England Develops a Voracious Appetite for a New Diet

LONDON — Visitors to England right now, be warned. The big topic on people’s minds — from cabdrivers to corporate executives — is not Kate Middleton’s increasingly visible baby bump (though the craze does involve the size of one’s waistline), but rather a best-selling diet book that has sent the British into a fasting frenzy.

“The Fast Diet,” published in mid-January in Britain, could do the same in the United States if Americans eat it up. The United States edition arrived last week.

The book has held the No. 1 slot on Amazon’s British site nearly every day since its publication in January, according to Rebecca Nicolson, a founder of Short Books, the independent publishing company behind the sensation. “It is selling,” she said, “like hot cakes,” which coincidentally are something one can actually eat on this revolutionary diet.

With an alluring cover line that reads, “Lose Weight, Stay Healthy, Live Longer,” the premise of this latest weight-loss regimen — or “slimming” as the British call “dieting” — is intermittent fasting, or what has become known here as the 5:2 diet: five days of eating and drinking whatever you want, dispersed with two days of fasting.

A typical fasting day consists of two meals of roughly 250 to 300 calories each, depending on the person’s sex (500 calories for women, 600 for men). Think two eggs and a slice of ham for breakfast, and a plate of steamed fish and vegetables for dinner.

It is not much sustenance, but the secret to weight loss, according to the book, is that even after just a few hours of fasting, the body begins to turn off the fat-storing mechanisms and turn on the fat-burning systems.

“I’ve always been into self-experimentation,” said Dr. Michael Mosley, one of the book’s two authors and a well-known medical journalist on the BBC who is often called the Sanjay Gupta of Britain.

He researched the science of the diet and its health benefits by putting himself through intermittent fasting and filming it for a BBC documentary last August called “Eat, Fast and Live Longer.” (The broadcast gained high ratings, three million viewers, despite running during the London Olympics. PBS plans to air it in April.)

“This started because I was not feeling well last year,” Dr. Mosley said recently over a cup of tea and half a cookie (it was not one of his fasting days). “It turns out I was suffering from high blood sugar, high cholesterol and had a kind of visceral fat inside my gut.”

Though hardly obese at the time, at 5 feet 11 inches and 187 pounds, Dr. Mosley, 55, had a body mass index and body fat percentage that were a few points higher than the recommended amount for men. “Given that my father had died at age 73 of complications from diabetes, and I was now looking prediabetic, I knew something had to change,” he added.

The result was a documentary, almost the opposite of “Super Size Me,” in which Dr. Mosley not only fasted, but also interviewed scientific researchers, mostly in the United States, about the positive results of various forms of intermittent fasting, tested primarily on rats but in some cases human volunteers. The prominent benefits, he discovered, were weight loss, a lower risk of cancer and heart disease, and increased energy.

“The body goes into a repair-and-recover mode when it no longer has the work of storing the food being consumed,” he said.

Though Dr. Mosley quickly gave up on the most extreme forms of fasting (he ate little more than one cup of low-calorie soup every 24 hours for four consecutive days in his first trial), he finally settled on the 5:2 ratio as a more sustainable, less painful option that could realistically be followed without annihilating his social life or work.

“Our earliest antecedents,” Dr. Mosley argued, “lived a feast-or-famine existence, gorging themselves after a big hunt and then not eating until they scored the next one.” Similarly, he explained, temporary fasting is a ritual of religions like Islam and Judaism — as demonstrated by Ramadan and Yom Kippur. “We shouldn’t have a fear of hunger if it is just temporary,” he said.

What Dr. Mosley found most astounding, however, were his personal results. Not only did he lose 20 pounds (he currently weighs 168 pounds) in nine weeks, but his glucose and cholesterol levels went down, as did his body fat. “What’s more, I have a whole new level of energy,” he said.

The documentary became an instant hit, which in turn led Mimi Spencer, a food and fashion writer, to propose that they collaborate on a book. “I could see this was not a faddish diet but one that was sustainable with long-term health results, beyond the obvious weight-loss benefit,” said Ms. Spencer, 45, who has lost 20 pounds on the diet within four months and lowered her B.M.I. by 2 points.

The result is a 200-page paperback: the first half written by Dr. Mosley outlining the scientific findings of intermittent fasting; the second by Ms. Spencer, with encouraging text on how to get through the first days of fasting, from keeping busy so you don’t hear your rumbling belly, to waiting 15 minutes for your meal or snack.

She also provides fasting recipes with tantalizing photos like feta niçoise salad and Mexican pizza, and a calorie counter at the back. (Who knew a quarter of a cup of balsamic vinegar dressing added up to a whopping 209 calories?)

In London, the diet has taken off with the help of well-known British celebrity chefs and food writers like Hugh Fearnley-Whittingstall, who raved about it in The Guardian after his sixth day of fasting, having already lost eight pounds. (“I feel lean and sharper,” he wrote, “and find the whole thing rather exhilarating.”)

The diet is also particularly popular among men, according to Dr. Mosley, who has heard from many of his converts via e-mail and Twitter, where he has around 24,000 followers. “They find it easy to work into their schedules because dieting for a day here and there doesn’t feel torturous,” he said, adding that couples also particularly like doing it together.

But not everyone is singing the diet’s praises. The National Health System, Britain’s publicly funded medical establishment, put out a statement on its Web site shortly after the book came out: “Despite its increasing popularity, there is a great deal of uncertainty about I.F. (intermittent fasting) with significant gaps in the evidence.”

The health agency also listed some side effects, including bad breath, anxiety, dehydration and irritability. Yet people in London do not seem too concerned. A slew of fasting diet books have come out in recent weeks, notably the “The 5:2 Diet Book” and “The Feast and Fast Diet.”

There is also a crop of new cookbooks featuring fasting-friendly recipes. Let’s just say, the British are hungry for them.

This article has been revised to reflect the following correction:

Correction: March 2, 2013

An earlier version of this article misstated part of the name of the national healthcare organization in Britain. It is the National Health Service, not the National Health System. The article also misidentified the Balsamic product that has 209 calories per cup. It is Balsamic vinegar dressing, not Balsamic vinegar.

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'Like finding lost Rembrandts'

Peter Mullin cracks open the door of a 1935 Voisin Type C25 Aerodyne at the back of the auto museum bearing his name. He points out the intricate details of a vibrant Art Deco interior, restored to its original luster.

A small ashtray hangs on the inside of each door — made from etched Lalique crystal.

Light streams into the car through three small glass windows in the fully retractable roof. A bold black and white patterned fabric covers the doors, seats and roof, sourced from the same French textile mill that wove the original fabric more than seven decades ago.

"You can see why this one is kind of the favorite," Mullin says of the C25 with a smile.

Once relegated to the scrap heap of automotive history, the Voisin brand has undergone a renaissance within the classic car world. The cars, which cost as much as a Bugatti in the 1920s and 30s, are worth millions of dollars today. They were the creation of Gabriel Voisin, a colorful yet fastidious French architect and engineer who made a fortune selling airplanes during World War I.

Mullin's navy blue and grey C25 won Best of Show at the 2011 Pebble Beach Concours d'Elegance, arguably the most prestigious prize in the classic car world. Another Voisin, a 1934 C15 ETS Saliot-bodied Roadster, won Best of Show in 2002.

When Pebble Beach Concours hosted Voisin as the featured marque in 2006, it provoked a frenzied reaction among collectors.

"It was like finding the lost Rembrandts," said Richard Adatto, an expert in classic French cars and a member of the classic car show's selection committee.

Prior to 2006, he said, no Voisin had sold for more than $1 million. After that, prices nearly doubled. Peter Mullin's C25 could be worth as much as $5 million today, said David Gooding, president and founder of the Gooding & Co. auction company. Most experts estimate there are 250 to 300 known Voisin automobiles, though they are starting to turn up as barn finds throughout Europe.

Fortunately for Mullin, he got into the brand early.

"I fell in love with the Art Deco nature of Voisin a number of years ago," Mullin said. "One by one, they found their way into the collection."

In addition to his prize-winner, Mullin owns 15 other exceptionally rare and valuable Voisin models on display at the Mullin Automotive Museum in Oxnard until the end of April. The museum is also home to dozens of gleaming prewar cars from other French marques like Bugatti, Delahaye and the odd Talbot-Lago.

Mullin, the man, owns nearly everything in the building. But the Voisin cars have become his favorite, not just for their intricate details, but because they embody the values of the man behind their nameplate.

Gabriel Voisin was a colorful figure who made a name for himself in the early 1900s as an aviation pioneer. Despite being in their mid-20s, Voisin and his younger brother Charles started the world's first aircraft company. Their early planes set several European flight records.

Gabriel Voisin kept the company open after his brother was killed in a 1912 car crash, and sold several thousand fighter planes to the French military and its allies for use in World War I.

After the war ended, a glut of planes and little demand for new ones pushed Voisin to build a machine with a more benevolent purpose. He spent roughly the next 20 years building some of the most elaborate and expensive cars of the era. The rigors of aviation engineering and attention to detail carried into Voisin's forward-thinking automobiles.

"Everything was designed all the way out," Adatto said. "Even the taillights were handmade."

Many of Voisin's cars have struts connecting the front wheel fender to the grille — like the wing struts common on aircraft from the era. The cars were largely built from lightweight materials such as aluminum or magnesium. Most cars from that time — and even today — were built from heavier steel.

Inside, the dashboard of many Voisin vehicles had gauges to show oil pressure and temperature in an era when most cars didn't even have a fuel gauge, Adatto said. A complex engine design used sleeve valves rather than the standard overhead poppet valves found on engines today.

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Bell jurors ordered to begin anew after panelist is dismissed

After nearly five days of deliberations, jurors in the Bell corruption trial were ordered Thursday to begin anew after a member of the panel was dismissed for misconduct and replaced by an alternate.

The original juror, a white-haired woman identified only as Juror No. 3, told Los Angeles County Superior Court Judge Kathleen Kennedy she had gone onto a legal website to look up jury instructions and then asked her daughter to help find a definition for the word "coercion."

Although all but one defense attorney requested that the woman stay, Kennedy said the juror needed to be removed. "She has spoken about the deliberations with her daughter, she has conducted research on the Internet, and I've repeatedly, repeatedly throughout this trial — probably hundreds of times — cautioned the jury not to do that," the judge said.

The removal came after jurors notified the judge that they were deadlocked and that continued deliberations seemed fruitless.

It was unclear how to interpret the day's events, whether the dismissed juror had been a lone holdout or an indication of a fractured jury.

The juror started to tell the judge which way she was leaning in the case, saying she had gone online "looking to see at what point can I get the harassment to stop.... How long do I have to stay in there and deliberate with them when I have made my decision that I didn't think there was —"

Kennedy cut her off before she could finish.

The woman clasped her hands over her mouth and said, "I'm sorry."

Two defense attorneys thought she was leaning toward acquittal and wanted her to stay. "I would have preferred the deadlock to a guilty verdict," said Alex Kessel, the attorney for George Mirabal, one of six former council members charged with misappropriation of public funds.

The council members are charged with inflating their salaries in what prosecutors contend was a far-reaching web of corruption in which fat paychecks were placed ahead of the needs of the city's largely immigrant, working-poor constituents.

When attorneys and defendants were summoned to the courtroom Thursday morning, they were initially told that the jury appeared to be deadlocked.

"Your honor, we have reached a point where as a jury we have fundamental disagreements and cannot reach a unanimous verdict in this case," read a note signed by two jurors, including the foreman, that was given to Kennedy.

A note from another juror alerted the judge that Juror No. 3 had consulted an outside attorney. That did not appear to be the case, but her other actions were revealed under questioning from the judge.

The same juror made a tearful request Monday to be removed from the panel because she felt others were picking on her. Kennedy told the woman that although discussions can get heated, it was important to continue deliberating.

On Thursday, however, the juror again broke into tears and said she had spoken with her daughter about "the abuse I have suffered." She said her daughter told her, "Mom, they're trying to find the weak link."

The woman said she had turned to the Internet to better understand the rules about jury deliberations and came across the word "coercion." After her daughter helped her look up the word's definition, she wrote it down on a piece of paper and brought it with her to court. When the judge asked to see the paper she went into the jury room to retrieve it.

The woman later left the courtroom in tears.

With an alternate in place, Kennedy told the panel to act as if the earlier deliberations had not taken place. The alternate had sat in the jury box during the four-week trial but did not take part in deliberations.

Former council members Luis Artiga, Victor Bello, George Cole, Oscar Hernandez, Teresa Jacobo and Mirabal are accused of drawing annual salaries of as much as $100,000 a year by serving on boards that did little work and seldom met, part of a scandal that drew national attention to the small city in 2010.

Prosecutors said that Bell's charter follows state law regarding council members' compensation. In a city the size of Bell, council members should be paid no more than $8,076 a year.

The trial began in late January, and the case went to the jury last Friday.

As the jury resumed deliberations in downtown Los Angeles, the verdict was clearly in on the streets of Bell.

One resident unfurled old protest banners and signs from the days when the pay scandal was first exposed and then called former members of an activist group that had led the charge for reform in the city.

"We're holding our breaths and waiting," Denise Rodarte, a member of the grassroots group Bell Assn. to Stop the Abuse, said in regard to a verdict.

"It's cut and dry: Local elected officials were supposed to make a certain amount of money, and they made a lot more."

corina.knoll@latimes.com

jeff.gottlieb@latimes.com

Times staff writer Ruben Vives contributed to this report.

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Suit over hiring of Jackson doctor to go to trial

LOS ANGELES (AP) — A judge has dismissed all but one count in a civil lawsuit by Michael Jackson's mother against concert giant AEG Live, which hired a doctor who was convicted of involuntary manslaughter in the singer's death.

Superior Court Judge Yvette Palazuelos' ruling Thursday means that Katherine Jackson will have a trial on her claim that AEG negligently hired and supervised former cardiologist Conrad Murray. The ruling dismisses claims that AEG could be held liable for Murray's conduct and breached its duty to properly care for the pop superstar.

AEG Live was promoting a series of comeback concerts by Michael Jackson in London titled "This Is It." Jackson died in June 2009 while in final preparations for the shows after Murray administered a lethal dose of the anesthetic propofol in the singer's bedroom.

Katherine Jackson's attorney Kevin Boyle was not immediately available for comment but argued at a hearing Monday that AEG controlled Murray's actions and failed to properly investigate him before agreeing to pay him to work as the singer's physician.

He cited Murray's debt problems as a red flag that AEG should have spotted and contends the company created a serious conflict between his responsibility to Jackson and his own financial well-being.

Jackson died at age 50 before a contract that would have paid Murray $150,000 a month was finalized.

AEG attorney Marvin Putnam has said Murray was not employed by the promoter and he expects the company to win at trial. He said Katherine Jackson's lawyers will be unable to prove that AEG should have foreseen that Murray was a danger to the "Thriller" singer.

A trial is scheduled to begin April 2.

___

Anthony McCartney can be reached at http://twitter.com/mccartneyAP .

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Well: A Rainbow of Root Vegetables

This week’s Recipes for Health is as much a treat for the eyes as the palate. Colorful root vegetables from bright orange carrots and red scallions to purple and yellow potatoes and pale green leeks will add color and flavor to your table.

Since root vegetables and tubers keep well and can be cooked up into something delicious even after they have begun to go limp in the refrigerator, this week’s Recipes for Health should be useful. Root vegetables, tubers (potatoes and sweet potatoes, which are called yams by most vendors – I mean the ones with dark orange flesh), winter squash and cabbages are the only local vegetables available during the winter months in colder regions, so these recipes will be timely for many readers.

Roasting is a good place to begin with most root vegetables. They sweeten as they caramelize in a hot oven. I roasted baby carrots and thick red scallions (they may have been baby onions; I didn’t get the information from the farmer, I just bought them because they were lush and pretty) together and seasoned them with fresh thyme leaves, then sprinkled them with chopped toasted hazelnuts. I also roasted a medley of potatoes, including sweet potatoes, after tossing them with olive oil and sage, and got a wonderful range of colors, textures and tastes ranging from sweet to savory.

Sweet winter vegetables also pair well with spicy seasonings. I like to combine sweet potatoes and chipotle peppers, and this time in a hearty lentil stew that we enjoyed all week.

Here are five colorful and delicious dishes made with root vegetables.

Spicy Lentil and Sweet Potato Stew With Chipotles: The combination of sweet potatoes and spicy chipotles with savory lentils is a winner.

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Roasted Carrots and Scallions With Thyme and Hazelnuts: Toasted hazelnuts add a crunchy texture and nutty finish to this dish.

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Carrot Wraps: A vegetarian sandwich that satisfies like a full meal.

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Rainbow Potato Roast: A multicolored mix that can be vegan, or not.

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Leek Quiche: A lighter version of a Flemish classic.

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Dow rises 35 points but stops short of record again

The Dow Jones industrial average is within striking distance of a new record.

Still.

In what has become a near-daily ritual, the world's best-known stock index inched closer to an all-time high Friday but stopped short once again.

The Dow climbed 35 points to rise for the second straight week. That marked a fresh five-year high and the third-best close of all time.

But whether it's the budget stalemate in Washington or the typical jitters that precede such milestones, the blue chips couldn't push into new high ground.

The Dow ended at 14,089.66 — just 75 points, or roughly 0.5%, from its peak close of 14,164.53 on Oct. 9, 2007.

Since climbing above 14,000 on Feb. 1, the index has largely meandered sideways, unable to muster the additional 165 points needed for the record.

Many experts think that will happen eventually, given the generally upbeat spirits among U.S. investors and consumers.

"The bottom line is stocks are headed higher," said John Bollinger, head of Bollinger Capital Management in Manhattan Beach. "It's going to be volatile and hard going. It won't be easy money, but it will be money."

The Standard & Poor's 500 index is further away from a new high — about 3% — largely because of the continuing travails of Apple Inc. After a 2.5% drop to $430.47 on Friday, the technology behemoth has sunk 39% from its mid-September peak above $700.

Investors are encouraged that stocks have risen in the face of the budget showdown in Washington. The $85 billion in automatic spending cuts, known as sequestration, began taking effect Friday after federal lawmakers could not reach agreement on a plan to avert them.

The Dow might have achieved a new high already if not for the economic uncertainty brought about by the budget clash, said A.C. Moore, chief investment strategist for Dunvegan Associates Inc. in Santa Barbara.

"There's an undercurrent of positive worldwide economic developments that continues to buoy stock prices," Moore said.

Some experts think stocks have risen because of sequestration rather than in spite of it. Their logic is that investors cheer anything out of Washington, albeit unwieldy and scattershot, if it reduces budget deficits.

"Is it possible that the market actually likes the idea of sequestration?" Bollinger said. "It's the only way it sees that any of this is going to get cut."

Consumer confidence surged in February as the improving job market offset concerns about higher taxes and looming federal spending cuts.

The monthly consumer sentiment index from Thomson Reuters and the University of Michigan rose 5.1% last month from January. The new reading of 77.6 also was up 3.1% from a year earlier.

"Consumer confidence continued to improve in February due to expected gains in employment," said Richard Curtin, the survey's chief economist. "These expected job gains have partially offset concerns about higher payroll taxes and the impending reduction in federal spending."

Although the unemployment rate ticked up to 7.9% in January, the economy added 157,000 jobs and figures for the last three months of 2012 were revised sharply upward. Weekly jobless claims have been trending down.

Meanwhile, consumers spent slightly more in January than in the previous month even as their income plummeted by the largest amount in 20 years because of the "fiscal cliff," the Commerce Department said Friday.

People boosted their spending by saving less money as they sought to offset tax increases that took effect. The personal saving rate in January was 2.4%, down from 6.4% in December, the lowest monthly level since late 2007.

The U.S. economic data offset downbeat news from Europe, where joblessness hit a new high.

The Eurozone's jobless rate went up in January to 11.9%, from 11.8% in December, as the region continued to grapple with recession and government cutbacks.

walter.hamilton@latimes.com

jim.puzzanghera@latimes.com

Staff writer Don Lee contributed to this report.

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Jury in Bell corruption trial may be deadlocked

A court spokeswoman said Thursday the jury in the Bell corruption case appears to be deadlocked.

“The jurors may be at an impasse,” said Patricia Kelly, a spokeswoman for L.A. County Superior Court.

Jurors sent a note to the judge Thursday morning, and all the attorneys in the case were called in.

Six former Bell City Council members are accused of stealing public money by paying themselves extraordinary salaries in one of Los Angeles County’s poorest cities.

Luis Artiga, Victor Bello, George Cole, Oscar Hernandez, Teresa Jacobo and George Mirabal are accused of misappropriation of public funds, felony counts that could bring prison terms.

They were arrested in September 2010 and have been free on bail.

The nearly $100,000 salaries drawn by most of the former elected officials are part of a much larger municipal corruption case in the southeast Los Angeles County city in which prosecutors allege that money from the city’s modest general fund flowed freely to top officials.

The three defendants who testified painted a picture of a city as a place led by a controlling, manipulative administrator who handed out enormous salaries, loaned city money and padded future pensions. Robert Rizzo, the former adminstrator, and ex-assistant city manager Angela Spaccia are also awaiting trial.

The four-week trial of the former council members turned on extremes.

Deputy Dist. Atty. Edward Miller said the council members were little more than common thieves who were consumed with fattening their paychecks at the expense of the city’s largely immigrant, working-poor residents.

Miller said the accused represented the “one-percenters" of Bell who had “apparently forgotten who they are and where they live."

Defense attorneys said the former city leaders -- one a pastor, another a mom-and-pop grocery store owner, another a funeral director -- were dedicated public servants who put in long hours and tirelessly responded to the needs of their constituents.

Jacobo testified that Rizzo informed her she could quit her job as a real estate agent and receive a full-time salary as a council member. She said she asked City Attorney Edward Lee if that was possible and he nodded his head.

"I thought I was doing a very good job to be able to earn that, yes," Jacobo said.

Cole said Rizzo was so intimidating that the former councilman voted for a 12% annual pay raise out of fear the city programs he established would be gutted by Rizzo in retaliation if he opposed the pay hikes.

The defense argued that the prosecution failed to prove criminal negligence -- that their clients knew what they were doing was wrong or that a reasonable person would know it was wrong.

The attorney for Hernandez, the city’s mayor at the time of the arrests, said his client had only a grade-school education, was known more for his heart than his intellect and was, perhaps, not overly “scholarly.”

Prosecutors argued that the council members pushed up their salaries by serving on city boards that rarely met and, in one case, existed only as a means for paying them even more money.

Jurors were also left to deal with the question of whether council members were protected by a City Charter that was approved in a special election that drew fewer than 400 voters.

Defense attorneys say the charter allowed council members to be paid for serving on the authorities.

But the prosecutor argued that the charter -- a quasi-constitution for a city -- set salaries at what councils in similar-sized cities were receiving under state law: $8,076 a year. Because council members automatically serve on boards and commissions, the district attorney said the total compensation for all of each council member's work was included in that figure.

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'Girls Gone Wild' files for bankruptcy over debts

LOS ANGELES (AP) — The company behind the "Girls Gone Wild" video empire has filed for bankruptcy in a move it says is an effort to restructure its legal affairs after several disputed court judgments.

GGW Brands LLC and several subsidiaries filed for Chapter 11 bankruptcy on Wednesday in Los Angeles, listing more than $16 million in disputed claims.

The largest claim is $10.3 million that Wynn Resorts Limited is seeking from the company for judgments entered against "Girls Gone Wild" founder Joe Francis over a gambling debt and statements he has made about the casino and its founder, Steve Wynn.

The figure does not include a $19 million judgment Wynn won against Francis in a slander trial last year. The case, which centered on Francis' claims that Wynn threatened to kill him over the gambling debt, is being appealed.

Francis no longer GGW Brands, which has made a fortune selling videos and magazines of young women flashing their breasts. Subsidiary companies GGW Magazine and GGW Events have also filed for bankruptcy. Bankruptcy proceedings generally halt efforts to collect judgments in other courts.

"Girls Gone Wild remains strong as a company and strong financially," the company said in a statement, likening itself to other businesses such as American Airlines and General Motors that have filed for bankruptcy to restructure. "The only reason Girls Gone Wild has elected to file for this reorganization is to re-structure its frivolous and burdensome legal affairs."

The second largest claim listed in the proceedings is a nearly $5.8 million judgment a St. Louis woman won against Francis last year in a Missouri court. Tamara Favazza sued after she learned she had been featured on a "Girls Gone Wild" DVD over an incident when she was a 20-year-old college student and someone lifted her tank top at a bar and flashed a camera.

Francis and his company, Mantra Films, are seeking to have the judgment overturned in federal court.

The bankruptcy filing also lists unspecified legal fees in the Wynn and Favazza cases.

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Doctor and Patient: Why Failing Med Students Don’t Get Failing Grades

Tall and dark-haired, the third-year medical student always seemed to be the first to arrive at the hospital and the last to leave, her white coat perpetually weighed down by the books and notes she jammed into the pockets. She appeared totally absorbed by her work, even exhausted at times, and said little to anyone around her.

Except when she got frustrated.

I first noticed her when I overheard her quarreling with a nurse. A few months later I heard her accuse another student of sabotaging her work. And then one morning, I saw her storm off the wards after a senior doctor corrected a presentation she had just given. “The patient never told me that!” she cried. The nurses and I stood agape as we watched her stamp her foot and walk away.

“Why don’t you just fail her?” one of the nurses asked the doctor.

“I can’t,” she sighed, explaining that the student did extremely well on all her tests and worked harder than almost anyone in her class. “The problem,” she said, “is that we have no multiple choice exams when it comes to things like clinical intuition, communication skills and bedside manner.”

Medical educators have long understood that good doctoring, like ducks, elephants and obscenity, is easy to recognize but difficult to quantify. And nowhere is the need to catalog those qualities more explicit, and charged, than in the third year of medical school, when students leave the lecture halls and begin to work with patients and other clinicians in specialty-based courses referred to as “clerkships.” In these clerkships, students are evaluated by senior doctors and ranked on their nascent doctoring skills, with the highest-ranking students going on to the most competitive training programs and jobs.

A student’s performance at this early stage, the traditional thinking went, would be predictive of how good a doctor she or he would eventually become.

But in the mid-1990s, a group of researchers decided to examine grading criteria and asked directors of internal medicine clerkship courses across the country how accurate and consistent they believed their grading to be. Nearly half of the course directors believed that some form of grade inflation existed, even within their own courses. Many said they had increasing difficulty distinguishing students who could not achieve a “minimum standard,” whatever that might be. And over 40 percent admitted they had passed students who should have failed their course.

The study inspired a series of reforms aimed at improving how medical educators evaluated students at this critical juncture in their education. Some schools began instituting nifty mnemonics like RIME, or Reporter-Interpreter-Manager-Educator, for assessing progressive levels of student performance; others began to call regular meetings to discuss grades; still others compiled detailed evaluation forms that left little to the subjective imagination.

Now a new study published last month in the journal Teaching and Learning in Medicine looks at the effects of these many efforts on the grading process. And while the good news is that the rate of grade inflation in medical schools is slower than in colleges and universities, the not-so-good news is that little has changed. A majority of clerkship directors still believe that grade inflation is an issue even within their own courses; and over a third believe that students have passed their course who probably should have failed.

“Grades don’t have a lot of meaning,” said Dr. Sara B. Fazio, lead author of the paper and an associate professor of medicine at Harvard Medical School who leads the internal medicine clerkship at the Beth Israel Deaconess Medical Center in Boston. “‘Satisfactory’ is like the kiss of death.”

About a quarter of the course directors surveyed believed that grade inflation occurred because senior doctors were loath to deal with students who could become angry, upset or even turn litigious over grades. Some confessed to feeling pressure to help students get into more selective internships and training programs.

But for many of these educators, the real issue was not flunking the flagrantly unprofessional student, but rather evaluating and helping the student who only needed a little extra help in transitioning from classroom problem sets to real world patients. Most faculty received little or no training or support in evaluating students, few came from institutions that had remediation programs to which they could direct students, and all worked under grading systems that were subjective and not standardized.

Despite the disheartening findings, Dr. Fazio and her co-investigators believe that several continuing initiatives may address the evaluation issues. For example, residency training programs across the country will soon be assessing all doctors-in-training with a national standards list, a series of defined skills, or “competencies,” in areas like interpersonal communication, professional behavior and specialty-specific procedures. Over the next few years, medical schools will likely be adopting a similar system for medical students, creating a national standard for all institutions.

“There have to be unified, transparent and objective criteria,” Dr. Fazio said. “Everyone should know what it means when we talk about educating and training ‘good doctors.’”

“We will all be patients one day,” she added. “We have to think about what kind of doctors we want to have now and in the future.”

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Student loan delinquency rate is increasing

More people borrowing for education are failing to pay off their loans.

Almost a third of student-loan borrowers in repayment were delinquent at the end of last year, up from about a quarter in 2008 and 20% in 2004, according to a report on household debt and credit released Thursday by the Federal Reserve Bank of New York.

The amount of educational debt, which includes federally backed and private loans taken out by students and parents, has almost tripled in the last eight years to $966 billion, the bank said. With costs to attend college continuing to outpace the inflation rate, more borrowers are struggling to pay. That makes it harder for people, especially those ages 25 to 30, to secure other types of credit, including home mortgages.

"Student loan debt is the only kind of household debt that continued to rise during the Great Recession and has now the second-largest balance after mortgage debt," wrote Donghoon Lee, an economist at the New York Fed. "With delinquent student debt, mortgage origination is very difficult."

The New York Fed report is based on a sample of data provided by the credit bureau Equifax Inc. and examines borrowers' current debt. It doesn't measure how much was taken out at origination.

About 44% of student loan borrowers aren't repaying their loans because of deferments, forbearance or continued schooling.

Delinquency rates in 2012 were highest among borrowers younger than 30 who are repaying their loans. Thirty-five percent were 90 or more days behind, compared with 21% in 2004.

The Fed also reports on the share of all borrowers who are delinquent 90 days or more, including those in deferral, forbearance or still in school. That rate is 16% for those younger than 30, up from almost 8% in 2004.

As more people attend college, the average educational loan balance and the numbers of borrowers and delinquencies are increasing. The number of student-loan borrowers was almost 39 million in 2012, up 70% from about 23 million in 2004. The average borrower's balance in 2012 was $24,700, compared with $15,308 eight years earlier.

Total student-loan debt in the fourth quarter was $966 billion, up $10 billion from the previous quarter, according to the New York Fed. The federal Consumer Financial Protection Bureau put the number at $1 trillion last year.

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