Jackson National Life Medical Examination Report: Fill & Download for Free

This answer may contain sensitive images. Click on an image to unblur it.There’re several actors that suffered from fame so these are a few you may or may not know about:Robert Cletus “Bobby” DriscollVery few people about know him but Bobby Driscoll was a child star for Disney and started in many successful films for them. Born March 3, 1937 in Cedar Rapids Iowa, he spent his early years in Des Moines until 1943 when his family moved to Los Angeles, California after his dad was suffering from health issues due to handling asbestos. Driscoll began acting starting with the 1943 film “Lost Angel” after impressing the director with his curiosity and intelligence at such a young age after noticing a mock-up ship without any water.the inspiration for their adaptation of Peter Pan. Driscoll provided the voice and model which was then rotoscoped and used in the film. Under Disney’s employ, he was one of the most successful child actors in the late-40’s and early-50’s. He starred in movies such as “So Dear To My Heart”, “Song of the South”, “The Window” and of course “Peter Pan”. He also provided the voice of Goofy Jr. in some of the 50’s Goofy shorts. Originally one of Disney’s personal favorite “live-actors”, as he got older and began to reach puberty, Disney’s view of him changed: He initially saw him as an embodiment of his childhood but during a meeting for Peter Pan, he saw him better suited in roles as a bully rather than a likable protagonist many knew him for.When the acne and deeper voice became too much for Disney studios to cast him in any future roles, Disney let him go. Following his termination, he returned to school where he was ridiculed for his career: "The other kids didn't accept me. They treated me as one apart. I tried desperately to be one of the gang. When they rejected me, I fought back, became belligerent and cocky—and was afraid all the time."It was at this point where he began dabbling into drugs. His parents transferred him as per his request where he graduated but unfortunately, he was hooked on drugs by that point and his usage continued: "I was 17 when I first experimented with the stuff. In no time I was using whatever was available... mostly heroin, because I had the money to pay for it."His struggles didn’t end there as he struggled to find work. He had a few brushes with the law, a short-lived marriage and difficulty regaining his footing in the industry. Needless to say, this left him bitter: "I have found that memories are not very useful. I was carried on a silver platter—and then dumped into the garbage." He began going by “Robert Driscoll” to distance himself from his Disney past in hopes of finding more roles. When they dried up, he moved to New York and turned to Broadway in hopes of reviving his career. When that failed, he turned to art. He joined Andy Warhol’s The Factory to concentrate on his art on the advice of a poet he befriended named Wallace Berman. Sadly, he never recovered from his glory days and around 1967 or 68, his body was found in an abandoned building in East Village by two boys who were playing.The cause of death was heart failure due to his drug use. He was only 31. His body remained unclaimed until a year later when his mom reached out to Disney studios to contact him for a reunion with his near-dead father whom they didn’t speak to in a while. His body and identity were found, yet his remains are still on Hart Island.Despite his initial fame, Bobby was discarded when he was no longer considered cute by the man he originally saw himself in. Originally bathed in fame and adulation, he ended up alone and penniless. It’s even more backhanded knowing that after all these years, he has yet to be made a Disney Legend. This’s the price of fame. R.I.P. Bobby Driscoll.Johnathan BrandisJohnathan Brandis was born April 13, 1976 in Danbury, Connecticut. He began modeling at the age of 2 for Buster Brown shoes and began acting in tv commercials at the age of 4. At age 6, he won the role Kevin Buchanan on the soap opera “One Life to Live”. He later became best known for starring in Steven Spielberg’s hit show, seaQuest DSV. Brandis also became popular starring in movies such as “Ladybugs”, “The NeverEnding Story 2: The Next Chapter” and “Sidekicks”. He also voiced Mozenrath in the Disney series, “Aladdin” and even worked as a producer later on in his career. His role as Lucas Wolenczak in seaQuest DSV helped launch him into being a teen heartthrob. He was very popular with girls, so much so that he received approximately 4,000 letters of fan mail a week and had to have three security guards around whenever girls were present.Sadly, after seaQuest DSV ended, so did virtually his career. While he continued to appear in movies and make guest appearances, Brandis never reached the amount of fame that he did on the show. His last movies were “Bad Girls from Valley High” and “Puerto Vallarta Squeeze”.With his career declining, Brandis began to drink heavily and according to friends, he told them that he was going to kill himself. On November 11, 2003, Brandis was found hanged in his apartment in Los Angeles. He didn’t leave behind a suicide note. He was transported to Cedars-Sinai Medical Center but tragically died the following day due to his injuries.Such a tragic end to a bright star.Brad RenfroTo begin with, he had a rough life from the start. Brad Renfro was born in July 25, 1982 in Knoxville, Tennessee. He grew up in a trailer with his grandma after his parents divorced. He allegedly didn’t have a good relationship with his dad. His big break came in the form of the 1994 thriller film called “The Client” that was based on the book by John Grisham. Director, Joel Schumacher wanted a “tough kid” who knew what it was like growing up in the gutter, "I wanted a kid who understood in the marrow of his psyche what it was like to grow up too soon”. The movie was a hit and soon, Renfro began receiving attention from Hollywood.The roles and money kept coming in as did the attention he got from it. He starred in Disney’s “Tom and Huck”, “Sleepers”, “Apt Pupil”, “Bully”, “Tart”, “The Cure” and many others such as “Ghost World”. Unfortunately, as his fame rose, so did his personal problems and they were out in the open for all to see. He was arrested a few times mainly for drug-related offenses and was either in jail or rehab. This caused his career to decline. The last film he starred in was a 2008 drama called “The Informers”. That and a short film simply called “Collectors”.On January 15, 2008, he was found dead in his apartment. According to the autopsy reports, his death was accidental and was caused by Morphine/Heroin intoxication. Since his death, questions have been raised about Hollywood’s role in how child actors are treated in the industry. Controversy about how well he was supervised came when an article from Buzzfeed theorized that despite not breaking any laws, Hollywood still failed to protect him.What also caught many off guard was his maturity and self-confidence for someone his age. Many who met him thought he was 15 or 16 when really, he was only 12 or 13. He had a girlfriend who was twice his age and they supposedly had sex a few times. Even as a kid, he would get explicit letters from teens. A good example is one where the writer claimed that she fantasized waking up with him in her bed. Yikes! It didn’t help that they sexualized him at such a young age either. In one scene in “Apt Pupil”, he’s literally taking a shower while barely censored.Despite being what Hollywood wanted him to be, when he grew too much to handle, they let him go; sadly with disastrous results. Hollywood’s no place for a kid that young. Ever. You won’t be forgotten Brad. R.I.P.Thomas Lee “Tommy” KirkTommy Kirk was born in December 10th, 1941 in Louisville, Kentucky. He’s the first of four sons. His parents moved to Downey in LA County, California for better opportunities when he was just 15 months old. He got his first taste of acting when he accompanied his brother Joe to an audition of Eugene O’Neill’s “Ah, Wilderness!” in Pasadena, California. Joe lost the audition amazingly to Bobby Driscoll and wasn’t cast but Tommy was. "It was five lines, it didn't pay anything, and nobody else showed up, so I got the part," said Kirk. An agent from the Gertz agency saw him and signed Kirk on. He then successfully got him a part in an episode of “TV Reader’s Digest”, "The Last of the Old Time Shooting Sheriffs". His brother Joe, later on became a dentist.He became a steady in television, getting parts for shows such as “Crossroads”, “Gunsmoke”, and ““Letter to Loretta”. He was very popular so naturally he was in demand all the time. According to Dabolique magazine "Kirk was in heavy demand as an actor almost immediately. Watching his early performances it’s easy to see why – he was wide-eyed, gangly, keen and immensely likeable… the very picture of Eisenhower Era American youth, unaffected and natural, surprisingly non-annoying, extremely easy to cast as someone’s kid brother, or son, or neighbour."Later on, he moved to film. In April 1956, Kirk auditioned to play as Joe Hardy in the Mickey Mouse Club serial ““The Hardy Boys: The Mystery of the Applegate Treasure”. He successfully got the part and was selected to co-star with Tom Considine. Filming began in June and early July 1956, and was broadcast in October during the start of the show’s second season. Both the show and Kirk’s acting were praised.In August 1956, Disney hired him and former Mouseketeer Judy Harriet to attend both the republican and democratic presidential nominating conventions, for newsreel specials that later appeared on the show. It wasn’t until January 1957 when Disney cast him in Old Yeller as Travis Coates. That was his big break. It was a boy and his dog story and a very good one. A classic even today still. Due to the film’s success, Disney made him the go-to whenever they needed an all-american boy for the lead role. Kevin Corcoran, who played his younger brother in the film later starred as such in the films they starred together. They were originally meant to star in Disney’s adaptation of L. Frank Baum’s “Rainbow Road to Oz”, but it was never produced.Kirk’s career remained strong until 1958 when after filming for “The Shaggy Dog”(Disney’s first live-action comedy) Disney told him he didn’t have any projects lined up for him and was being dropped. "I was thin and gangly and looked a mess... I thought the whole world had fallen to pieces," he said. He returned to television briefly until the success of “The Shaggy Dog” caused Disney to reconsider. He contacted him offering him a long-term contract and a role as Ernst Robinson in 1960’s “A Swiss Family Robinson”. Much like the former it was a success and Kirk’s career was back on track. Kirk has said that’s his favorite movie. He was then signed to two more movies upon returning from filming in the West Indies.Kirk continued to act in Disney movies. Most of them were light comedies to varying degrees of success. Amazingly, despite being hired by Disney, Kirk only met him once outside of a studio. Regardless, Kirk claimed Disney was his “good luck charm”. That all changed during filming of “The Misadventures of Merlin Jones”. Kirk knew since he was a kid that he was gay and due to the conservative time period, was deeply unhappy. In 1963 while filming the movie, Kirk who was 21, began seeing a 15 year old boy he met at a swimming pool. The boys mom found out and told Disney who decided not to renew his contract:I consider my teenage years as being desperately unhappy. I knew I was gay, but I had no outlet for my feelings. It was very hard to meet people and, at that time, there was no place to go to socialize. It wasn't until the early '60s that I began to hear of places where gays congregated. The lifestyle was not recognized and I was very, very lonely. Oh, I had some brief, very passionate encounters and as a teenager I had some affairs, but they were always stolen, back alley kind of things. They were desperate and miserable. When I was about 17 or 18 years old, I finally admitted to myself that I wasn't going to change. I didn't know what the consequences would be, but I had the definite feeling that it was going to wreck my Disney career and maybe my whole acting career. It was all going to come to an end.After reviewing the complaint, Disney personally fired him: “Even more than MGM, Disney was the most conservative studio in town.... The studio executives were beginning to suspect my homosexuality. Certain people were growing less and less friendly”. Despite being let go in 1963, Disney did ask him to return to star in the sequel The Monkey’s Uncle due to the success of the first one and the fact that he made them bank.Thankfully, Tommy Kirk found work at American International Pictures(AIP). He starred in what was later known as Pajama Party(1964) where he played a Martian originally sent to invade only to fall in love with some partying teens. One of who he falls in love with played by former Mickey Mouse Club star, Annette Funicello. The success led him to star in the follow-up “How to Stuff a Wild Bikini”. Just when things were looking up for him, on Christmas Eve 1964, Kirk was arrested for suspicion of pot possession at a house in Hollywood. The district attorney’s office refused to file a complaint against him on the marijuana charge but unfortunately, the city attorney’s office did as they found barbiturates in his car. Thankfully, the charge was dismissed by the judge in early January when his lawyer proved that they were medically prescribed to him.Sadly, the damage was done and he was replaced in the later sequels. The experience left him bitter: "This town is full of right-wingers—the world is full of right-wingers—intolerant, cruel sons-of-bitches", he did acknowledge his mistake though, admitting he "richly deserved to be fired from the studios because of my irresponsibility. A person on drugs is not fit for work".His career regained momentum with movies of varying quality but by 1966, his personal problems began to affect his career: I was drinking, taking pills and smoking grass. In fact, I was pretty wild. I came into a whole lot of money, but I threw a lot of parties and spent it all. I wound up completely broke. I had no self-discipline and I almost died of a drug overdose a couple of times. It's a miracle that I'm still around. All of that didn't help the situation. Nobody would touch me; I was considered box office poison.”By the time his racing film Track of Thunder was done, Kirk became an addict by this point. "I was about half awake in that film. I just sort of walked through it and took the money." After doing two non-Screen Actor Guild movies in 1970, he nearly lost his SAG card. Realizing he hit rock bottom, he vowed to turn his life around. "Finally, I said, to hell with the whole thing, to hell with show business, I'm gonna make a new life for myself, and I got off drugs, completely kicked all that stuff."Three years later he publicly came out as gay in an interview with Marvin Jones. After appearing in a few movies, Kirk finally quit acting in the mid-70’s and got a job as a waiter and chauffeur before going into the car cleaning business in San Fernando Valley. Despite getting out, Kirk admitted he was “poor” by that point:“I made a lot of money and I spent it all. No bitterness. No regrets. I did what I did... I wasn't the boy next door anymore. I could pretend to be for a few hours a day in front of the camera. But I couldn't live it. I'm human. I'm not Francis of Assisi”.It’s great to know that he made it out and is taking it slow. He occasionally acts still and was made a Disney Legend in 2006:“I don't blame anybody but myself and my drug abuse for my career going haywire. I'm not ashamed of being gay, never have been, and never will be. For that I make no apologies. I have no animosity toward anybody because the truth is, I wrecked my own career”.In 2006, he claimed to have retired on “a nice pension” while living in Redding, California as of today:“As I look back on the whole thing, it gave me the chance to be in three or four movies that people will enjoy long after I'm gone. I heard Pat Boone say in an interview that the bombs are just as important as the hits, because they are all part of life. I'm not bitter. I'm not unhappy things didn't go the way I wanted them to go with my career. I tried to be a good actor and an ethical person. I'm still trying to be an ethical and honest person. But I'm glad to be retired. I live in the middle of a national park, basically, with miles and miles of wilderness. Redding ain't glamorous. Monte Carlo it is not. It's small-town life, and it suits me”.Glad to know that’s he still kicking…Corey HaimKnown for roles in films such as “License to Drive”, “The Lost Boys”, “Lucas”, and “Dream A little Dream of Me”, the Canadian actor had a string of hits in the 80’s and was a teen heartthrob. Born in Toronto, Ontario, Canada, December 23, 1971, he initially wasn’t interested in acting. At the time, he preferred things such as Ice Hockey, collecting Comic Books, and Piano playing. He got into the biz by accompanying his sister Carol to auditions. During one of them, he was noticed and began getting offered roles. He began acting at age 10. He played a character named Larry for a kids show called The Edison Twins. The show ran from 1982 to 1986. Between that, he made his film debut in the movie First Born where he starred alongside Peter Weller of Robocop fame. Slowly and slowly he hagan reviewing attention which led to greater roles such as The Lost Boys. It was there on the set where he became friends with Corey Feldman and the two were dubbed “The Two Coreys” by the media. They bonded by hanging out in hotels and playing arcade games. Together they were a force to be reckoned with; making hit after hit. Things seemed to be great for them… but what few people knew about was the dark shit that went on behind the scenes:Feldman has claimed multiple times that they were both raped and abused by powerful men in the industry. The abuse took a toll on them, particularly Haim who’s career spiraled downwards when his addiction got the best of him. His roles were relegated to Direct-to-Videos of varying quality.Once he did clean up his act, he went on to reunite and star alongside Corey Feldman in the infamous reality show, “The Two Corey’s”. At first things went well but as time went on, dark aspects of their careers began to be brought up and soon, Haim began to relapse and become more self-destructive. This forced Feldman to cancel the show in order to try and save him. They later on reconciled behind the camera.In the last few weeks of his life, he lived close to his mom, still trying to rebuild his life. On March 10, 2010, he was rushed to the hospital after he collapsed. Despite being rushed to the paramedics at 2:15am, he was pronounced dead at age 38. The cause of death was pneumonia. After his death, they found a lot of medications prescribed to him. Many were obtained illegally using false aliases.Despite being a successful actor, he died broke and the costs for his funeral had to be covered elsewhere. Despite his last few years being less than ideal, we will never forget Corey again for bringing joy in our lives and making us smile.R.I.P. Corey 😔Fernando Ramos da SilvaBorn November 29, 1967 in Sao Paulo, he was the sixth of ten kids and lived with his parents in a slum called Diadema. When he was eight, his father died leaving his mom widowed and a single mom. In order to survive, she received a $10 pension every month and the family sold lottery tickets as a source of income. After briefly attending grade school, he joined a theater group and began acting in plays when he was eight. His big break came when he was picked out of 1,300 applicants by director Hector Babenco for the title character which he became famous for. The 1981 film, Pixote: A Lei do Mais Fraco is known for its gritty portrayal of Brazilian street life which he knew all too well as he lived it early on. Much like his role, you could say it was semi-autobiographical.Despite the controversy in its depiction of the street children as they do whatever it takes to survive the street ranging from pick pocketing, survival sex, drug dealing, and finally murdering, the film became successful and launched Da Silva into stardom. The film received strong reviews from critics such as Roger Ebert who described it as "a rough, unblinking look at lives no human being should be required to lead. And the eyes of Fernando Ramos da Silva, [Babenco's] doomed young actor, regard us from the screen not in hurt, not in accusation, not in regret - but simply in acceptance of a desolate daily reality."Shortly afterwards, Da Silva got a one-year contract TV Globo for a soap opera called O amor é nosso. Sadly, it wasn’t meant to last as he was fired shortly afterwards due to his perceived laziness. He was actually illiterate which may’ve contributed to that false perception. He managed to land a small role in Bruno Barreto’s Gabriela and enrolled in acting school before dropping out two days later. According to friends and family, he never settled down. After being arrested in 1984 in Diadema, the Mayor of Duque de Caxias, outside Rio de Janeiro, gave him a house in the neighborhood. His mom and some family members moved in briefly before returning to the slum a few months later due to missing it.Realizing his fame was fleeting, he returned to the life he knew best: A life on the streets. He struggled to distance himself from his role and claimed that police constantly harassed him because of his iconic role. ''I just want people to forget my image as Pixote,'' he told a reporter after his second arrest, in 1985. ''I want a chance to live as a man, without being persecuted. They created a Pixote, but they did not know how to prepare him for life.'' He wanted to play in romantic roles rather than just criminals. This would lead him on a downward spiral. In 1984, he was arrested for robbery charges in Diadema. This would be a reoccuring thing for him. The following year, he married Maria Aparecida Venancia da Silva and the two had a daughter named Jacqueline. Their relationship wouldn’t last long as 2 years later on August 25, Da Silva was shot 7 times by 3 cops who claimed he was resisting arrest. Due to Brazil having a history of police brutality, especially in the slums, few believed the official report with some claiming he was unarmed. Despite the report, a forensic examination showed he was fatally shot while lying on the ground.Both his wife and mom labelled his death as “a police execution”. His sister Maria Aparecida Luz claimed that he was a friend’s house playing cards when he learned that the house was going to be raided and fearing that he’d be arrested, fled unarmed where he was chased by the cops into another house where he was fatally shot.Despite his short life, Da Silva hasn’t been forgotten. His life was made into a movie in 1996 called Quem Matou Pixote? The sad thing is it seemed he was trying to turn his life around yet continued to struggle. The odds were always stacked against him.Corey Haim - WikipediaHow Hollywood Failed Brad RenfroBrad Renfro - WikipediaJonathan Brandis - WikipediaBobby Driscoll - WikipediaTommy Kirk - WikipediaFernando Ramos da Silva - WikipediaThank you for the views and upvotes!

Well, firstly, what do you mean by socially viable?What kind of society do you think we’re going to have if we carry on as we have been? We’re running out of insects for god’s sake!But okay, let’s start with the meat of the issue.It’s the economy stupid.What does the Green New Deal offer?Don’t worry; I’m going to cater for the under ’30s by sticking to easily digestible bullet points bereft of passive voice nuance and punctuation.Even so, it’s an ambitious project.· 100% Clean and Renewable Electricity by 2035· Zero Net Emissions from Energy by 2050· 100% Net-Zero Building Energy Standards by 2030· 100% Zero Emission Passenger Vehicles by 2030· 100% Fossil-Free Transportation by 2050· National Clean Air Attainment· Cut Methane Leakage 50% by 2025· National Lead Pipe Replacement & Infrastructure Upgrades· Guarantee Access to Affordable Drinking Water· Protect Two Million New Miles of Waterways· Reforest 40 Million Acres of Public and Private Land by 2035· Restore 5 Million Acres of Wetlands by 2040· Expand Sustainable Farming and Soil Practices to 30% of Agricultural Land by 2030 and 70% by 2050· Cleanup Brownfields and All Hazardous Sites· Establish a National Fund for Urban and Rural Resilience· Expand Public Green Space and Recreational Lands and Waters· Modernize Urban Mobility and Mass Transit· Zero Waste by 2040· Capture 50% of Wasted Methane by 2040Now, usually, I’d go through this list one by one but if I di that, this answer would be very long.So I won'tI recently discovered a way of making my own vegan sausages and ever since then every day has been a ‘bad burrito,’ day. Trying to accommodate the additional time spent squatting atop the compost toilet installed in my hipster-doufas loft apartment has not been easy on me. I’ve tried to save time by growing a beard that the under 30s assure me is known on the street as ‘The Full Mumford and Sons’, but even so, restricting personal grooming can only shave off so much time in the day.Oh, look, I made a joke.I didn’t mean to, and I'm not glad I did. But If I have one rule in my life that I adhere to religiously it’s this. I never delete anything I write on Quora because I make a living as a writer and if I crafted the stuff on Quora the way I do when I’m being paid then… well, let’s just say that it’s not an economic model I’m overly comfortable with.So, let’s take an overview of what the Green New Deal ( hereafter GND), is trying to do instead.But before we do, we have to acknowledge that the political mechanics of the U.S are such that pretty much all legislation involves compromise of some sort. The bullet points above represent an ideal that is unlikely ever to see the light of day. It’s going to be as watered down as music festival cola by the time it receives a presidential signature and that – in part– is probably why it seems so radical at the offset.Still, it’s a useful review of what needs to be done and so what if some of the target dates move around a little? My beard is the texture of Yak’s fur but if you want to know what that looks like you’re going to have to follow me on twitter. If you want to know what that feels like, then I’m prepared to send you a sample for a reasonable price. Or you could find a yak.So, in brief, clean air, less pollution, drinkable water, nature reserves, green spaces and butt loads of job creation.Fucking commies eh?Right or FlightIf you spend time watching Fox news, then you’ve probably already seen the right-wing reaction to the GND. They react to notions of sustainability in much the same way I behave when I wander into a field with a male Yak on heat.They run for the hills.We’ve watched Tucker Carlson look like he went to doctors complaining of heartburn and left with an unscheduled dick-swab, a script for ceftriaxone and some explaining needing doing to his wife.We’ve seen Jennine Pirro stand up in such sudden fury that camera two inadvertently captures a full foot and a half of the stick jammed up her ass thus causing the producer to cut to a commercial rather unhelpfully proselytizing Baker’s Best extra-smooth cake improver.And of course, you cannot have failed to notice Sean Hannity twitch like hemorrhoid ridden Bison whenever the topic of trying to improve the lives of ordinary peasants come up.So you might be surprised to learn that the Green New Deal poses no economic threat to American whatsoever.None.Part 2: The Bit where I get to the pointI know, shocking, right?All that huffing and puffing over something that’s no threat to anyone. Well, not anyone. There are a few industries I can think of that are going to have to adapt. But the question of economic viability is a canard or such massive proportions that the closest thing it could get to floating in a duck pond would be by squeezing the rear end of its body into Lake MichiganBecause here’s the thing.Would you like to buy Manhatten?I mean, if you really wanted to buy it and ­­­– assuming it was for sale and that I had the title deeds – could you afford it? Could anyone?In 2014, a paper in Regional Science and Economics journal in 2014 found that developable land in Manhattan—excluding parks, roads, and highways—was worth between $1.54 and $1.95 trillion. You can read the whole thing here. Impressive though that figure is – it’s close to Canada’s entire GDP for a year – it’s only part of the story. Manhattan is, in fact, worth far more than the land value of the island itself. As Max Galka points out in his rather excellent post, residential real estate – i.e., the apartments condos and whatever the hell a duplex is– are worth around 1.54, trillion.He also noted that he hadn’t:“Gone through the analysis for commercial property, but the City's reported market value is about 260 billion. I think that is also an underestimate, but not by nearly as much as residential.”Let’s call the running total $2 trillion then. But even that’s not going to suffice. Because the island comes with a raft of income attached to it: rent in Manhattan fluctuates. Some 900 square feet in an expensive part of town is going to set you back $3, 584, a month whereas 480 Sqft in an average area comes in at $1,936.I think. I really should not get involved in numbers. Inevitably, someone in the comments below is going to tell me how wrong I am and then wish me luck in finding an apartment for that price or else talk about rent control and how its possible to rent a disused lavatory just off central park for a mere $437 bucks plus utilities ( of which there are none). I get it, my knowledge of the New York rental market is not what it once was.As I think I mentioned I have a self-mulching toilet, so I’m not moving to New York City ever again…The point is that whatever figure we come to, it’s going to be a high one and we have to add such valuable future earnings into any price valuation of the island of Manhatten.Which leaves us with what?I doubt that anyone would sell Manhattan for less than 10 Trillion. You might be able to lease it for less. The U.K did that with Hong Kong for a while, but it was snatched up as a spoil of war, and the Victorians didn’t give a dingo’s kidney about egregious assaults on sovereign nations.I’m probably undervaluing it anyway.Sorry, New Yorkers. I remember your hot almonds so well.Still, that’s a lot of money, Half of the U.S debt in fact and if you’ve ever wondered who or why keeps lending American so much money, the scratch valuation of Manhatten no doubt answers that question for you. (Its assets y’all.)Now, how much is Manhatten worth underwater I hear you ask?Well, OK, maybe that’s part of my internal dialogue, but it’s a pertinent question nonetheless, and it’s hardly your fault that my medication does not work as well as it used to. I started hoarding them back in 1996, and I think I’ve been taking them in non-chronological order.Now, I know, predictions about the watery future of New York have been made like this before and not always in Stephen Spielberg productions either.But, if you look at some of the gutter Press, they’ll insist that scientists insisted that New York would be submerged by 2015 and that the fact that its now mostly above ground proves that: A) Neil Armstrong never walked on the moon and that that b) Amazon Alexa connects to an individual NSA agent armed with a notepad, walkie talkie and an empty bottle of Snapple in case he needs to pee while you’re spilling your secrets.Of course, you cannot believe everything you read. Let’s look at where this story originates from:Back in 1988, Professor Jim Hansen was looking down at Broadway when a journalist asked him if anything would look different in 20 years?“I expect I’ll have grown me some man boobs,” he answered.Of course, that’s not what he said at all. I was trying to emphasize the last point I made about not believing everything you read and it backfired. What he really told the journalist was this:“Well, there will be more traffic. The West Side Highway which runs along the Hudson River will be under water. And there will be tape across the windows across the street because of high winds. And the same birds won't be there. The trees in the median strip will change."That’s it! Smoking gun! Proof if proof is need be say the climate deniers (unaware that their command of grammar does more to infuriate the urban liberal elite they so despise than any slur they could post on social media).It’s all a hoax, mic drop with no fear of electrocution because the floorboards are dry!But let’s look a little more closely. Hansen’s vision for Manhatten was of a likely scenario taking place in 20-30 years resting on an assumption of humanity doing what it does best.Nothing.But that’s not how things panned out.In fact, we made quite a lot of progress.In 1994 for example, the United Nations Framework Convention on Climate Change came into force. In 1998 the Kyoto Protocol was adopted, and Elton John released ‘Candle in the Wind,’ although those two events are not related. EU trading emissions launched in 2005, the same year the Kyoto protocol came into effect. In 2016 the Paris Agreement was adopted by most nations including the U.S although the ‘literal embodiment of the Hooter’s business model’ that is President Donald Trump of pulled out of it like he was barebacking a porn star.So, that ’s not nothing. And no, spell check, I don’t mean ‘anything; you’re not the boss of me, and I’m going to be dead long before AI becomes sophisticated enough to outthink me so the jokes on you, you future, immortal-genius overlord bastard!Still, the progress we made was according to Anderson Cooper* both ‘small and twatty’, in comparison to what actually needed to be done. Indeed, the measures we undertook to stave off our eventual demise were reminiscent of that scene in Titanic when Théoden King suggests that the ship’s pumps might help.“Too little too late my bearded friend,” replied the ship's engineer (who has to be Scottish thanks to a legally binding clause between Holyrood and Hollywood signed in the 1950s.)“We’re going to sink like super-glued ducks’” he added sadly before staring off wistfully at an Edwardian clock.Maybe I remember it wrong… I haven’t seen it since it was in the cinema.Regardless of the point that I’m pretty much sure I’m trying to make is this. Back to the bullet points, I think.· The estimates climate scientists gave were based on incomplete data which we now have in much higher quantity.· We have taken steps to offset Climate Change, and that has bought us some time. We just have not done enough.· New York did actually flood in 2012 causing tens of billions of dollars in damage and killing 43 people. It annoys me when people forget that.· Manhattan is spending 1 billion dollars in flood defense to combat growing evidence that the island is at risk.· Here’s a picture of what it might look like if the sea levels rise by 8 feet.Which brings us to the crux of the matter.When Fox and Friends talk about the damage to the U.S economy, they never take into account the cost of doing nothing.The cost of rehousing everyone in Miami. The cost of helping refugees in far-flung islands after their entire nation gets swept away. The cost of policing a population used to plenty during times of mass crop failure. The cost of mass extinctions. The cost of building up coastal defenses in a nation that famously has an awful lot of coast. The cost of rising extreme weather events. The medical cost of record levels of respiratory disease. The political cost of trying to manage large swaths of voters who are forced to drink poisoned water from aging infrastructure.I could go on, believe me, I could.Losing Manhatten to encroaching ocean would make the 2008 financial crisis look like a misprinted and quickly sorted out the next day overdraft statement form a 1950’s bank.And you talk of the societal cost?What on that GND bullet list is going to hurt society more than our current way of doing things already has?We are entering an age where autocratic China is rising resurgent. An era where retail jobs might disappear entirely. The next quarter of a century will see off trucking as an industry. That’s over 3 and a half million jobs people! In just one sector.What exactly are humans going to do with themselves? Who wants a job re-planting the forests? Who wants contracting to replace ever pipe in America with modern materials? Who wants to clear the brownstone sites? Any takers for a 20-year sub-contract to install the infrastructure needed to build a zero-emission car network?I’m pretty sure that there would be many, many takers.And where are the people who want to breathe shitty air? Where are the people who fail to see a link between access to green spaces and human happiness? Who exactly is pro-methane? Because I know you exist because you keep voting for a bunch of industry shill whang handles who seem to have convinced you that the most significant risk to civilization is a modest hike in an estate tax that you personally are never going to have to pay.Newsflash, the big business octagenarian White-Guy brigade led by Turd- Biscuit in Chief @realdonaldtrump doesn’t have your best interests at heart. They distract you with endless diatribes about illegal aliens in the hope you won't even notice the elephant in the room. Big oil, big pharma et al., they are all as bad as one another. The billionaires club have already made their investments and they sure as hell did not make their mountain of cash by investing in people. They want to screw you for every penny you have and leave nothing for the next generation.Some of them are building bunkers to prepare themselves for the trials to come.Not only is the New Green Deal economically viable it’s America’s last, best hope of getting itself out of the mess its got itself into.China just landed a probe on the dark side of the moon. They built the world’s fastest computer. They are outpacing the U.S in the development of A.I. They are showing the seeds of soft power that all but guarantees that the 21st century is going to be the Chinese century. Saying to yourself ‘Oh but they don’t innovate as we do,’ isn’t going to help you anymore. ( It’s also a bit racist).And while Chian is surging ahead, what’s going on in the U.S?You’re shutting down your government for a month at a time. You’re taking more satisfaction at sticking it to the ‘Libtards’ than you are to actual success on the world stage. Why make American great again when you can speed it towards a cliff edge while wearing the soothing placebo of a MAGA hat?The U.S of today convinces itself that NASA never landed on the moon, congratulates itself on closing down essential projects such as – oh, I don’t know, educating its population – and looks at companies like Amazon as a replacement for lost middle-class incomes. Sure, small government sounds good. Until the bridges collapse and the fire department struggles to recruit for lack of decent wages. Until the schools crumble and sinkholes show up in the nation’s capital.Yeah, if NASA wants to send someone to space, they need to ask Russia for a lift and if that’s not MAGA then what the hell is?USA, USA USA! No?Every nation is entitled to its quirks and cultural oddities, but America’s hostility towards government, commonwealth and sensible adherence to scientific principles, has got to go. Without healthcare, there is no life, and you see what happens to your liberty as the elite move towards ever more sophisticated methods of policing an ever more disgruntled population. And as for the pursuit of happiness? Well, without access to clean water it just sort of takes on a sarcastic tone now doesn’t it?You need jobs, good ones. You need air, fresh air. You need to follow the evidence where it leads.That last point is essential.If 99.9 percent of scientist got together and concluded that a comet large enough to wipe out all life on the planet was on a collision course with the Earth circa 2050, what should we do about it? The rational answer is that we should devour our time, resources and ingenuity to figuring out some way to divert the disaster.The GOP, however, would no doubt deny the existence of the ‘so-called cosmic bullet.’ They’d find the half dozen astronomers – mostly in their 70s – willing to take bribes from vested interests opposed to the government devoting money to expensive ‘continuation of the species programs,’ of no personal use to those guaranteed to be dead before D day.We should force them to wear Dead Before the D-Day shirts whenever the testify come to think of it.“Can we afford to throw billions of dollars into ‘Everyone is going to die in a horrible explosion fund?” Tucker Carlson would ask before staring at the camera and looking like he’s trying to figure out of the prostate examination has started yet.“The radical pro-humanity fringe of the Democratic party!, Jeanine Pirro would warn us“Is hellbent on spending your tax dollars on making sure that human life as we know it carries on into a hellish future that directly affects my tax bracket while leaving yours relatively unscathed.”It’s not even funny.As scientists work their way to virtual unanimity on how our flagrant disregard for the planet we live on is going to end us, right-wingers insist that there is nothing to be done.They bring on sophists whose job it is to distract. It’s unavoidable they say ( it’s not), the scientific community is divided ( it isn’t) the radical hipster doufas under the 30s with their extensive vocabulary, unfamiliar vegetables, and inability to focus on anything for more than 18 seconds are a bunch of self-obsessed hippies…OK, there’s some truth to that last one.Still, if a doctor tells you that he needs to remove a tumor then, by all means, get a second opinion. If you ask a thousand doctors and 999 of them agree with the initial diagnosis then its probably an excellent idea to prep for an operation.Do not, under any circumstances follow the advice of the outlier –who just so happens to be on a retainer from the world’s largest consortium of funeral directors – that you should kick back and enjoy life while you’ve still got some butThe recent study on insect populations published in the Journal of Biological Conservation painted as bleak a picture of the future we face as one could imagine. We are running out of insects. We are not on the cusp of Earth’s sixth mass extinction event; we are living through it. I mean right now. Hence the bunkers. Because without insects, human life as we know it CANNOT continue. It’s not my place to teach basic ecology, but I’m more than happy to report basic facts.No bugs: No Bread.There is no viable alternative to the Green New Deal, and any discussion of its lack of viability should be treated with the contempt it deserves.Climatologists say that things are going to get dystopian if we don’t do something NOW. If they are wrong, and we clean up the planet for good and provide good jobs for ordinary hard-working people in doing so then fine, I’m good with that.Now tidy your room and think about what was said here today.For general musings or indeed if you want to contact me/ yell at me or ask for my phone number, you can contact me via twitter.

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!