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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!

Finding A Psychiatrist, Part 1 - Patient NeedsBefore you worry about finding a fitting doctor, you have to figure out what sort of doctor you might fit with—you have to understand your own treatment goals and preferences about healthcare philosophies and professional dynamics.Below are some examples of questions to ask yourself. They do not cover all the potential options, and should be understood as primers and ‘for instances’ rather than comprehensive presentations of what is out there.Do you want a doctor who will just do a very basic medication management plan, or are you looking for a psychiatrist who will help you with side effects and with understanding the most ideal treatment options?Do you want a doctor who handles complex cases or multi-drug regimens, or are you just looking to sustain a basic drug plan for a basic problem?Are you interested in a single-doctor private practice, or would a treatment group or multi-specialist office be more appropriate?Do you want someone who is pretty available, or who can take you during emergencies, or is it okay to have a doctor where booking weeks in advance is the only way to see someone?Are you looking for someone that is an accomplished diagnostician that can fiddle around with drug plans, or have you settled into a course of treatment that works for you already?Do you want a doctor or care center that offers you more than just drugging, or do you have things like nutritional health, supportive psychological habits, healthcare and treatment information, and social support covered elsewhere?You also have to consider aspects like cost, accessibility, and how long you plan to be seeing a psychiatrist for. What your insurance will cover (if you have insurance), how much you can afford to pay (as a deductible or out of pocket for out-of-network support), how far you can drive, whether you can make it up stairs or across streets, whether this is going to be a short term or indefinite attempt at treatment, and other aspects can play a significant role in what doctor or practice seems ideal.What you care for in terms of personality, approach to mental health, knowledge, understanding, and wisdom, training and expertise, and specialization of focus can all influence which doctors are more potentially relevant or compatible. A doctor being highly regarded, or well-studied, or rather successful does not mean they are necessarily the best fit for you, or providing the sort of care you are looking for.Finding A Psychiatrist, Part 2 - LogisticsThere are different ways to go about finding a psychiatrist, and I will list a few below. You can cold call these people, or ask for specific referrals, or get input from other patients or professionals before trying to have a sit-down with them as a part of making your decision.These are just professional consultants—they are their to offer you information, not dictate what you do or how. If you don’t like how well they consult, or what they have to offer, you are not indebted to them or obligated to decide on or keep someone that is not going to get you where you want to go.Insurance network referrals - you can browse databases, ask for customer service help in finding ones that are close by or taking new patients, or perhaps even ask for a ‘provider search request’ that will match you with an appropriate doctor for your particular needs.Doctor referrals - talk to trusted physicians you are already familiar with and see if they know anybody they would recommend for you personally. High quality doctors tend to know some of the other high quality doctors—and can also warn you about some of the low quality doctors out there, oftentimes.Friend, family, and peer referrals - if you know anyone who has a specific recommendation, you can talk to them about why they think a particular psychiatrists is good for them. You can also look online and see what other patients are saying about facilities and practitioners, both within mental healthcare communities and also on websites that ‘rate’ doctors or allow for detailed feedback to be left.Browsing public databases - healthcare listings, for instance those at psychologytoday.com, can sometimes give you leads to follow up on. It is not always easy to get much meaningful information about a doctor through database listings, but you can always call the doctor or facility up and ask them some preliminary questions. Some databases pertain to particular fields of specialty, but some are for finding any sort of doctor in your area.See who the experts are - if you can afford it, or think you need it, finding an expert instead of an everyman might narrow the field quickly and help you focus on a selective subgroup of potentials. Reading websites with medical and treatment information, using search engines for prominent and well-regarded physicians, and seeing if there are doctors who have published books you find useful or accurate to your own perspectives are some examples of how to sort the wheat from the chaff.See who is affordable - some people are stuck with low-income options, or rely on the government, aid organizations, or sliding-scale pay physicians to see psychiatrists. If you have practical or financial limitations in this regard, the likelihood of finding a competent and fitting doctor is lessened significantly but it can still be possible. Instead of letting people send you to only one place, ask for the full list of possibilities and do your own checking up to see what care situations or professionals are more appealing to you. You can start looking at these options by calling 211 or visiting UnitedWay.org, in addition to consulting with your local and regional government offices or looking for healthcare advocacy organizations to get resources and referrals from.Finding A Psychiatrist, Part 3 - The InterviewDespite all this research and preparation, it is always just “a guess” to one extent or another. That is why scheduling a time to meet without being diagnosed or prescribed drugs is ideal when your scheduling allows for it. Have a discussion about your treatment goals, expectations for recovery, and standards for quality of care.There are so many different doctors, philosophies, and treatment settings that it can be like putting together a puzzle. And, even if you have information that makes someone seem appealing, only interacting with them face-to-face in a professional setting will allow you to assess their potential in the most realistic way possible.Sometimes, despite feeling comfortable or supported at first, a psychiatrist begins to feel less fitting. A switch is necessary to get the most out of treatment, sometimes, or to keep safer when a doctor is pitching dangerous ideas or refusing to listen to the problems you are experiencing with the drugs.Doctors tend to have blind spots, weak areas, or difficulties that are not always apparent but can make a bigger difference at one point of treatment rather than another. It is okay to move on to someone more helpful if discussing the problem with your doctor does not resolve the issue.For old doctors, new doctors, and anyone else, I made a list of some helpful questions you might want to ask a psychiatrist before you decide to undergo treatment from them. These are not exhaustive, but cover several important points:Beliefs About Treatment:What is your treatment philosophy? When do you think medications are the best idea for someone?Are psychiatric drugs safe? What does “safe” mean to you?How do you feel about informed consent? What does “informed consent” mean to you?Do you think “mental disorders” are presently well understood by science? What about psychiatric drugs?What do you think are reliable sources for medical information for psychiatric issues and drugs?Do you read meta-analyses of unpublished trial data?Do you think there is a conflict of interest when pharmaceutical companies are testing the safety and efficacy of their own products?Side Effects:What do you rely on for statistics regarding the relative incidence of particular side effects?Are you competent in recognizing and handling all the potential side effects of the drugs you might prescribe me? Are you able to give me specific referrals for side effects you are not qualified to deal with?Do you report adverse events to the FDA (or appropriate regional regulatory body) and pharmaceutical companies?Do you have experience in risk-reducing tapering protocols for all classes of medications you prescribe? Are there physicians you refer patients to if you feel unable to adequately provide tapering support?Do you know about the possible symptoms and range of severity for psychotropic withdrawal syndromes? Do you understand that all types of psychiatric medications can cause withdrawal syndrome?Do you understand that withdrawal syndrome can happen even if a slow taper is used, and that there is no limit in duration to the withdrawal and post-discontinuation symptoms of psychiatric drugs for some patients?How much do you know about long term side effects, including epigenetic side effects?Treatment Setting:How much experience do you have in psychiatric care?What is your scheduling availability? How far in advance do I have to schedule appointments, or cancel previously scheduled ones?What is your emergency contact availability?What adjunct treatments do you think are appropriate for handling the conditions I am being evaluated for?Do you receive any form of compensation or rewards from institutions, corporations, or government agencies?Are there any other potential conflicts of interest you might have?Have you ever taken any of these drugs yourself? On a regular basis?You can also check out two full Quora threads on this sort of topic, including the one I was quoting those questions from, and resources from a few other websites that focus on psychiatric care:What are good questions to ask a potential psychiatrist?What signs should I look for in a good psychiatrist?Guides and PapersPublications

This answer may contain sensitive images. Click on an image to unblur it.Many have already answered very similar questions, without the political slant.The following is from: Fred Lead's answer to What should be done about school shootings?How can we stop the school shootings?There isn’t anything that will make mass shootings and school shootings end completely, but there are ways we can decrease the frequency and deadliness of such attacks.Learn from Serial Killings and SuicidesWe have been experiencing a massive drop in the number of serial killings in the US for the past three decades and a drop in the number of serial killers. Much like with “gun deaths”, the US has and still does outpace the rest of the world in serial killings. In some decades the US had about 500 more cases than the rest of the world. In every decade since the 1970s and 1980s the US has cut serial killer activity dramatically.http://maamodt.asp.radford.edu/S...As serial killings have decline have mass shootings filled the gap?But this perception [that mass shootings are increasing] isn’t because of some unprecedented rise in the rate of mass public shootings—far from it. They’re roughly as common now as they were in the 1980s and ’90s. And the data offer a stark finding: Over the past decade, mass public shootings haven’t become particularly more prevalent, they’ve simply become deadlier.Mass Shootings Are Getting Deadlier, Not More FrequentWhat we see, thanks to a variety of variables, is (mostly) young disturbed men prefer to become mass shooters and not serial killers. The only difference is fewer are successful in acting out their plans. The general profile of serial killers and mass shooters are remarkably similar as well.Then there is this factor,The media's growing obsession with serial killers in the 1970s and '80s may have created a minor snowball effect, offering a short path to celebrity.The decline of the serial killer.The public eye has long moved on from the serial killer shows and news series of the past, placing mass shooters as the surest road to fame. The news reports have become more detailed, more graphic, and often focus on every aspect of the attacker’s life for weeks to months later. This kind of attention is appealing to those that feel nameless, faceless, and voiceless.This has been a phenomenon the FBI identified after a mass shootings in the 1990s,Ever since Columbine, the FBI has been studying what drives people to commit mass shootings. Last fall it issued a report on 160 active-shooter cases, and what Simons could disclose from its continuing analysis was chilling: To a much greater degree than is generally understood, there’s strong evidence of a copycat effect rippling through many cases, both among mass shooters and those aspiring to kill. Perpetrators and plotters look to past attacks for not only inspiration but operational details, in hopes of causing even greater carnage. Emerging research—including our own analysis of the “Columbine effect“—could have major implications for both threat assessment and how the media should cover mass shootings.Inside the race to stop the next mass shooterFrom a recently foiled shooting we can see pretty clearly the media attention is a pretty big deal, shooters are motivated by fame, and that they do learn from past shooters. From the journal of a foiled shooter,“I’ve been thinking a lot,” he added, according to the court records. “I need to make this shooting/bombing at Kamiak infamous. I need to get the biggest fatality number I possibly can. I need to make this count.“I’ve been reviewing many mass shootings/bombings (and attempted bombings) I’m learning from past shooters/bombers mistakes, so I don’t make the same ones.”https://www.washingtonpost.com/n...In addition to a shift in media attention we have also been experiencing a shift in general culture. We know with the advent of social media people have become more isolated and lonely, as well as instilling a preference for instant gratification. It would make sense that deranged people would gravitate toward instant results, but this is a topic I have not seen much research on.Just like with serial killings suicides decreased after media attention was severely curbed. Suicide research provides a pretty clear model of “behavioral contagion”, which may be at play with mass shootings as it most likely was with serial killings, emphasis mine,The media affords the opportunity for indirect transmission of suicide contagion, the process by which one suicide becomes a compelling model for successive suicides.1,2 This means of influence is potentially more far reaching than direct person-to-person propagation. Suicide contagion can be viewed within the larger context of behavioral contagion, which has been described as the situation in which the same behavior spreads quickly and spontaneously through a group.3 Behavioral contagion has also been conjectured to influence the transmission of conduct disorder, drug abuse, and teenage pregnancy.4,5 According to behavioral contagion theory, an individual has a preexisting motivation to perform a particular behavior, which is offset by an avoidance gradient, such that an approach-avoidance conflict exists.6 The occurrence of suicides in the media may serve to reduce the avoidance gradient—the observer’s internal restraints against performing the behavior. Social learning theory also provides a foundation on which aspects of suicide contagion may build. According to this theory, most human behavior is learned observationally through modeling.7 Imitative learning is influenced by a number of factors, including the characteristics of the model and the consequences or rewards associated with the observed behavior.8 Consequences or rewards, such as public attention, may lower behavior restraints and lead to the disinhibition of otherwise “frowned upon” behavior.9http://www.columbia.edu/itc/hs/medical/bioethics/nyspi/material/SuicideAndTheMedia.pdfTo me the case looks pretty clear; some troubled people turn into monsters but now have shifted from serial killings to mass shootings in step with the shift in media attention and society in general. Media coverage is an important motivator for most shooters; it allows them to address a perceived wrong in front of the entire world, immortalize their name, and ensure the entire world knows all about their life. Past trends in serial killings and suicide show media restrictions can save lives.Dr. O'Toole, who is Editor-in-Chief of Violence and Gender, calls on the media to stop using the names of mass murders, which only fuels their desire for fame and is "a very powerful motivator," Targeted mass killings can be preventedMental Health ReformMental illness is often cited as the primary motivator in a shooting, but that is a flawed sentiment as there are obviously other motivators. If it were truly due to mental health issues alone mass shootings most likely would be completely random and not planned. Mental health issues are a contributing factor, but not the factor as many make it out to be,In an analysis of 235 mass killings, many of which were carried out with firearms, 22 percent of the perpetrators could be considered mentally ill. Checking Facts and Falsehoods About Gun Violence and Mental Illness After Parkland ShootingIf a minority of mass killings the attacker was found to have some sort of mental illness. Why does it seem mental health is such a big deal? We need to understand the motivations of the attackers in order to find any kind of predictable factors. Experts have researched this topic extensively,Although some mass shooters are found to have a history of psychiatric illness, no reliable research has suggested that a majority of perpetrators are primarily influenced by serious mental illness as opposed to, for example, psychological turmoil flowing from other sources. https://psychiatryonline.org/doi/pdf/10.5555/appi.books.9781615371099The major issue with mental health reform as a primary mechanism against mass shootings is that mental health is completely voluntary.Even if mental health services are free that does not mean individuals who need them most, from society's perspective, will seek the services out. In fact, the mental health disorders that are most prevalent in violent individuals typically push those individuals away from help if left on their own. Anecdotally, someone in my extended family has some mental health issues that clearly damage the well-being of themselves and their children, but not to the point where Child Protective Services or law enforcement can intervene. This individual refuses to accept help, even though others have offered referrals and to pay for the services. No one can force mental health services on anyone until there is a breech large enough for the legal system to intervene. Oftentimes in the case of a mass shooter the individual is a loner and has no one to advocate for them and do not have any breeches that warrant investigation or intervention by the legal system.When these individuals are forced to use mental health services in many cases it is not like a medical procedure that operates separate of the will of the individual, and prescription drugs alone are not a solution. Psychotropic drugs have actually been shown to increase destructive behavior and the severity of the destructive behavior in many cases. The individual must necessarily want to be better in order for any treatment to be effective. Mental health is also a process, it is not a silver-bullet instant fix. Even if an individual is getting help they may still be a risk to themselves or others at any point during the process; once someone begins to get help that doesn't mean they are immediately fixed and peaceful. In fact, in many cases people become more irate and agitated by facing their issues and giving up destructive coping mechanisms throughout the process. I think many people have a deep misunderstanding of mental health; it isn't like yoga where you go for an hour and feel peaceful and relaxed afterward. Sometimes it works out like yoga, but in some cases it can be deeply unsettling and uncomfortable, but it is required to get to real long-term healing. For severe cases that justify the use of prescription drugs it's as simple as not taking the medication and you now have an individual that is on par with someone that has never had any help.We do need to increase mental health care in the United States and that may decrease the number of cases of violent crime, including mass shootings, but that is a difficult argument to make at this point. I do not believe better funded mental health services will end mass shootings completely, especially if it is viewed as the singular silver bullet fix, but I do believe it will benefit society as a whole. Mental health access in conjunction with other points here can help through a multi-layered approach to help reform people and shift them to a better path, but even that is not foolproof.InterventionWhat we find in the past profiles of mass shooters are preexisting motivations, consistent with the behavioral contagion theory in a previous section, that are obvious “warning signs” after the fact. The problem is there are too many people that have these warning signs that are adequately deterred by a number of conditions for these “warning signs” to have any predictive value. In addition, the actions law enforcement can take against the individuals that display such “warning signs” is quite limited until a breech that is serious enough is committed. In some cases this breech is simple assault, theft, or other petty crimes that could be called “cries for help” or otherwise emotional outlets, in the most rare of cases it is a mass shooting attempt.What can we do about this? We need to be involved as a community with our youth and those in our lives. Parents, family, friends, we are all the first line of defense for a safe society. We know the troubled people in our lives more than anyone else, and we are in positions to not only monitor them but intervene in their lives. We can help them find the help they need to keep their issues from escalating, if they will accept help and want to face their issues. The profile of mass shooters usually includes isolation and estrangement from family, lack of friends, and so on so this isn’t always possible, but it does help us as a society and may reduce the escalation of issues that lead to mass shootings.This idea has been tested and it has worked to a degree, but it is a constant effort,The threat assessment team had to decide just how dangerous Ayala might be and whether they could help turn his life around. As soon as they determined he didn’t have any weapons, they launched a “wraparound intervention”—in his case, counseling, in-home tutoring, and help pursuing his interests in music and computers.“He was a very gifted, bright young man,” recalls John Van Dreal, a psychologist and threat assessment expert involved in the case. “A lot of what was done for him was to move him away from thinking about terrible acts.”As the year went on, the team kept close tabs on Ayala. The school cops would strike up casual conversations with him and his buddies Kyle and Mike so they could gauge his progress and stability. A teacher Ayala admired would also do “check and connects” with him and pass on information to the team. Over the next year and a half, the high schooler’s outlook improved and the warning signs dissipated.When Ayala graduated in 2002, the school-based team handed off his case to the local adult threat assessment team, which included members of the Salem Police Department and the county health agency. Ayala lived with his parents and got an IT job at a Fry’s Electronics. He grew frustrated that his computer skills were being underutilized and occasionally still vented to his buddies, but with continued counseling and a network of support, he seemed back on track.The two teams “successfully interrupted Ayala’s process of planning to harm people,” Van Dreal says. “We moved in front of him and nudged him onto a path of success and safety.”But then that path took him to another city 60 miles away, where he barely knew anyone.Inside the race to stop the next mass shooterIntervention works until you stop working at it. Combined with mental health services and the coping skills they can provide intervention and social engagement goes a long way. Sometimes that intervention goes beyond logical discourse, referring to mental health services, and caring. At that point law enforcement must step in,[A]uthorities say that Cathi O’Connor contacted police after reading entries in 18-year-old Joshua Alexander O’Connor’s journal.Grandmother Stops Teen Who Was Allegedly Planning a School Shooting“This is a case where the adage ‘see something, say something’ potentially saved many lives,” Everett Police Chief Dan Templeman said late Thursday in the statement. “It is critically important for community members, to include students and parents, to remain observant and immediately report odd or suspicious behaviors with our children or with fellow students. We were fortunate that a family member believed there were credible threats and contacted law enforcement for further investigation. I’m sure the decision was difficult to make, but fortunately, it was the correct one.”https://www.washingtonpost.com/news/post-nation/wp/2018/02/15/a-would-be-shooter-tossed-a-coin-to-pick-a-school-police-say-his-grandmother-foiled-his-plan/?utm_term=.c4f8a8bf1ab5Law EnforcementIn recent shootings many have placed the blame squarely on failures in law enforcement. Multiple tips were not followed up on, but that doesn’t mean we should stop reporting suspicious activity. To make our communities safer from all kinds of crimes community policing is the answer, as shown in New York City, which has experienced a steady drop in crime to all-time lows,The NYPD credited the stark reduction to its new precision policing approach to fighting crime, in which investigators focus on people who have shown a pattern of committing crimes.In March, several NYPD units, including the department’s detective squads and vice, narcotics, gangs and organized crime investigation divisions, were given new bosses — an “investigative chief” in each patrol borough. The chiefs, in turn, report to Chief of Detectives Robert Boyce, officials said.The overhaul — which dismantled the department’s Organized Crime Control Bureau, placing its units under Boyce’s umbrella — has been credited with reducing the number of shootings across the city, officials said.NYC saw historically low number of shootings in 2016Who could have guessed targeting career criminals would decrease crime? Oh yeah, criminologists,In an email, Pfaff pointed out that Monday’s data matched what scholars already knew. “Crime has always been highly localized,” Pfaff said. “Studies in several cities have shown that about half of all reported crime occurs in under 10 percent of all city blocks, and almost all crime in under half. And those ‘at risk’ blocks remain fairly constant over time. So talking about crime in ‘the U.S.,’ or ‘Illinois,’ or even ‘Chicago’ has always been somewhat misleading.” What the FBI's Latest Crime Report Really ShowsBut New Yorkers knew this already,It’s a very small percentage of the population in New York City that’s involved in crime,” O’Neill said in an interview with the Daily News in September. “If the same cops are there every day, they know who the good people are — which is the vast majority of them. ... It’s going to have a real effect on what goes on. NYC saw historically low number of shootings in 2016The move to effective policing not only results in lower crime and more lives saved it also frees up resources to conduct more on-the-ground investigations, the lack of which led to the failures by law enforcement in recent shootings. Generally, the community knows who the problem people are and can point police in the right direction. Why don’t all areas use community policing? Many can’t because a career in law enforcement is not appealing, so getting local applicants isn’t really an option. In some areas the local populace feels victimized and abused by law enforcement and so they have a deep level of distrust. This decreases the effectiveness of police and builds up an attitude of “us vs them”, also called police militarization.When people in authority abuse power, trust and connectedness to a community erode. "It leads to a breakdown of that which holds society together," Teresa Cordova, director of the Great Cities Institute at the University of Illinois at Chicago, told us. "It's that sense of connectedness that has always been such a powerful part of Chicago neighborhoods."When Chicagoans don't trust police, the city suffersJustice officials make the case that building trust and combating crime will be intertwined. "For Chicago to find solutions — short- and long-term — for making those neighborhoods safe, it is imperative that the City rebuild trust between CPD and the people it serves, particularly in these communities," the report says.Chicago police use excessive force, scathing Justice Department report findsSo what does all this have to do with mass shootings? The more connected a community is with police and the more trust that exists the easier it is for police to do their job and the more likely they will do a better job of it as well. As we saw in the example of the grandmother calling on her grandson, the ability to pick up the phone to call the police, and feel safe doing so, goes a long way. If you suspect something call on it; see something, say something.We certainly don’t make it easy for law enforcement to do their job in many cases. The background check system is our most important law enforcement tool in terms of controlling access to guns. Federal gun control legislation in the context of mental health relies on this question on the background check form: “Have you ever been declared incompetent or involuntarily committed to a mental institution?”. That would leave out quite a few mass shooters of the past, and did not stop others. Here’s the real problem, though. Even with the laws in place they cannot be effectively enforced,There are an estimated 3 million living Americans who have been involuntarily committed to mental institutions. The NICS database only contains the names of about 90,000 of these individuals. There are only 17 states that provide information on involuntary commitment for inclusion in the NICS database. Many of the noncompliant states simply have not computerized their records on involuntary commitment. However, a large number of the noncompliant states are also grappling with serious health-information privacy issues and are reluctant to provide the required data to NICS before these issues are resolved.Under the federal Health Insurance Portability and Accountability Act, mental health records may only be released to medical professionals, health insurance workers and quality-control personnel. Ohio’s attorney general has not yet determined how to gain access to the medical records needed to process CCW applications. Because Ohio has a relatively new CCW law, sheriffs are being asked to assist temporarily in checking courthouse records for involuntary-commitment orders. This exercise is both time-consuming and labor-intensive. It’s also unlikely to produce all of the information needed to verify the accuracy of answers provided on Ohio CCW permit applications.Although federal and state laws establish involuntary commitment as a prohibiting factor for gun purchases, mental health professionals contend that there is no scientific basis for this prohibition.According to Dr. Paul Applebaum, vice president of the American Psychiatric Association (APA), “checking for involuntary commitments…doesn’t make sense because past mental illness does not predict future violence.”Mental Illness And Gun Ownership - Guns & AmmoWe could take recent events and use it as a rallying cry against law enforcement, but we really need to stand by our law enforcement officers and find ways to help them do their jobs better because our safety is not their job, it’s everyone’s job. We also need to look at some of the gaps and ineffective policies in the current laws we have to make them more easily enforceable and more effective at getting the results we want.ResistanceMetal detectors, harsh punishments for infractions, and general education are all great, but will not stop attacks. These measures all have flaws that can allow an individual to slip through the cracks and do not matter to a motivated monster. The only measure that will save lives when all the preventative measures have failed or been completely skipped over is immediate overwhelming force. Overwhelmingly mass shootings have taken place in gun-free zones. Whether it is the gun-free zone policy that impacts the location picked is up for debate; there is usually a primary motivator beyond just the gun-free zone status, such as some kind of injustice, but with the recently foiled shooting plot we do see a clear case that the location was picked for “maximum damage”. Regardless, making it easier to kill doesn’t help the people in those situations. Armed resistance is a simple way to save lives.This can take many forms. There is the idea of arming school teachers (or simply allowing them to be armed) that are willing or have already become licensed and trained to carry a firearm. Some teachers have already taken the necessary training and licensing to carry a concealed firearm in public, but cannot carry inside the school building. What makes them fundamentally unfit to carry a firearm in a school building when they are deemed fit to carry a firearm in public, sometimes around the same children that are in the school? If the concern is due to a firearm on the teacher’s person there is the idea of securing a gun safe in the room with access to the teacher and an administrator. In the case of a shooting accessing the firearm does not change the lockdown procedure.Since some deem teachers inept and fundamentally too incompetent to carry a firearm upon entering a school building there is the idea of external security, such as security guards. The idea of employing veterans to do this has been tossed around as well. School Resource Officers can be found in some schools but not all, so some argue we should apply the same protection to each school, employing a SRO for security and general order in the school.Each of these ideas have backlash, but the idea is sound. Responding police have the luxury of waiting in safety for backup (and have in many cases in the past), despite going against protocol. When you are faced with an attacker you have to respond, being armed gives you one more tool to respond with, otherwise you are limited to running and hiding and cannot help anyone but yourself.There are many instances where armed resistance has stopped a shooting. Most of the stories are not as well-publicized as the “successful” mass shootings, most likely because they don’t have the same ability to keep viewers (and sell ads).How an Assistant Principal With a Gun Stopped a School ShooterOpinion | Do citizens (not police officers) with guns ever stop mass shootings?These examples are often ignored or even worse said not to exist in the first place. The arguments against immediate armed resistance are head-scratchingly fuzzy, such as Mother Jones arguing because an individual may be wounded or killed by the attacker they should not have the ability to shoot back at the attacker and instead it would be better to be wounded or killed while unarmed or that in some cases the responding individual was a security official or ex-military/LEO. These cases clearly show armed resistance acting immediately can save lives, it doesn’t matter who makes up that resistance. There is also the argument individuals should not be armed because in one case,it was “not clear at all” whether the kid had intended to do any further shooting after he’d left the building.I don’t believe “the kid only killed the people he wanted to and left” is a good reason to keep people that are licensed, trained, and willing to carry firearms from being able to do so.Armed resistance also presents a deterrent effect, although we can’t really measure this effectively for any topic. One of the interesting shifts in programming around serial killers was a move from “we’ll never catch them”, “cold cases”, “mystery murder” shows and news programs to “how we caught them” shows. The messaging changed from “serial killers can’t be caught” to “serial killers will be caught”, changing the way people feel about serial killers, including those that may have considered doing it themselves. This created a deterrent effect that we really can’t quantify. The issue with mass shootings is the attacker is usually motivated enough to not care about dying or actually wants to die, but we also know mass shooters are cowards. We can’t quantify and compare the “coward quotient” compared to the motivation to conduct a shooting, but the potential benefit from armed resistance remains: lives saved.The SolutionThere is no single silver-bullet fix to end mass shootings or school shootings. We need to do the hard work of building up and maintaining a stable and peaceful society. That means being active in our communities (especially with youth), improving access to mental health, supporting our police, calling for effective evidence-backed legislative policies and not “feel good” legislation, and protecting what matters to us all along the way. I wish there were a way to pass a law and end all bad things, but that is not the way it works. Evil will always exist, but we can work in the lives of those around us to integrate people into society and create a sense of belonging. One pattern seems to emerge from the past; whether it be serial killings, suicides, or mass shootings, the people that commit these acts overwhelmingly feel disintegrated from society, isolated, alone, and “other” from those around them. With the prevalence of social media in place of social interaction the main factors that cause negative patterns to develop are only exacerbated. We all need to do the work to keep us all safe, including those that on their own would develop into monsters we could one day hear about on the news.