Background and hypotheses This study is the first to offer an in-depth comparison of elimination testing with the scoring rule of Arnold & Arnold (hereafter referred to as elimination testing with adapted scoring) and negative marking. As such, this study is motivated by the search for an alternative for negative marking that still discourages guessing, but is less disadvantageous for non-relevant student characteristics such a risk-aversion and does not result in grade inflation. The comparison is structured around seven hypotheses: in comparison with negative marking, elimination testing with adapted scoring leads to (1) a similar average score (no grade inflation); (2) students expressing their partial knowledge; (3) a decrease in the number of blank answers; (4) no gender bias in the number of blank answers; (5) a reduction in guessing; (6) a decrease in self-reported test anxiety; and finally (7) students preferring elimination testing with adapted scoring over negative marking. Methodology To investigate the above hypotheses, this study implemented elimination testing with adapted scoring and negative marking in real exam settings in two courses in a Faculty of Medicine at a large university. Due to changes in the master of medicine the same two courses were taught to both students of the 1st and 2nd master in the same semester. Given that both student groups could take the same exam with different test instructions and scoring methods, a unique opportunity occurred in which elimination testing with adapted scoring and negative marking could be compared in a high-stakes testing situation. After receiving the grades on the exams, students received a questionnaire to assess their experiences. Findings The statistical analysis taking into account student ability and gender showed that elimination testing with adapted scoring is a valuable alternative for negative marking when looking for a scoring method that discourages guessing. In contrast to traditional scoring of elimination testing, elimination testing with adapted scoring does not result in grade inflation in comparison with negative marking. This study showed that elimination testing with adapted scoring reduces blank answers and finds strong indications for the reduction of guessing in comparison with negative marking. Finally, students preferred elimination testing with adapted scoring over negative marking and reported lower stress levels in elimination testing with adapted scoring in comparison with negative marking.