tests. Often, these are people who are traditionally smart, high-intelligence students who have made learning very easy for themselves.

    They are, however, in my humble opinion not perhaps the best doctors.

    A medical doctor is, by and large, a people person. These soft, but essential skills can usually be well-assessed in interviews and personal statements; however, it is a technically trained doctor’s dilemma as to how a random sample of people hailing from an institution that one deems respectable be granted the privelege of such an opportunity.

    Here come to the rescue the so-called standardized exams. Well, not really. A test is so often a measure of rote memorization that one needs only measure a person’s time at study to determine their effectiveness at an exam. Point being noted, how do we suggest improving the tests…this is the discretion of accreditation boards and beyong the scope of my present message.

    Overall, I think, in all your wisdom, you agree that people who work well in a team are often cheerful, conscious and motivated. These are not exclusionary qualities by any manner and can be cultivated by all.

    Are we to say that we are in biased of such people on our recommendations? Laughably, yes.
    Should that exclude someone from being granted a high-pass or a high-honors, in my sincere opinion, where one fails is often a sign of commitment. If surgery rotations require a call every four nights, who is to say that the intern does not mind your leaving early so you can study for the USMLE.

    Regardless, I applaud your sensitive treatment of a topical subject, and would urge you to support the present evaluation method.

  25. Student says:

    It doesn’t make sense to base residencies on just test scores or on just clerkship grades. You get a better picture of someone’s ability as a doctor when you look at both. Can we all agree that both are important?

  26. Lemon says:

    The problem is that most “Clerkship” grades aren’t about how well you did on the clerkship, they are about how well you did on the SHELF EXAM at the end of the clerkship! So it all comes back to test scores … unfortunately. Otherwise, you have to connect with people and use social skills to get where you want to be. End of story.

  27. Disagree says:

    The article you cite was in 1999, just as the tide was turning away from primary care towards the specialties. At a time when applications to specialties wasn’t intense, board scores were not as emphasized. Fast forward eight years, and I’d say that Step 1 is most important, followed by clerkship grades. Why else would Derm/Plastics/ENT step 1’s be an entire standard deviation higher than say psych/im/fp? My guess is the authors harken from a time when the step 1 wasnt important for residency selection. it certainly is now.

  28. drawkward says:



    you guys are neurotic. do you really think that there’s a secret formula out there that everyone uses to determine which residency you get? do you really think that a number (whether it’s your awesomely awesome board scores or your honor society membership or your 3rd year grades) is going to be the sole determinant of where you end up?

    lemme break down some knowledge for you: there is no single thing that will gaurantee/disqualify you from the bestest residency evah. we know you all like, totally rawk and each of you is unique and special. that’s why med school and residency applications leave only a few lines for your academic acheivements. b/c you’ve all already shown you’re the smartest dawg out there. now all you have to do is show what other tricks you can do.

    did you ever join the student government and ry to actually help out your school or student body? work with faculty, not to get a letter out of them, but to get some meaningful work done? ever volunteer at a shelter in medical school? ever stay late to help out your intern (w/o then trying to weasel your way into a higher grade)? have you ever done anything for others that you haven’t put down on your resume? because if you have, then you wouldn’t be worrying if your board scores were just 10 points above the national average, or if you only high passed your biochemistry class. because you’d realize that there is no one field out there that will make you the happiest, or one program where all your dreams would be realized. you’d finally wake up and realize you’ve already made it.

    a common problem among medical students is that we’re always racing to the next place. basically, you’ve spent your life going to infinity and beyond. and when you reach infinity, there’s really nowhere else for you to go but . . . beyond.

    so calm down.

  29. Larynxxz says:

    Interesting article and comments. I see that Dr. Desai has stirred up a storm here. This is a sensitive topic for many colleagues (I am a 4th year) and I can understand people’s outpour. Articles and comments such as these used to give me tachycardia but honestly, I don’t care anymore. I am actually drinking a glass of wine as I type this.

    I must mention this: if I ever become a program director, I will probably not take a second glance at clerkship grades. Yes, an H looks fantastic…but there is no information about the site, workload, the attending, organization etc (and I don’t/won’t bother to ask). After straight 52 weeks of requires and electives in private, county and independent nonprofit healthcare facilities, I have slowly realized that your clerkship grade may say a lot OR nothing at all but you are the only soul who holds the answer to that.

    So, let’s face it: while step 1 scores may not be the best predictor for overall performance, it’s the best tool in initial application strength. I don’t care what the PDs say–their secretaries do the screening while they are in the OR (they really don’t have time to screen 400 applicants for, let’s say 4 positions in ENT). Plus, if you can do well on step 1 & 2 enough to distinguish you from peers, then you either worked really hard like most medical students or you are just gifted in taking exams such as these.

    So, if I become a PD, yes, step 1 would be important. More than clerkship grades. In surgery, I busted my a$$ on the floor, carrying more than 5 patients at once and practically present in all surgeries and trauma call. Studied everyday. Aced the oral…average on shelf (I actually thought I was going to fail) and ended up with an E…primarily because of a surgeon. In OB, I paid more attention to taking histories, and doing pelvic floor surgeries. LDR was boring, csections were interesting. And I definitely had a great time raiding the surgery lounge refrigerator while looking forward to my ‘S” (at this point, I was a fustrated third year medical student—I was really pi$$ed off with the bureaucracy and unethical nature of clerkship grading). But I got an H. And guess what? PDs have no clue how I got those grade.

    So, for the PDs that love clerkship grades, goodluck in perpetuating your delusions. I’d rather focus on step 1, research and community involvement. Back to my wine…

  30. Larynxxz says:

    Oh yeah…just to drive in the ridiculous percentage rule home, after all the fluids, learning and sleep deprivation, I managed an overally 93% in medicine. Clinical grade was H but final grade was transformed in an E? Why? Because I took it towards the end of the year and the % limit for honors was 30%. The next period, a friend took the course, ended up with a 87%, clinical grade H, final grade H. Why? it was the start of the new academic year thus he had a better chance.

    Seriously, tell me that is not messed up. I am proud of my E in medicine but if any PD looks into me eyes and tell me that my E is not good enough for them, then I am better off in a different program and they can shove the H. Literally.

  31. Homer says:

    #1 PDs will never admit that they use step 1 to cull the number of applicants. Say A PD has 100 applications for 2 spots in rad onc… (this would not be unusual). You bet the program secretary screen’s out ~75% applicants bansed SOLELY on USMLE step 1.

    #2 Can you imagine if a PD admitted to #1 above? It would undermine the very philosophy of undergraduate medical education.

  32. Anonymous says:

    amen drackward

  33. Nate says:

    HI…. my girlfriend is studying medicine in english at a medical university in europe and is a 3rd year student she would love to come and do her clerkship here in the states this summer. can anyone here offer me any advice about how this process can be completed or what must take place for her to come. any advice would help. thanks

  34. Vasca says:

    Wow, med school grading during clerkship years is very different than in Mexico.

    My 3rd year while it was traumatic in two subjects because I kind of unfortunately ended up in the toughest “base” hospital by random selection (or maybe simply because the guy at my university in chrage of doing the selection simply dislikes me). But, other teachers knew how tough we had it and made our lives easier by demanding less of us than students from the easier base hospitals. I got a 9.7 in Medical Genetics and I’m still not fully sure how I did it. Students from a different base hospital that had the same teacher got on average 8.4 or something.

    Save for a few subjects, most of my subjects were in the base hospital and so while I had different rotations that lasted a couple weeks each, they were all in the same hospital. It’s now in my 4th year that we’re running all over the place. I’ve had days where I had to be in two hospitals in two very different parts of the city plus another trip to my university faculty for another non clinical class. Without a car.

    In my experience, unless you’re rotating with the head honcho doctor of that specific clerkship subject, you can do crappily on a rotation and it won’t matter much at all in your final grade. As long as you show up (or maybe just skip the rotation half of the time and just show up once for the signature that you at least kind of showed up), that’s all that matters. I never sucked up to any doctor, I was just polite, knew when I didn’t know the answer to something and participative because I felt like it. Only once has a resident complained about me and the guy was a jerk to everyone (plus his opinions never afected my grade in the subject). In mexico showing up for rotations is more because YOU WANT TO LEARN, rather than sucking up for grades. Your numeric grades comes from the exams of that specific subject. You won’t have many chances in the future to do pelvic exams unless you dedicate to OB/GYN, so use the chance while you still can to have a taste of every medical field even if you won’t dedicate yourself to it as a resident. I’ll never become a surgeon but still volunteered to help in operations anytime I could. I took out a placenta just a few weeks ago and would have caught the baby had I washed my hands just 30 second quicker. >_< Stuff like that just can’t be learned from a book.

    Of course, mexican med schools don’t have USMLE equivalent exams, just the final professional exams that are done after you finish your internship year. You’d think then that becomming a resident was easy but it isn’t. Your sole chances of getting into a residency depends on your scores on the national residency exam which they say is tough as hell to pass with flying colors; much less to pass, period. It’s an exam designed to screw people and require book knowledge above all, and to know how to answer those kinds of exams.

    Therefore, over here as long as you pass the subjects, your rotations don’t matter much academically in a direct way, but skipping rotations means you learn less which will affect your performance later on.

  35. 3rdyearhater says:

    Third year grades do probably matter significantly, but unfortunately, doing well in them is not really in your control. Some schools, like mine, give barely any weight to shelf exams, so your grades are mostly about your interpersonal luck at that time.

    It was relatively rare that an attending actually took the time to watch me take a history or do a procedure, yet they were asked to rate (and routinely DID rate) my abiities in those realms. Given how busy they are, I think most attendings just come to a gestalt impression of students based on a few minutes of interaction. Giving a lukewarm impression in those crucial moments can wipe out the impact (on your grade) of hours of work on the wards.

    If you’re good at impressing people in brief interactions, then you’re golden for third year.

  36. seraphmaiden says:

    So I’m trying to figure out where I stand with the application process I have some really good things on my application – 252 board score, 3 publications one first author, but my third year grades have been pretty evenly split between B and B+. My comments have all described strong work ethic and playing well with others – but not so much translated into the grade.
    So, am I screwed? I’m looking to match in anesthesia…

  37. Somebody says:

    Hi guys. Do clerkship grades matter for IMGs? Or does it just come down to USMLE scores and Letters of recommendation? I’m confused now.

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