Petition For Letters Of Administration Standard Form 3: Fill & Download for Free

I’m unclear what you are asking, so I will provide some assumptions:Someone has died.It is not known if they had a Will.You hire an attorney to open a probate for the Decedent’s estate and ask the Court to appoint you as its Administrator (ie, Personal Representative with no Will).The Court does so and issues to you Letters of Administration.In the course of your administration of the estate, you discover a Will for the Decedent (this happens more often than you might suspect)—- the Will names either you or someone else as the Executor (ie, Personal Representative with a Will).Question: What do you do now?In any case, you promptly file the Will with the Court as a document in the Decedent’s probate estate —- best with your Declaration re how and when and where etc. you found it.If the Will names you as Executor, you petition the Court to admit the Will to probate, to remove you as Administrator, to cancel your Letters of Administration, to appoint you as Executor, and to issue to you Letters Testamentary.If the Will does not name you as Executor, you write a letter to the named Executor and include a COPY (not the original, which you have filed) of the Will, inform him/her of the situation, and ask how he/she desires to proceed. If they want to proceed, they should petition the Court to do as above, ie, to admit the Will to probate and remove you as Administrator, and to appoint them as Executor. If not, then inform the next successor Executor named in the Will. If no named Executor is willing to serve, then you petition the Court to have the Will admitted and to appoint you as Administrator WWA (“with Will Annexed”), meaning that the Decedent died testate but with no named Executor who is willing to serve. I’ve been in this position many, many times. It’s no big deal. Just a matter of following standard procedure.Richard Wills, retired probate attorney originally licensed in CA & WA

Time frame: mid 1980's.I had nearly perfect grades. My high school used straight percentage points (100% meant you didn't miss a single question). At graduation my average was 97.24% (on average I missed 1 out of every 36 questions). Regular GPA's (4.0 scale) hide the difference between a high A, an A and a low A. I had the highest average in my school every year during high school and was consistently ranked #1 in my class and the entire school.Math skills: I completed the math curriculum by my junior year (through AP calculus). My senior year I taught the class 1 day/week. I also won a few county wide math contests. Because I completed the math curriculum early (I couldn't take AP Calculus again for credit), I would have been ineligible, for academic reasons, to play varsity football my senior year. The faculty and administration, petitioned the state legislators to rewrite the academic requirements to match my exceptional circumstances (which the state did).Science: I had a perfect ACT score for sciences.Extra curricular activities: Varsity letters in Cross Country (3 years), Track and Field (3 years as a thrower and runner), Swim Team (1 year - my high school started the swim program at my request), Football (1 year), Rifle Team (1 year). I played in the band (first chair), was a sailing instructor (NJROTC high school) and was the second highest ranking cadet (300+ students). I was also a member of half a dozen different clubs.Every teacher I had volunteered to write letters of recommendation.

Q. In medical schools with pass/fail system, how do residencies discriminate the good candidates from the bad ones?A2A:Can a Pass/Fail Grading System Adequately Reflect Student Progress?Selection criteria for emergency medicine residency applicants.Effect of USMLE on US Medical Education (aamc.org).Pass-fail is here to stay in medical schools. And that's a good thing.Grading Systems in Medical School: Pass/Fail or A-F Scale?A Medical School goes Pass/Fail only: Why this is an Excellent Change!Can a Pass/Fail Grading System Adequately Reflect Student Progress?At Vanderbilt University because we maintained four grading intervals in the clinical years, we experienced no measurable change in the outcomes of our residency match. For schools that use a pass/fail only system throughout the 4-year curriculum, program directors rely more on qualitative measures, such as the comments recorded on clerkships assessment forms, letters of recommendation, and the nature of student leadership and scholarship accomplishments. With a sense that these subjective measures are less reliable than the objectivity of grades, program directors also tend to rely more heavily on Step 1 scores and the reputation of the medical school.Selection criteria for emergency medicine residency applicants.Acad Emerg Med. 2000 Jan;7(1):54-60.Survey of program directors in Emergency Medicine.Most important: EM rotation grade, interview, clinical grades, and recommendations.Moderate emphasis: elective done at program director's institution (USMLE) step II, interest expressed in program director's institution, USMLE step I, and awards/achievements.Less emphasis: (AOA) status, medical school attended, extracurricular activities, basic science grades, publications, and personal statement .Of the 94 respondents, 37 (39.4%) had minimum requirements for USMLE step I (195.11 +/- 13.10), while 30 (31.9%) replied they had minimum requirements for USMLE step II (194.27 +/- 14.96).Results are compared with those from previous multispecialty studies.Curriculum Inventory in ContextJuly 2016 Volume 3, Issue 7Click to view complete chart onlineEffect of USMLE on US Medical Education (aamc.org)Pre-clerkship curricular enhancements in medical education are undermined by medical students’ focus on their USMLE Step 1 scores and the threat of not acquiring a residency position. Fears of the licensure examination also thwart medical school efforts to created patient-centered care from day one.Medical educators are challenged continuously on issues around enhancing student learning, providing them with support throughout medical school, preventing and addressing burnout, and much more. We struggle with how much content to expect students to master in medical school, how to balance new content with foundational content, and how to help students become self-directed learners for life. The Curriculum Inventory reveals that over 90% of US medical schools have changed their curricula recently or currently are planning or implementing change. These curricular and pedagogical changes require a large investment of resources on the part of medical schools and their faculties. We hope the returns on those investments are medical students who acquire the knowledge, skills and behaviors necessary to ease seamlessly into their clerkships and graduates who are prepared to transition into residency and the supervised practice of medicine.For decades, schools have focused attention on reducing the competitiveness that the pre-medical system required of students in order to get into medical school. We recognize that these behaviors are unhealthy for student wellness, for their learning and for patient care. We know that the best learning, patient care, research and administrative leadership emerges from high functioning and diverse teams— the antithesis of the “cut-throat pre-med.” According to the Curriculum Inventory, dichotomousPass/Fail grading has been implemented at 60% of medical schools as an effort to encourage collaboration and teamwork among students. It largely has been effective. When our school converted to P/F grading in 2003, we realized a more collaborative and supportive learning environment with no statistically significant change in performance on assessments and no change in USMLE Step 1 scores. We did see a statistically significant improvement in student well-being until the semester prior to the taking of USMLE Step 1 when that improvement fell off. (Bloodgood, et al.)A recent conversation on the Dr-ED list serve highlighted the conundrum currently facing students and medical educators. It seems that no matter how we change the learning environment to support our students’ well-being and their professional development, the threat posed by the score a student achieves on USMLE Step 1 is more harmful and powerful than anything we can do to mitigate its negative impact. Students now enter medical school believing that nothing in the pre-clerkship phase of medical education matters other than their performance on USMLE Step 1 as it will determine not only where they will obtain a residency but IF they will obtain a residency.We try to engage them in active learning but they prefer the efficiency of lectures on what they need to memorize. We try to help them learn about ethics, human development, interviewing skills, and they reject us saying those topics are “common sense” and “fluff” and not highly represented on USMLE Step 1 so we’re wasting their time. Carry this to the logical conclusion, and medical schools are producing students who are well-prepared for Step 1 but ill-prepared for the clinical learning environment of clerkships. All of the time, effort and money invested in improving medical education may be for naught. Why? Medical students focus their efforts on memorizing facts for Step 1—not because it’s necessary for licensure but in order to get a premier residency. But medical students are bright and insightful and display cognitive dissonance regarding their medical education. Students will say they know that active learning, problem solving and a focus on clinical reasoning will make them better doctors, but despite this cognition they behave in a way that focuses on memorizing for Step 1.The simple solution to this worsening problem is to score USMLE Step 1 as pass or fail or delay the release of numerical scores until after residency interviews are completed. Anxiety about the numerical scores compromises the education of our medical students.About the author:R. J. Canterbury, M.D., M.S., DLFAPA, is the Senior Associate Dean for Education and Wilford W. Spradlin Professor of Psychiatry and Neurobehavioral Sciences at the University of Virginia School of Medicine. His research interests include substance abuse, epidemiology of substance abuse and AIDS, and health services research.References:Bloodgood, Robert A, Short, Jerry G, Jackson, John M, Martindale, James R. A Change to Pass/Fail Grading in the First Two Years at One Medical School Results in Improved Psychological Well-Being, Academic Medicine, 84(5), May 2009, pp 655-662.Pass-fail is here to stay in medical schools. And that's a good thing.FRANCIS DENG, MD AND AUSTIN WESEVICH | EDUCATION | AUGUST 3, 2016Starting this fall, second-year students will no longer have the stress of grades at our medical school, Washington University in St. Louis (WashU). In extending the pass-fail system from the first year to the second preclinical year, WashU joins the other 18 of the top 20 research medical schools on U.S. News and World Report that grade the entire preclinical curriculum on a pass-fail basis. (The sole holdout is Penn, which maintains a graded system for two of three preclinical semesters.)Locally, the change caps an evolving, years-long conversation between students, instructors, and administrators. But we are just one of the many medical schools lately to catch onto a national movement that started long ago.Turbulent sixtiesSome schools such as Harvard, Stanford, and Yale have maintained preclinical pass-fail for decades. Many other schools dabbled in curricular reform in the 1960s. Opponents hoped the storm would pass. A provocative article published in the New England Journal of Medicine in 1978 blamed the “transient sociopolitical turmoil” of the preceding decade for causing a revolution in medical education with digressions such as “social medicine,” “primary care,” “elective scheduling,” and especially “the experiment in pass/fail grading.” The authors decried the subversion of traditions and erosion of standards, pleading for maintaining “elitism in education.”It’s important to note that these authors’ beliefs came from the perspective of resident selection rather than of medical education. They believed that “it is impossible to prevent a bright student in a good environment from becoming an excellent physician by manipulating such inconsequentials as the curriculum and the grading system,” but they saw evidence that inferior residents were selected in the absence of a class ranking based on grades.Preclinical pass-fail trendNow, the storm has settled somewhat. Though the politics have changed, pass-fail grading is no fad. Schools are now increasingly reaching a stable compromise: grades for clinical clerkships, pass-fail for preclinical courses. In fact, more than half of the aforementioned medical schools changed to all-pass-fail preclinical curricula in the past decade, and none have reverted back to multi-tier grading.The current trend for preclinical pass-fail is driven by two major factors: 1) decreased relative importance of preclinical grades in residency applications, and 2) increased focus on student wellness and mental health.Emory University Match DayLow importance in residency applicationsA dwindling minority of residency programs place value on performance in basic science courses. Practically speaking, the data are often uninterpretable. Grade distributions vary dramatically between schools or even within a single institution. These days, preclinical curricula differ in length, course naming, degree integration, and grading scales. In contrast, the USMLE Step 1 exam provides a commonly understood measure of basic science knowledge for all MD students. With the availability of standardized assessment, it is no wonder that surveys of program directors rank basic science honors among the least commonly considered factors for interviewing and ranking applicants. Step 1 scores rank among the most common.Given the importance of Step 1 scores to residency applications, some have worried about the effect of changing grading policies on Step 1 performance. We now know from the experience of several schools that changed to pass-fail that students perform just as well as before. Moreover, schools that switched did not find significant differences in residency match quality.Focus on student wellnessEven though preclinical grades do not greatly affect residency applications, they still appear on transcripts and factor into class rank and AOA medical honor society selection. Chronic pressure to get the best grades can lead to significant distress. In recent years, academic leaders have increasingly recognized the importance of mitigating unnecessary stress during medical training.We found that an overwhelming majority of students at all stages at our medical school thought they would be somewhat or much less stressed during the preclinical years if they were evaluated on a pass-fail basis. Multiple peer-reviewed studies verify these beliefs.In a multi-institutional study, students in 3+-interval graded schools had significantly higher stress, emotional exhaustion, and depersonalization and were more likely to have burnout or considered dropping out compared to students in schools with pass-fail grading. Grading scale was more strongly associated with student well-being than the number of contact days or tests.When the University of Virginia changed to pass-fail, preclinical students had higher well-being and vitality and reduced anxiety and depression. When Mayo Medical School switched part of its curriculum to pass-fail, students had less stress, improved mood, and even greater group cohesion. When Saint Louis University changed to pass-fail as part of a multifaceted preclinical curricular reform, students had lower levels of moderate or severe depression symptoms, anxiety symptoms, and stress. We believe a simple change in grading systems can lead to a clinically significant change in student wellness and mental health.National organization endorsementThe alarming levels of burnout among physicians, residents, and medical students demand greater national attention to wellness. The American Medical Student Association passed policy in 2012 stating that it “STRONGLY URGES all medical schools to adopt the use of a strictly pass/fail grading policy during the preclinical years of medical school” to reduce the risk of poor student health and wellness and to promote teamwork and collaboration rather than competition. In 2012, the American Medical Association (AMA) approved policy entitled “Supporting Two-Interval Grading Systems for Medical Education,” which acknowledged the benefits of a pass-fail system for the non-clinical curriculum. By 2013, as tabulated by the AMA and published in JAMA, pure pass-fail was the most common preclinical grading system across the country, found at 41 percent of allopathic schools.We believe the so-called “pass/fail experiment” has finally proven itself and will continue to propagate, not as a reaction to “transient sociopolitical turmoil,” but as an enduring curricular reform that prevents unnecessary mental turmoil during training.Francis Deng is a resident physician and can be reached on Twitter @francisdeng. Austin Wesevich is a medical student.AMA Journal of Ethics®Illuminating the art of medicineVirtual Mentor. November 2009, Volume 11, Number 11: 842-851.Can a Pass/Fail Grading System Adequately Reflect Student Progress?Commentary by Bonnie M. Miller, MD, Adina Kalet, MD, MPH, Ryan C. VanWoerkom, Nicholas Zorko and Julia HalseyAs David, a second-year medical student, made his way into the lecture hall, he was surprised to see how packed the room was. A group of 25 third-year students, or one-fifth of the class, had recently petitioned to switch from a traditional letter-grade system to one that was pass/fail at their school, and the medical student government organized a townhall meeting for students to discuss the matter. Unable to find a place to sit, David stood against the wall alongside his good friend Beth, a fellow second-year. In the room he saw students of all levels, from first-years to fourth-years, engaged in excited chatter.LEARNING OBJECTIVE: Identify the objectives of effective medical school grading systems and how medical schools can design them.The third-year class president, Sam, stood up. “Okay everyone, quiet down so that we can begin the discussion. We had not expected a turnout of this magnitude; it’s clear that this is an issue many of you feel quite passionately about. The administration has informed us that adopting a pass/fail system will require a majority vote from the student body.”The volume level in the room suddenly increased.He continued, “So, we hope that this meeting will serve as a lively debate where students on either side of this issue can share their arguments with the voting body.”“Pass/fail is such a great idea,” David whispered to Beth.To his surprise, she disagreed. “I don’t think so,” Beth replied. “I personally work harder and perform better when I am graded.”One of the third-year petitioners stood up to argue, “Our medical school is known for being one of the most intensely competitive programs in the country. We are already so stressed out—becoming pass/fail would remove an atmosphere of hypercompetition, and that will be a good change for our mental, emotional, and physical well-being.” His words were met with applause from some students in the hall.Another third-year petitioner presented a counterargument. “The majority of our graduating students match with residency programs each year, and most of those match at one of the programs they ranked in their top three. We’ve done very well with grades—would the same be true if we became pass/fail? Also, those of us interested in matching into very competitive specialties, such as dermatology, ophthalmology, and surgical specialties are put at a disadvantage since class rank and academic performance are highly regarded by residency directors in these specialties.”David, who himself had a particular interest in going into surgery, looked around the hall and saw a number of students nodding their heads in agreement. Beth nudged him playfully and whispered, “See what I mean?”Commentary 1by Bonnie M. Miller, MDThe primary purpose of any grading system is to measure student achievement of established learning objectives. Performance data let individual students know where they stand in the development of needed competencies. Aggregated performance data supply faculty and medical school administration with information about the effectiveness of teaching. A traditional grade stratifies students according to level of achievement and can motivate students, reward effort, and perhaps signify suitability for a potential area of study. A pass/fail grade indicates simply that a student has achieved an expected level of competence, information that is critically important if medical education is to fulfill its obligation to the public.The ideal grading system would also encourage the development of desirable professional behaviors. Does a traditional grading system encourage students to constantly strive for excellence, a habit that, theoretically, they would maintain when they no longer receive grades? Does a pass/fail system encourage collegiality, collaboration, and teamwork, since no one is disadvantaged by another’s success, and mutual benefit can result from sharing. In the case scenario we are commenting on, is Beth correct in fearing a lack of motivation in the absence of grades, or is David justified in his concern about grade-induced hyper-competitiveness?I believe that concerns about both consequences are justified, but my experience with grading systems suggests that neither is inevitable. Based on our grade-system change at Vanderbilt University earlier in the decade, I believe that elements such as faculty role modeling, selection of teaching strategies, careful and inclusive selection of the qualities that are being assessed, and use of criteria-based grading systems are more important contributors to student evaluation than whether or not letter grades are used.Faculty RoleGrading systems exist within the larger context of an educational environment that can powerfully mold the professional development of students. If students are hypercompetitive, it is unlikely that the grading system alone creates that behavior. Similarly, if students consistently aim their efforts at minimal passing performance, the environment might lack the ingredients needed to inspire excellence. Regardless of the grading system, medical school faculty and administration should be aware of the environments they create and monitor them with vigilance to assure that they support the attitudes and behaviors expected of the profession.In any grading system, faculty members should serve as role models who demonstrate a passion for excellence and a quest for improvement, both in their teaching efforts and their patient-care responsibilities. Role models who strive for excellence, not because of grades but for the good of those they serve, help students move beyond the external rewards that motivated them in their previous endeavors. Whether in teaching teams or in clinical teams, faculty members can also model the collaboration and collegiality that are important for effective, high-quality patient care. Finally, when faculty members care for the well-being and professional growth of their students, they model the compassionate and nurturing attitudes we hope those students will adopt.Teaching and Course-Management StrategiesTeaching strategies can also ameliorate the potentially negative side effects of a grading system. Many students study best in groups or learn most deeply when they are challenged to teach their peers, and schools with traditional grading systems can actively promote these approaches. Faculty can use course-management systems that allow all students to see the answers to all questions asked, and students can be encouraged to post helpful articles and learning tips. Team-based learning rewards group performance as opposed to individual effort, while creating pressure not to let one’s peers down, which discourages the slacking that a pass/fail system might encourage.Choosing What to MeasurePerhaps the grading system a school uses is less important than the qualities it chooses to grade. Assessment indeed drives learning, and if we feel that the professional development of our students is critical, we should demonstrate that by assessing it. In both science-based and clinical courses, students should be evaluated on their initiative, engagement with and concern for their own learning, interpersonal skills, teamwork skills and collegiality. Schools can devise grading policies, whether pass/fail or traditional, in which failure to demonstrate one of these key attributes can lead to failure in the course, regardless of cognitive achievement.Criteria-Based GradingFinally, the use of a normative versus a criteria-based grading system can influence student behaviors. In the former, the grade distribution is determined by comparative student performance, limiting the number of highest grades and creating an atmosphere in which one student’s performance can influence the grade of another. This is more likely to induce competition. In a criteria-based system, the requirements for each grade interval are predetermined, and any student who meets the designated requirements receives the designated grade, even if an entire class qualifies for an A. While this model could lead to grade inflation, it does recognize all students who achieve a certain level of excellence. And shouldn’t all medical teachers aspire to the goal of having all students excel?The Vanderbilt Grading ExperienceIn 2002, Vanderbilt University reexamined its traditional letter grading system. Like students at David and Beth’s school, our students performed very well in the residency match, and we were leery of changes that would make it more difficult for program directors to evaluate students. Unlike students at David and Beth’s school, ours did not complain of an overly competitive atmosphere. I’d like to think that this was because of our collegial educational environment, but a criteria-based system probably helped. Our greatest concern at that time was for the fairness of grades in the first year of medical school. Because of the wide variation in our students’ undergraduate preparation and the difficulties of adjusting to medical school, we felt that letter grades reflected not only effort and ability, but also the strength of the undergraduate program, the major a student had selected, and the ease of social transition. Most of our students who received marginal grades in the first year subsequently performed at very high levels, but were left with transcripts that marred their overall records.To balance our concern for first-year grades with our concern for the impact of a pure pass/fail system on the residency application process, we decided upon a hybrid system with pass/fail in the first year only; honors/pass/fail in the second year; and honors/high pass/pass/fail in the third and fourth years. We hoped that the noncompetitive culture of collaboration established in the first year would continue throughout the remaining 3 years, even as more grade intervals were introduced.Some faculty feared, like Beth, that first-year students would lack the motivation to put forth their strongest efforts. Fortunately, this fear never became a significant reality. Our curriculum remains rigorous and demands hard work, and the environment still encourages our students to reach for excellence. Occasionally a student’s performance slips on the last exam in a course if he or she is easily within the passing range, but this has not been a large enough effect to diminish overall class performance from year to year. Student performance in the subsequent years of medical school and on Step 1 of the United States Medical Licensing Examination (USMLE) has actually improved, relieving anxieties about the grading system’s long-term negative impacts on the learning habits.Paradoxically, in the first year of the transition, students and faculty sensed an increase in student competitiveness in the second-year class, even though this class entered with a traditionally graded system. We quickly realized that this resulted from a concurrent switch to a normative-based system that limited the number of honors grades to 25 percent of the class. In the following year, we reverted to a criteria-based system that set the honors bar extremely high to combat grade inflation but allowed all students who cleared that bar to receive an honors grade. Many students in that second-year class were also unhappy with the change and reported that they had selected Vanderbilt because of its traditional grading system. We learned from this experience that whenever possible, major policy and curriculum changes should be phased in with the entering classes. I have also become a strong believer in a criteria-based system that sets high standards but proudly recognizes all students who meet them.Because we maintained four grading intervals in the clinical years, we experienced no measurable change in the outcomes of our residency match. For schools that use a pass/fail only system throughout the 4-year curriculum, program directors rely more on qualitative measures, such as the comments recorded on clerkships assessment forms, letters of recommendation, and the nature of student leadership and scholarship accomplishments. With a sense that these subjective measures are less reliable than the objectivity of grades, program directors also tend to rely more heavily on Step 1 scores and the reputation of the medical school.No grading system is perfect in its ability to assess learners accurately, promote professional behaviors, and predict future accomplishments. Regardless of the system selected, a school must be aware of the potential for unintended consequences and should strive for an educational environment that counters these and encourages students to excel for the right reason, which is that their excellence will someday improve the lives of others.Bonnie M. Miller, MD, is the senior associate dean for health sciences education at Vanderbilt University School of Medicine in Nashville.Commentary 2by Adina Kalet, MD, MPHAs medical educators, our responsibility to society is to ensure that all physicians are competent to practice medicine. Ideally, both faculty and students should enthusiastically engage in an evaluation system that facilitates our fulfilling this responsibility. I am a strong believer in a grading system that is ultimately pass/fail—but is at the same time rich in confidential, formative feedback that helps students identify their strengths and weaknesses. To be meaningful, the “pass” thresholds must be competency- and criterion-based, not arbitrary or norm-referenced, i.e., predetermined percentages of students pass and fail.Competitive residency programs choose residents based on whatever evidence of their abilities exists. Residencies are looking for students who are a good fit for their program, well prepared, and capable of handling the work. The absence of letter grades on the formal transcript, without evidence of a rigorous, reliable assessment process is problematic for two reasons. First, it places enormous, undeserved pressure on students to do well on National Board Exams. Second, this approach overemphasizes the reputation of the medical school and its admissions policies.The debate presented in the case scenario focuses on the wrong outcomes. For example, students often defend pass/fail systems as more conducive to a relaxed learning environment because there is less interpersonal competition. I am not certain that this reflects reality. All medical students are highly achievement-oriented and many are competitive by nature. To be successful and competent physicians they must learn to manage the negative impact of these otherwise valuable personal traits in complex and competitive environments. On the other side of the argument, pass/fail systems disadvantage students who are consistently struggling because it allows them to squeak by without being identified for special attention early. In addition, even in schools like mine, NYU Medical Center, that operate with a pass/fail preclinical system, numeric grades are generated and followed for certain purposes (e.g., AOA determination), and students are well aware of this contradictory policy.In saying that the grades debate often focuses on the wrong outcome, I also mean that scores on exams are only useful if the exams themselves are reliable and valid measures of what they are meant to measure. Ideally, competency exams would provide students with detailed information to help determine whether they had the minimum competency to serve as physicians. We would overcome current weaknesses in measuring the remarkable capacities some students have in areas such as interdisciplinary teamwork and complex critical thinking. Once we have decided on fair, criterion-based measures that assess critical competencies, there is no way we could ethically, morally, or professionally argue against using such measures. Since most of our exams or grading systems do not reach this level of evidence, however, we use them as blunt instruments rather than sources of meaningful information.In sum, I don’t care as much as many students do about whether we use pass/fail or other systems. I care that we measure what is important and act on those measures to ensure excellence in our graduates.Adina Kalet, MD, MPH, is the Arnold P. Gold Professor of humanism and professionalism and an associate professor of medicine and surgery at New York University School of Medicine. She has a long-standing research interest in assessment of clinical competence and the relationship between medical education and patient outcomes. She has mentored three cohorts of NYU SOM Virtual Mentor student editors.Commentary 3by Ryan C. VanWoerkom, Nicholas Zorko, and Julia HalseyDuring the late 1960s and early 1970s, medical schools moved away from traditional grading systems and began adopting pass/fail or honors/pass/fail evaluation [1]. It is thought that the impetus for these changes originated with the concern that grade-based learning did not prepare for lifelong learning outside of the academic world and that it suppressed creativity and increased stress [1, 2]. On the other hand, it is well-known that residency directors hold the dean’s letter in high regard and favor the more discriminative letter-grade evaluation report [1, 3, 4].The ultimate quick test in medicine is applying the principle of primum non nocere (first do no harm). Is there a possibility that by changing the grading system to a less rigorous, more comfortable pass/fail system we may be harming patients? This would occur indirectly by allowing some students to slip through the cracks of a low-demand education and evaluation system. Gonnella et al. noted that students in need of remediation (not meeting basic standards set for competence in medical education) often went unidentified under a pass/fail system. “Failure to identify students who pass only narrowly results in the suppression of information that is critical to the future development of the students, and is important in the prevention of problems in professional practice” [5]. This does not bode well for patients, even if only a few sub-par students slip through the system without undergoing appropriate remediation.One example of a problem in professional practice could occur while a student or resident is caring for patients on a hospital team. The extra effort spent by one student studying for an “A” may trigger a memory for the correct tests needed to arrive at a diagnosis and implement an alleviating treatment, a connection that another student who only wanted to pass may not have made. The use of pass/fail grading has been correlated by some groups with poorer performance on exams [8, 9]. Additional information supporting this view was found in a study of surgery residents trained under different grading systems in medical school. Moss et al. found that residents who attended medical schools that assigned grades performed better than those who attended schools that used pass/fail systems [6]. Proponents of pass/fail grading argue that students working in such systems report a greater sense of satisfaction and well-being, but there is evidence refuting this reduction in anxiety upon implementation of a pass/fail grading system [7]. This perceived decrease in anxiety, regardless of validity, may not be worth the decrease in knowledge acquisition that may occur with less rigorous study habits.Students’ personal characteristics and attributes may influence their behavior and attitudes as strongly as a strictly graded traditional system with its intense pressure to perform well—the extrinsic factors—but the two are not easily separated. As one comes closer to measuring an extrinsic factor in medical education, he or she inadvertently affects the intrinsic. Consider, for example, the competitiveness that is said to infect medical students. A student who is willing to pull ahead at the risk of alienating classmates may be innately achievement-oriented, so the cause for his or her behavior is independent of the medical school environment and its pressure to compete.Kaitlyn died by suicide in medical schoolMany schools have opted for the honors/pass/fail grading system, which does not eliminate the pressure or incentive for students who wish to compete for honors grades. Honors/pass/fail may have the paradoxical effect of placing additional pressure on competitive students to perform even better simply because their grading system fails to discriminate adequately.A survey of surgery clerkship directors revealed consensus that a three-tiered system did not do enough to differentiate students appropriately. Pass/fail programs, this Ravelli et al. study concluded, “produced little reliable discrimination” between the quality of students and their peers [2]. With this in mind, it is more just to acknowledge a continuum of grades properly than to differentiate only between pass/fail. Consider a student who received the all-time top score for a medical school exam and was given the same grade as a student who passed by one question. This system results in general statements of evaluation for a majority of students without providing a means of recognition for outstanding efforts.Although many medical schools tout their pass/fail grading system as a means of attracting prospective medical students, these same schools, in truth, rank their students because they know that residency programs want them to distinguish among students. If students are not ranked in a traditional numerical order (e.g., 1/125), they are lumped in quartiles. In order for medical schools to maintain clout in placing their students in competitive residencies, the Medical Student Performance Evaluations (MSPEs) that they send to residency programs must rank students in some useful way. This may even lead to confusion among students regarding their own rank systems.Turning to the other side of the debate—the argument for pass/fail grading—students have more compelling motivators than grades. Having made it through the weeding process in high school and college classes and even the application process where grades were the most important criteria, medical students need to acquire the knowledge necessary to pass the national boards, obtain residencies and fellowship, and establish a satisfying career. At this point in their medical education, they have greater motivators to learn than simply to get an A on a test.The letter-grading system also suffers from grade-inflation, which has caused distress in admissions committees and employers of various disciplines. Grade inflation has placed a greater significance on standardized testing as the most objective way for schools to compare candidates from different programs. This in turn, may make the medical board exams a more stressful experience.While much of this discussion may not seem to be directly related to ethics, in the grand scheme of things, performing at a level which is anything less than one’s best has the potential to be detrimental to a patient’s well-being and is therefore unethical. The AMA Code of Medical Ethics states,Incompetence, corruption, or dishonest or unethical conduct on the part of members of the medical profession is reprehensible. In addition to posing a real or potential threat to patients, such conduct undermines the public’s confidence in the profession [10].Therefore, medical students’ ethical obligation encompasses the duty to prevent incompetence within their profession.Steve Prefontaine put it best: “To give anything less than your best is to sacrifice the gift.” As physicians or future physicians, we owe it to our patients and society to give our absolute best effort in exchange for the trust and responsibility for their lives they have given over to our care. We have been given a gift and privilege to study and practice medicine and should thus handle it appropriately regardless of the method used to evaluate us.ReferencesDietrick JA, Weaver MT, Merrick HW. Pass/fail grading: a disadvantage for students applying for residency. Am J Surg. 1991;162:(1)63-66.Ravelli C, Wolfson P. What is the “ideal” grading system for the junior surgery clerkship? Am J Surg. 1999;177(2):140-144.Lurie SJ, Lambert DR, Grady-Weliky TA. Relationship between dean’s letter rankings and later evaluations by residency program directors. Teach Learn Med. 2007:19(3):251-256.Provan JL, Cuttress L. Preferences of program directors for evaluation of candidates for postgraduate training. CMAJ. 1995;153(7):919-923.Gonnella JS, Erdmann JB, Hojat M. An empirical study of the predictive validity of number grades in medical school using 3 decades of longitudinal data: implications for a grading system. Med Educ. 2004;38(4):425-434.Moss TJ, Deland EC, Maloney JV Jr. Selection of medical students for graduate training: pass/fail versus grades. N Engl J Med. 1978;299(1):25-27.Yarbro RC. A comparison of anxiety levels of students taking pass/fail versus grade in student teaching. Tenn Educ. 1982;12(2):33-36.Weller LD. The grading nemesis: an historical overview and a current look at pass/fail grading. J Res Devel Educ. 1983;17:39-45.Suddick DE, Kelly RE. Effects of transition from pass/no credit to traditional letter grade system. J Exp Educ. 1981;50:88-90.American Medical Association. Opinion 9.04. Discipline and medicine. Code of Medical Ethics. Chicago, IL: American Medical Association. 1994. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion904.shtml. Accessed October 12, 2009.Ryan C. VanWoerkomis a fourth-year medical student at the University of Utah in Salt Lake City, with plans to enter a career in internal medicine. He serves as the chair of the Committee on Bioethics and Humanities for the American Medical Association-Medical Student Section as well as being the Midwest representative to the American College of Physicians Council of Student Members.Nicholas Zorkois a fourth-year MD/PhD student at The Ohio State University in Columbus. He graduated from Ohio State with a bachelor’s degree in biology in 2006, and is currently the vice chair for the Committee on Bioethics and Humanities for the American Medical Association-Medical Student Section.Julia Halseyis a third-year medical student at the University of Missouri in Columbia. She graduated from Truman State University in Kirksville, Missouri, with a bachelor’s degree in biology and from Trinity International University in Deerfield, Illinois, with a master’s degree in bioethics. She currently serves as the student representative to the AMA’s Council on Ethical and Judicial Affairs.Related in VMNurturing Leaders for an Environment of Change, November 2009Is There More to Medical School than Grades? December 2003The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.© 2009 American Medical Association. All Rights Reserved.Grading Systems in Medical School: Pass/Fail or A-F Scale?Author: Veronica Reina Mar 25, 2014Up until medical school, the majority of your classes used the traditional A-F grading scale to rate your academic achievement. Everyone loves to get an A, and receiving an F is a sure sign that you blew it. When you begin your research for medical school, you’ll want to think about the importance of whether a school uses a traditional grading system or relies on Pass/Fail ratings. There are a number of factors to consider, and each medical school grading system has both advantages and disadvantages.In a more conventional A-F medical school grading system, future residency options are greatly increased based on that graded performance. The clear competitive benefit of a conventional grading system is that it can distinguish candidates based on how they performed as compared to their peers. Unfortunately, according to the National Institutes of Health (NIH), being ranked in an A-F medical school grading system raises anxiety levels and heightens depression as medical students compete for the most coveted residencies and other post medical career paths. Medical students must decide whether a coveted residency is worth the added stress inherent in a highly competitive A-F medical school grading system. These factors increasingly lead more medical schools to adapt the Pass/Fail system.The simplicity and non-competitive nature of the Pass/Fail medical school grading system depends on the intensity of the medical school curriculum and the degree of the Pass/Fail system. More schools are implementing a hybrid medical school grading system, wherecoursework completed during the first two years is evaluated as Pass/Fail and the final two years are graded using the conventional A-F scale. More widely used is the High Pass-Pass-Fail medical school grading system, which allows for students to distinguish themselves particularly by receiving a High Pass rating. The Pass/Fail medical school grading system places a critical amount of importance on letters of recommendation and national board testing as predictors of your future success in your residency.At a number of elite medical schools, including both the Yale School of Medicine and Stanford Medical School, the vetting process to gain acceptance to these institutions is so thorough that the grading system is secondary to the prestige of the medical school. Studies often show that attendance at elite medical schools leads to the most sought after residencies. A better predictor of student success during medical school and in applying to residency programs is your benchmark performance on the US Medical Licensing Examination. Ultimately, this exam is the most important gauge of a student’s success in medical school.Residency programs sets their own standards pertaining to acceptance and success. Acceptance in these programs is based on a number of factors. One of those is whether your medical school employs a conventional A-F grading system or Pass/Fail system. Medical school grades are not the only criteria for matching to your ideal residency program, but they are significant enough that you will want to do some research and be informed about the criteria by which you will eventually be evaluated. The road to becoming a medical professional is fraught with choices. Making well advised and thoroughly researched decisions, like the grading system used by your medical school, is critical to your success. — Post by Madeliane Kingsbury.A Medical School goes Pass/Fail only: Why this is an Excellent Change!september 17, 2016 by lifeofamedstudent, posted in med student adviceWell I’m officially THAT old, bitter resident. I had to walk uphill to medical school 10 miles there and back. “In my day” medical school was fail, pass, high pass, or honors. I just found out that the medical school I graduated from has changed the first 2 years of science courses to simply pass/fail (while retaining the honors/high pass grades in clinical rotations). I am so annoyed! Why does this bother me? Because that’s not how it was when I was there! Because having the extra high pass and honors adds a great deal of unnecessary stress to students as they are adjusting to the brutal workload of medical school. BUT BECAUSE I HAD TO GO THROUGH IT, SO SHOULD EVERYONE ELSE, DAMMIT!In all seriousness, I am in complete agreement and happy for the change.The first year of medical school was the absolute hardest of my life. The stress was monumental. The coursework is overwhelming. The absolute competition, while often among friends, is real. With the high pass/honors in place, it wasn’t good enough to just pass. It wasn’t good enough to even high pass! Everyone, admit it or not, felt the pressure of having those staggered “grades.”My first semester I had a hard time adjusting to the rigors of medical school. The study habits that had suited me so well in undergrad, were completely failing me. As a result, my grades that semester were also struggling. After one particularly bad exam result in anatomy, the idea of failing a class for the first time was unbelievably depressing. I had graduated high school and then even undergrad with a 4.0. I had never even had a “B” before. Yet, by November of that first semester, failing was a reality that I had to live with every day. The effect that had on my psyche was truly significant. Luckily, and with some serious hard work, I passed that anatomy class and all my classes that semester.By second semester, I began to find my study groove and was getting my confidence back. Even early in that semester, I no longer had to question whether I would pass or not. I was doing fine in all my courses. However, that did not take the pressure off. Once I realized, passing wasn’t the issue, it quickly became whether or not I would “high pass.” I’ve always been the type to push myself but in medical school the looming issue is always the competition. What residency you can realistically apply to is greatly affected by the scores you receive. So once I knew I could pass my classes, I felt I had to high pass them. Just like that first semester trying to pass, I was now only happy with a “high pass.” That second semester I ended up with a “high pass” in three of my courses, and I was honestly less happy about it than when I’d found out I’d barely “passed” that first semester.This trend would continue and by 3rd year, I wasn’t even happy with a high pass and downright disappointed when I only passed a rotation. Then my 4th year of medical school I managed to receive an honors grade in 6 of my 9 courses. Yet I still was probably not as emotionally satisfied or happy as the day I found out I passed that first anatomy class I was so worried about.My actual medical school transcript.While some might look at my story and feel I’m an example for why staggered grades HELPS students push to achieve more and more, I disagree. The added stress of always having the next higher grade to achieve is unnecessary and even harmful. Medical school IS stressful. It’s stressful no matter how you are graded. The goal IS to pass and be sufficiently trained to enter a residency, where only then are you actually trained to take care of patients. This isn’t 1960 and people are not practicing medicine unboarded straight from medical school. Medical school is now just a hoop to jump and likewise should simply be a course to pass.I consider myself a fairly emotionally robust person. I have entered a speciality (anesthesia) where the choices I make can have an instantaneous life or death consequence. I have always handled pressure well and may even enjoy it a little bit. Not everyone is like that. Fewer still enjoy or thrive under it. The staggered honors-high pass grades tends to adversely affect these people the most. It takes good passing students, who will become good doctors, and crushes them under the added pressure. Deflates them with the unstopping competition. Eventually, burning them out toward medicine. And horrifically, every year a few of them decide to commit suicide.Will a pass/fail only curriculum make medical school easy? Not even close. But it definitely could take unnecessary stress off students. That first two years of medical school were the hardest of my life. If had a pass/fail curriculum been in place maybe I wouldn’t be saying that today, at least after the second semester. And just maybe, there would be a lot of other great doctors out there that hadn’t been eventually burned out by the same system. If you are in a program that still uses a staggered honors grading system, I’ll give you the same advice that was given to me during those years: P = M.D, baby. Because you know what they call the person that graduates without a single honors grade? DOCTOR.What do you think? Is Pass/Fail a way to improve student wellness? Or is there benefit to having a staggered grading system? Add your thoughts in the comment section below!