Clerkships

Part of Medical School. Third year is the first time you are graded by people rather than by answer keys, and nobody hands you the rubric because there mostly isn't one. This is how clerkship grading actually works, why it rewards behavior no course taught you, what it looks like from the other side of the evaluation form, and what to do about the part of it that is not fair.

The short version

Your grade has two halves and they behave completely differently. A subjective clinical evaluation, and a standardized shelf exam. One is a person's impression; the other is a test.

The impression is formed early and by people who saw you intermittently. Residents and attendings rotate, and the person writing about you may have worked with you for a handful of shifts.

What reads as "strong" is mostly a set of behaviors nobody teaches, and students with a physician at home arrive already fluent in them. That is the hidden curriculum in its purest form, and naming it is most of the fix.

Clerkship grades matter more since Step 1 went pass/fail, because programs have one fewer number to sort on. The Step Exams covers that shift.

The two halves of a clerkship grade

The shelf exam is an NBME subject test at the end of the rotation. It is standardized, it is scored, and it is the half you can prepare for the way you have prepared for everything else. If you are good at exams, this is where that pays.

The clinical evaluation is a set of forms completed by residents and attendings who worked with you, usually rating you on things like knowledge, professionalism, reliability, and "commitment to learning," plus a free-text comment. Those comments feed your Medical Student Performance Evaluation, the letter your school writes when you apply to residency.

The weighting between the two varies by school and by rotation, and the free-text comments frequently matter more than the numbers, because they are what a program actually reads.

The evaluation is a judgment, and it has known problems

This is the part to understand clearly.

Grading is not consistent between schools. What counts as honors varies enormously, and the proportion of students receiving the top grade differs so much between institutions that the same performance can produce different grades depending on where you enrolled. Programs know this, which is part of why they lean on standardized measures.¹

Small differences in assessment become large differences in outcome. Clerkship grading compresses a continuous judgment into a few tiers, so a marginal difference in an evaluator's impression can move you a whole grade, which then moves honor-society eligibility and how your school describes you in its letter.

The best study of this looked at four years of one school's data and found the underlying ratings from clerkship directors differed only modestly between groups, while the outcomes did not: students underrepresented in medicine received roughly half as many honors grades and were about a third as likely to reach the honor society.¹ A small difference in judgment, amplified by the tiering, into a large difference in what a residency program sees.

The disparity shows up again at the honor society itself. A national study of Alpha Omega Alpha membership found that after adjusting for academic performance and other factors, Black students had an adjusted odds ratio of 0.16 relative to white students, and Asian students 0.52.²

If you are reading this as a student who has spent a long time being the only one in the room, none of that is paranoia and you are not imagining it.

None of that means the evaluation is worthless or that you should disengage from it. It means the evaluation is a human process with known failure modes, and the useful response is to be deliberate about the parts of it you can influence.

What this looks like from the other side

I want to step out from behind the third person for this part, because most of what follows is not research. It is what it is like to be one of the people filling in the form.

Residents and attendings are human. We are tired, we are behind on notes, and we are doing this on top of the job. We also see a lot of students, year after year, and the pattern recognition gets very good. We know who is dragging their feet and checking boxes, and we know who actually cares. The evaluation form has no box for that, and it is most of what the free-text comment is really describing.

That cuts both ways, and the encouraging half is the one students underestimate. Caring is legible. It shows up in whether you know what happened to your patient overnight, whether you looked something up because it bothered you, whether you are still curious at week five. None of that requires you to be the smartest person on the team, and none of it is a performance you have to sustain. It is mostly just being interested in the work in front of you.

The other thing, and it is the one I would most want a student to hear: you are spending something on the order of a quarter of a million dollars on this education, and third year is the part of it you cannot get back. Make it worth the money. Ask questions. Take the thing on before somebody assigns it. The students who treat the year as a hurdle to clear get through it, and they get a shallower version of it than the ones who treat it as the first year of the job.

A caveat on all of this, and it is a real one. My training is internal medicine, and the specifics below lean that way. The kernels generalize; the etiquette does not always. A surgery team and an outpatient allergy clinic run on different clocks and different manners, and a few of the concrete examples here will need translating.

Mistakes

Nobody expects a third-year to know everything, and anybody who acts like they do has forgotten what third year is. Making a mistake is fine. Making the same mistake twice is the thing that gets remembered.

That is the whole standard, and it has a practical consequence: when you are corrected, write it down. Not metaphorically. Actually write it down, that day, and read it back before the next shift. A student who is corrected once and never needs it again reads as someone who is going to be safe to work with in two years, which is what the person filling in the form is actually trying to predict.

The day does not end when you get home

This is the part that surprises people, and it is worth knowing before week two.

The shelf usually has to be studied for after hours. The clinical day is the clinical day. If your rotation is busy, the exam preparation happens in the evenings, and pretending otherwise is how people end up with a good evaluation and a bad shelf score.

Study every diagnosis your patient has, not just the one you admitted them for. A patient with heart failure, diabetes and cirrhosis is three curricula standing in one room, and you are the only person on the team with the time to read all three.

Become the expert on your own patients. Look up the trials that govern what you are doing for them. If the team is deciding between two drugs, find out what the evidence actually says and be able to say it in two sentences. This is the single highest-leverage habit available to a student, because it is the one place where you can genuinely contribute something the intern did not have time to find.

A post-it note of teaching on rounds, where it fits. Not a lecture, not every day, and read the room. Thirty seconds of "I looked into why we picked this one, and here is what the trial found" is what people remember six months later when they are asked to describe you.

Your patients

You have two or three patients. The team has thirty. That asymmetry is your whole advantage and it is also a genuine service.

Be the person they can find. Sit down. Explain what is happening in words they use. If you do this, your patients will start telling you things they did not tell anybody else, and some of those things will change the plan, and everyone will notice where that came from.

Go with them. To the procedure, to the cath lab, to the scan. Sit in on a physical therapy or occupational therapy session. Few students think to, and it is the fastest way to understand what actually happens to a person inside a hospital, which is knowledge you will use for the rest of your career.

Be kind, including when it is inconvenient. This is not a strategy and it should not need saying. It also happens to be the thing your patients report back to your attending.

What actually reads as strong

Be there, and be findable. Reliability is the most common thing praised in evaluations and the most common thing criticized in their absence. Arriving before your team, staying until the work is done, and telling someone when you leave will put you ahead of a real fraction of your class.

Know your patients better than anyone else on the team. You have two or three; the intern has ten. Depth is the one dimension where a student can genuinely be the most useful person present, and it is what makes a resident say you were good.

Read about your own patients, not the textbook in general. Look up the specific question your patient raises overnight, then say what you found on rounds. This reads as ownership and is also how you actually learn.

Ask for work. "Is there anything I can take off your plate?" is a sentence that changes evaluations. So is doing the unglamorous task without being asked twice.

Take feedback without defending yourself. The most damaging free-text comment is that a student was defensive about correction. Say thank you, write it down, do it differently tomorrow.

Ask for feedback in the middle, not at the end. Around the halfway point ask, in these words: what could I do in the second half of this rotation that would make you evaluate me more highly? That question is disarming, it is specific, and it converts a private impression into something you can act on while there is still time.

Work on your oral presentations until they are boring to you. The presentation is the unit of assessment on most teams, and it is a skill rather than a talent: a fixed order, the relevant positives and negatives, an assessment that commits to something. Practice them out loud, alone, before you give them. People will remember how you present and how you talk about your patients far more than they will remember your notes. Know what your team expects from a note and meet it, then put the extra hour into the presentation.

Be honest with yourself about what you do not know. Not performatively, in front of the team; privately, so you can fix it. Students who cannot name their own gaps do not close them, and by fourth year that shows.

If you have a physician in your family, you have been absorbing some version of this since childhood. If you do not, you are learning it now, and the fact that it had to be written down is the point.

The parts of the year that are not about you

You are being evaluated from the first hour. Impressions form fast and are updated slowly. The first two days of a rotation carry more weight than they should.

Residents write most of what is said about you, even where an attending signs it. Residents are exhausted and are doing this on top of the job. Being easy to work with is not sycophancy; it is the largest single input you control.

Rotation order is often a lottery, and it matters. Your first clerkship is the one where you are worst at being a medical student, and if it happens to be in a field you were considering, that is a bad sample rather than an answer.

The shelf can be scheduled against you. A six-week rotation with a heavy call schedule and a shelf at the end is a different exam than the same shelf after a lighter block. Ask upperclassmen which rotations at your school are known for that, and plan the study time accordingly.

Away rotations cost real money. Housing in another city, travel, and application fees, in a year when you are not earning. Specialty societies run visiting-student scholarships that are consistently undersubscribed, and your student affairs office knows which ones exist for your field. Fourth Year covers this cost block.

The etiquette nobody writes down

None of this is in a syllabus and all of it is being observed.

Residents are casual with you, and they still grade you. This confuses people, reasonably. The tone on a good team is friendly and the assessment is real, and both things are true at once. Being liked is not the same as being evaluated well, but being difficult to work with is reliably evaluated badly.

Your senior resident probably has the most say in your grade. Not the attending, in many cases. The senior is the person who watched you all month and the person the attending asks. Introduce yourself to them properly on day one, and set explicit goals with both of them early rather than waiting for the mid-rotation feedback conversation to be scheduled for you.

The downtime script. When there is nothing obvious to do, in order: ask if there is work you can take on. If there is not, ask whether it is all right for you to study. If there is genuinely nothing, "is there anything else I can do to help?" is the polite way to ask whether you can go, and it lands very differently from "can I leave?"

Do not be the student who is visibly waiting to leave. Standing near the door, doing question banks in the workroom while the team is still working, asking about the end time on day one. Even on a slow service, this is the most common thing I have heard held against a student, and it is usually a misread of the room rather than a character flaw.

Specialty cultures differ more than anyone warns you. Asking to leave a surgical service early does not land the way asking to leave an allergy clinic at four does. That is not a rule anybody publishes; you learn it by watching what the residents on that service do. When in doubt, match the seniors' behavior for the first week and adjust after.

None of that means you cannot advocate for yourself. Go to your own medical appointments. Take the day you need. Flag it early and in writing, to the senior and the clerkship coordinator, ideally before the rotation starts. A planned absence mentioned in week one is an administrative detail. The same absence mentioned the night before is a problem, and the difference is entirely in the timing.

Character is being assessed, and it should be

Some of this is uncomfortable to write down, and leaving it out would be worse.

Do not talk badly about your colleagues, the nurses, or other patients. Not in the workroom, not in the elevator, not when the person you are talking to started it. It travels, it always travels, and it is the fastest way to be remembered for something you cannot undo.

Do not let someone else's burnout become your standard. You will meet people who are cynical, short with patients, or checked out. Some of them have earned the exhaustion honestly and are still not people to copy. Their behavior is information about the system they are in rather than instruction about how to be.

There is no excuse for meanness in medicine. It exists, in particular places, specialties and people, and being tired is not a defense for it. Nobody is perfect, myself included, and that is not a reason to lower the standard you hold yourself to.

The line I was given in training was that the people you want are nice, hardworking and smart, in that order. Nice comes first. I have never seen a reason to reorder it.

The uncomfortable part

Evaluators often remember how a student made them feel more precisely than they remember what the student said or did. That is not how it should work and it is how memory works.

The practical consequence is unfair and it is still the consequence: a quiet, capable student is frequently less memorable than a student who is appropriately confident, visibly eager, and quick to take on something new. If you are introverted, read that as a reason to make the substance you already have visible rather than as an instruction to become somebody else: volunteer for the thing once a day, ask the question you were going to ask silently, and make your mid-rotation feedback conversation happen.

And if you are on the other side of this one day, remember that the shy student in the corner is often the one who knew their patients best.

If an evaluation is wrong

Sometimes one is, and there is usually a process.

Read your own evaluations. Many students never do. You cannot contest something you have not seen.

Distinguish a harsh evaluation from an inaccurate one. A poor grade you disagree with is usually not appealable. A factual error, or a comment describing an incident that did not happen, often is.

Go to the clerkship director first, in writing, calmly, with specifics. Escalate to the dean of students only if that fails.

If the problem is bias rather than accuracy, that is a different route, and it is worth using rather than absorbing. Most schools have an ombudsperson or an office for student mistreatment, and reporting is confidential. Absorbing it quietly is the default for students who feel they are guests in the institution, and it protects nobody.

Mistreatment, and the honest version of what happens when you report it

This section exists because third year is where it mostly happens, and because a student who has never had the word defined for them will absorb things that were never acceptable.

Know what it is. Mistreatment is a defined category rather than a feeling: public humiliation, being threatened with a lower grade for reasons unrelated to performance, being asked to perform personal services, being subjected to offensive remarks or discrimination based on race, gender, religion, sexual orientation or anything else, and unwanted sexual advances. Your school publishes its own definition and its own policy, because accreditation requires it to. Read it before you need it, in the first week, when it is an abstraction.

Know the routes. There is usually more than one: the clerkship director, the dean of students, an ombudsperson, an anonymous reporting line, and often a Title IX office for a subset of it. They are not interchangeable, and the ombudsperson is generally the one you can talk to first without starting a formal process.

And the part that gets left out. Most students who experience mistreatment do not report it, and one of the reasons students give is fear of reprisal.³ I am not going to tell you that fear is irrational. Our culture is behind on this, retaliation is not supposed to happen, and I will not claim it never does.

What I will say is that the calculation is worth making deliberately rather than by reflex. Talking to an ombudsperson costs you nothing and starts nothing. A pattern that is documented, even informally and even later, is the thing that eventually moves a person off a teaching service. And the students who most reliably absorb it in silence are the ones who already feel like guests in the building, which means the silence is not distributed evenly and neither is the cost.

If it happens to you, the first useful step is small: write down what happened, when, and who was present, on the same day. You are not committing to anything by having a record.

What belongs to other pages

Which exam carries a number now, and what the whole resource stack costs, is The Step Exams.

How the specialty decision actually gets made out of these rotations is Choosing a Specialty.

What the four years look like as a whole is The Match, and What Happens If You Don't.

If a rotation is where things stop being survivable, that is Imposter Syndrome & Burnout, and Taking a Leave covers pausing without wrecking your loans or your insurance.

Where this fits on the Road

Third year is where the abstract version of being a doctor becomes the actual job, and it is also the year that most shapes what you can apply to. A strong third year opens doors that stay open for a decade. A bad one narrows what you can realistically apply to, and it does that quietly, through a set of comments you may never read. That is a heavy thing to put on a twelve-month stretch, and the reason it is worth writing down is that most of what separates the two is preparation, information and mindset rather than ability.

The two things worth doing on day one are asking for mid-rotation feedback and reading about your own patients. Both are free, neither is taught, and together they are most of the difference between a good evaluation and an average one.

And underneath all of it: be a good human first. Everything else on this page is downstream of that, including the parts that look like tactics.

Grading structures, weighting between shelf and clinical evaluation, appeal processes, mistreatment definitions and reporting routes, and honor-society criteria are set by each school and vary widely. Confirm your own school's policies, which are published, before relying on anything here. The sections written in the first person are one internal medicine physician's account of evaluating students, not a rule, and rotation etiquette differs by specialty and institution more than any page can capture. Educational information, not advice. — Last reviewed: 2026-08-11

References

Teherani A, Hauer KE, Fernandez A, King TE Jr, Lucey C. "How Small Differences in Assessed Clinical Performance Amplify to Large Differences in Grades and Awards: A Cascade With Serious Consequences for Students Underrepresented in Medicine." Academic Medicine, September 2018. Verified 2026-08-03. Studying classes from 2013 to 2016, the authors found that differences in clerkship directors' underlying ratings were modest, while the resulting differences in outcomes were not: students underrepresented in medicine received roughly half as many honors grades and were about three times less likely to gain honor-society membership. That gap between a small difference in judgment and a large difference in consequence is the mechanism described above. https://pubmed.ncbi.nlm.nih.gov/29923892/ ↩ ↩²
Boatright D, Ross D, O'Connor P, Moore E, Nunez-Smith M. "Racial Disparities in Medical Student Membership in the Alpha Omega Alpha Honor Society." JAMA Internal Medicine 177(5):659–665, May 2017. Verified 2026-08-03. After adjusting for academic performance and other factors, Black students had an adjusted odds ratio of 0.16 and Asian students 0.52 for membership relative to white students. https://pubmed.ncbi.nlm.nih.gov/28264091/ ↩
The national numbers on mistreatment and on whether students report it come from the AAMC's Medical School Graduation Questionnaire, which every graduating student is asked to complete and whose All Schools Summary Report is published annually. Checked 2026-08-11: the summary reports are published as spreadsheets behind a download that returns HTML to automated tools, so this page states the direction rather than quoting a percentage it could not verify at source, which is the same choice footnote 2 above makes about grading systems. The consistent findings across editions and the peer-reviewed literature that analyses them are that a substantial minority of graduating students report having experienced at least one mistreatment behavior, that most of those students do not report it to anyone at the school, and that fear of reprisal is one of the reasons given, alongside believing the incident was not serious enough and believing nothing would be done. Your own school's definition and reporting routes are what matter for you and are published, because accreditation requires them to be. https://www.aamc.org/data-reports/students-residents/report/graduation-questionnaire-gq ↩