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Background: It is not known how well dean's letter rankings predict later performance in residency. Purpose: To assess the accuracy of dean's letter rankings to predict clinical performance in internship. Method: Participants were medical students who graduated from the University of Rochester School of Medicine and Dentistry in the classes of 2003 and 2004. In their Dean's Letter, each student was ranked as either 'Outstanding' (upper quartile), 'Excellent' (second quartile), 'Very good' (lower 2 quartiles), or 'Good' (lowest few percentile). We compared these dean's letter rankings against results of questionnaires sent to program directors 9 months after graduation. Results: Response rate to the questionnaire was 58.9% (109 of 185 eligible graduates). There were no differences in response rate across the four dean's letter ranking categories. Program directors rated students in the top two categories of dean's letter rankings significantly higher than those in the very good group. Students in all three groups were rated significantly higher than those in the good group, F (3, 105) = 13.37, p < .001. Students in the very good group were most variable in their ratings by program directors, with many receiving similarly high ratings as students in the upper 2 groups. There were no differences by gender or specialty. Conclusion: Dean's letter rankings are a significant predictor of later performance in internship among graduates of our medical school. Students in the bottom half of the class are most likely either to underperform or overperform in internship. [ABSTRACT FROM AUTHOR]