Each year, admissions officers throughout the United States commit many intense months to reviewing applications to their college/university. According to the College Board, there are established key elements considered in admissions decisions, including grades in college prep courses, standardized test scores, overall academic performance, and class rank. Approximately half of high schools in the U.S. provide class rank, yet it has maintained importance as the number four factor for over a decade, trumping other factors such as extracurricular accomplishments, teacher recommendations, and interviews. A student’s rank-in-class can be used to determine their relative achievement within his or her school, to compare them to the entire applicant pool at a college or university, and to rate students for scholarship selection, along with selections for countless other accolades and financial awards. Rank is calculated across a wide span of methods using grade point averages (GPAs) that sometimes account for course rigor, and sometimes do not. So that colleges/universities might evaluate rigor and competitiveness of each applicant based on the school’s institutional priorities, I contend that colleges/universities should recalculate GPAs as provided from the high school, giving weight to what they value as an institution. Over the past year, I have dramatically shifted my belief in the way rank ought to be used. Earlier in my admissions career, I believed rank was accurate and useful. Now that I have taken significant time to consider the role of rank from the perspective of a school counselor, I realize that it is not the beacon of precision. It has become increasingly clear to me that it is the job of colleges/universities to rank high school students; it is not the job of high schools. During months spent speaking with current and former school counselors, and my own motivation to become a school counselor, I realized that it does not ultimately benefit high schools to provide colleges with rank and it does not benefit colleges to use a precise rank that is born out of one specific context.

Moving to a pass/fail curriculum has generally been associated with decreased levels of stress and increased medical student well-being. However, not much research has been done to identify the specific effect of retaining class rank in a pass/fail curriculum and how this might affect student stress levels. The purpose of the current study was to fill in current research gaps in this area and to provide further insight into some of the factors that contribute to medical student burnout. The study was carried out using the Medical Student Well-Being Index (MSWBI), a self-reported survey that evaluates medical student fatigue, depression, burnout, anxiety/stress, and mental/physical QOL on a weighted and unweighted basis. Additionally, a set of add-on questions developed by the research team were distributed to participants along with the MSWBI. These questions asked the students to determine whether the change to a pass/fail curriculum increased, decreased, or did not change their perceived stress levels and to identify the major sources of their perceived stress. Participants were full-time medical students enrolled at ETSU Quillen College of Medicine from the Fall 2019 to Spring 2020 terms. They were divided by graduation year and asked to complete the MSWBI and IRB-approved add-on questions once per school year during this period. The number of add-on question respondents from each class reporting an increased or unchanged level of stress since switching to a pass-fail system encompassed 62.6% of all respondents. The most common reason provided by respondents for either increased or unchanged levels of stress after switching to a pass/fail curriculum was the continued reporting of class rank. This work will be useful in determining the true sources of student stress within the medical education system. While a pass/fail curriculum may reduce medical students’ perceived stress, this data indicates that class rank remains burdensome for many. Understanding the underlying factors that influence poor medical student well-being can lead to better targeted interventions.