Heart failure is defined by stages that are based on symptoms from at risk individuals to those with refractory symptoms. Along this continuum of care, we initiate optimal treatment that is then based on an individual's ejection fraction. Therapy is designed to reduce the progression of heart failure while reducing heart failure complications, deaths and hospitalizations.

Although virginity is not a medical term and is instead socially constructed, it remains unknown what medical providers believe about the biological basis of virginity. This study explored providers’ and medical students’ beliefs about virginity and the potential impact of such beliefs on healthcare. This was a concurrent mixed-method survey study of 124 medical students and 216 healthcare providers (Registered Nurse, Physician Assistant, Nurse Practitioner, and Doctor of Medicine) at Penn State Health and The Pennsylvania State University College of Medicine. Participants rated their level of agreement with common misconceptions about virginity on a six-point Likert scale. Open-ended questions gave respondents the opportunity to define virginity and to describe terms like virgin and virginal in the context of sexual experience and the medical lexicon. We identified common themes in the qualitative data using thematic analysis. Frequencies of misconceptions and statistically significant demographic associations were identified in the quantitative data. Definitions of virginity were varied and vague, most with negative connotations. A majority of respondents said that virginity has no biological basis. Many participants identified downsides to use of terms like virgin, virginity, and virginal in medicine. The most prevalent misconceptions about virginity were related to the hymen. Seventeen percent of students and 26% of providers at least somewhat agreed that it was possible to determine whether a person has engaged in vaginal intercourse through a gynecological exam. Misconceptions about virginity persist in medicine and bias, even if unintended, may impact the quality-of-care people with vaginas receive. Language around sexual health should be specific, inclusive, clinically relevant, and free from judgment. Medical education must continue to work to eliminate the concept of a biological basis to virginity.

Mask-making is an ancient art form that has been used throughout human history and across many different cultures, particularly during periods of transition. Mask-making is both a process (creating the mask) and a product (the mask itself). Individual masks offer the opportunity to explore elements of identity that individuals are comfortable sharing with the world (the outside of the mask) as well as elements of identity that they prefer not to reveal (the inside of the mask). This chapter explores the use of mask making to examine identity formation in the context of the workspace, with a particular emphasis on medical education.

INTRODUCTION:The optimal length of Family Medicine Residency is unknown. As part of the American Board of Family Medicine 4-year Length of Training (LoT) pilot project, Naval Hospital Jacksonville (NHJ) maintained a dual-track 3- and 4-year Family Medicine Residency, graduating seven 4-year residents over consecutive 4 years of the LoT program. One measure of success regarding the impact of 4-year residents on program outcomes is scholarly output during residency.MATERIALS AND METHODS:Cumulative scholarly activity points are tracked for all NHJ residents. Cumulative scholarly activity points, points per year per, and raw percentile USMLE/COMLEX scores from academic years 2016-17 to 2019-20 were compared between PGY3 and PGY4 graduates using one-way ANOVA to 95% confidence with post hoc Tukey honestly significant difference pairwise comparison to evaluate pairwise significance between groups where multi-group differences were found.RESULTS:During the 2016-17 through 2019-20 academic years, NHJ had 28 residents complete 3 years of training without interruption (3 Years), 11 residents complete 3 years of training interrupted by general medical officer tours (Resiterns), and 7 residents complete 4 years of training without interruption (4 Years). There were no significant differences in average raw USMLE and COMLEX scores between 3 Year (71%), Resitern (68%), and 4 Year (76%) residents (P = .335). 4-Year residents had significantly more cumulative scholarly points (103) than 3-Year residents (32.6, P < .001) and Resiterns (18.7, P < .001) and also had more cumulative scholarly points per year of residency (27.8) than 3-Year residents (9.8, P < .001) and Resiterns (7.0, P < .001).CONCLUSIONS:An observed benefit of a 4-year Family Medicine Residency was a marked increase in scholarly output at this program.

To the Editor: We read with interest the articles by Prince and colleagues1 and Kumagai,2 and are delighted to see that visual thinking strategies (VTS), a method to facilitate analysis of a visual artwork, is taking hold in medical education. However, we question the application of VTS as described by Prince and colleagues. Prince and colleagues describe facilitators “versed in the methods of VTS” who “guid[ed] participants from rudimentary to more critical observations and, ultimately, to interpretation and synthesis of the work.” At each session’s conclusion, “the facilitator revealed accepted and/or proposed interpretations of the work at hand….”1 In an Invited Commentary, Kumagai questions whether VTS with a “provisional summary” and a “closing reveal of accepted and/or proposed interpretations of the work” is an example of epistemological analysis in the humanities.2 We agree that the process described by Prince and colleagues does not exemplify analytic approaches used in the humanities. Their addition of a “closing reveal” deviates from VTS as practiced by certified facilitators who are trained to not add their own ideas or those of “experts” to the conversation. Rather, facilitators encourage participants to reflect and articulate authentic, intuitive, and often divergent interpretations. VTS facilitation emphasizes supporting a group in rigorous inquiry, rather than discovering a “right answer.”3 We appreciate how Prince and colleagues and Kumagai have helped us think about VTS in a way that expands potential applications in medical education. As we implement and evaluate VTS, we need to collaboratively build a foundation of knowledge and engage in rigorous scholarship examining the impact of VTS on educational outcomes. Honest discussion among colleagues is an integral part of scholarly inquiry. Let us keep the conversation going. Acknowledgments: The authors would like to thank Philip Yenawine for his feedback on an earlier version of this letter.

The COVID-19 pandemic presented unprecedented challenges in the context of holistic delivery of medical education. Little is known about the impact of the pandemic on developing professional identity formation (PIF) in matriculating medical students. The objective of this study is to explore the impact of COVID-19 on PIF in a cohort of first-year medical students using surveys, mask-making, and narrative reflection. This study took place in the spring of 2021. Following IRB exemption, Penn State College of Medicine’s University Park Regional Campus’ (UPRC) entering class of 2020 (n=12 students) was invited to create a mask to express the impact of COVID-19 on their sense of professional identity. Next, students were asked to complete a written narrative and a brief survey to further explore how COVID-19 affected their learning and professional development. Basic descriptive statistics were used to analyze survey responses. Themes based on the TIME (Transformation in Medical Education) PIF framework were curated from artistic masks and student narratives. Overall, students felt that the pandemic strengthened their resolve to become physicians and were optimistic that training would eventually return to normal. The most salient domains coded within the mask and narrative included “habits” and “personal characteristics” of developing physician identity. While COVID impacted medical training, this cohort of first-year students exhibited remarkable resilience, reported limited emotional impact from the pandemic, and expressed shared themes of developing strong habits and laudable professional characteristics as more central to their developing sense of PIF than any specific element of COVID.

Museum-based learning activities provide interactive and innovative ways to integrate the arts and humanities into medical education. Like other museum-based activities, the Group Poem supports the development of multiple clinically relevant skills and attributes, such as observation, communication, perspective-taking, empathy, and implicit bias awareness. In this paper, we present a step-by-step guide for educators seeking to design and implement a museum-based Group Poem activity for medical learners. The overall 'task' of the activity is for learners to collectively create a poem that they perform for others, a process that participants find to be engaging and meaningful to their formation as physicians. In this paper, we provide specific directions on pre-selecting the works of art, preparing the supplies, dividing into small groups, providing iterative instructions to learners, managing the timing of the session, and debriefing the activity. Although designed to be experienced in an art museum, we note that the Group Poem activity can also be conducted in the classroom or virtually using photographic or digital reproductions of artwork.

Visual Thinking Strategies is an arts and humanities pedagogical intervention increasingly incorporated into medical education. As a straightforward method that appears easy to use, its nuances are often overlooked or-less frequently-improperly implemented entirely. Such haphazard use can lead to lessened impact for learners, and result in inconsistent and non-generalizable findings in studies in the nascent field of arts and humanities medical education. Critical and often glossed-over components of Visual Thinking Strategies include choosing the appropriate artwork, adhering to the specific 3-question language of the method, facilitating dialogue with effective paraphrasing, framing and linking of participant comments, intentionally utilizing non-verbal communication, and carefully setting up the environment. These components can be systematically taught by strengthening Visual Thinking Strategies training for faculty and adopting faculty development techniques from the K-12 education realm, namely peer and video feedback, where VTS has been used and fine-tuned for decades. It is an opportune time to begin rigorous faculty coaching for Visual Thinking Strategies facilitation and set the standard for art and humanities interventions in medical education.

The COVID-19 pandemic presented the medical education community with unprecedented challenges. Little is known about the impact of the pandemic on professional identity formation (PIF) in matriculating students. The objective of this study is to explore the impact of COVID-19 on PIF in a cohort of first-year medical students using mask-making and narrative reflection. This study took place in the spring of 2021. Following IRB approval, Penn State College of Medicine’s University Park Entering Class of 2020 (n=12 students) was invited to create a mask to express the impact of COVID-19 on their sense of professional identity. In addition, students completed a written narrative and a brief survey to further explore how COVID-19 has affected their learning and professional development. Basic descriptive statistics were used to analyze survey responses. Visual thematic analysis was used to analyze the masks and principles of grounded theory with iterative constant comparison was used to extract emergent themes from student narratives. Ten students completed the survey. Five students further completed the reflection and created a mask. Students generally felt that the pandemic strengthened their resolve to become a physician and were optimistic that training will eventually return to normal. When analyzing masks and narratives, COVID was mentioned only in the context of qualities of an ideal physician, but not when relating elements of self-identity. The most salient domains coded within the mask and narrative included “habits” and “personal characteristics”, respectively. While COVID has had a significant impact on medical training, this cohort of first year students exhibited remarkable resilience, reported minimal emotional impact from the pandemic, and shared themes of developing strong habits and laudable professional characteristics as more central to their developing sense of PIF than any specific element of COVID.

Introduction:Professional identity formation is the complex and iterative process by which medical students learn to think, act, and feel like physicians.Methods:Using mask making, we iteratively explored changes in student perceptions of their identity across time during medical school.Results:Themes of impostorism, uncertainty, and identity progression/integration were identified.Conclusion:Mask making represents a unique method to examine fundamental themes in identity formation for medical students.

Introduction: The humanities enrich and transform the practice of medicine. What remains to be seen, however, is how best to integrate humanities into the medical curriculum to optimize both educational and patient-related outcomes. The present study considers the structure of an innovative student-driven humanities curriculum and seeks to understand its strengths and limitations, as well as make recommendations for improvement. Methods: The Penn State College of Medicine, University Park Regional Campus uses an inquiry-based approach to education, whereby students are responsible for creating learning objectives in four core pillars of exploration: Foundational Science, Clinical Science, Health Systems Science, and Health Humanities. This study explores student-derived humanities learning objectives (HLO) across four years of the curriculum. Results: 420 HLOs met criteria for analysis and were coded as instrumental (developing direct clinical skill), non-instrumental (non-skill based), or both. Of these, 125 (30%) were instrumental, 239 (57%) were non-instrumental, and 56 (13%) were coded as both. Most instrumental HLO centered around communication skills. Non-instrumental HLO most commonly focused on bearing witness and critiquing a particular experience within a social and/or political context. Conclusions: Findings from this study contribute to the development of a humanities curriculum in a student-directed learning program. Non-instrumental HLO lacked a theoretical framework to guide student’s investigations to a deeper level of analysis. Student-directed learning offers many strengths, but can be enhanced through external direction from humanities trained faculty, particularly given that many medical students have a limited humanities background.

Background: Among adults, weight stigma is associated with markers of poor cardiometabolic health. Although weight-based teasing (WBT) is common among youth with high body weight, few studies have examined its associations with cardiometabolic markers. Owing to unique stressors (e.g., parental deployment and frequent moves), military-dependent youth may be at particularly high risk for obesity, WBT, and poor cardiometabolic health. We, therefore, assessed associations between WBT and cardiometabolic health markers among adolescent military dependents presenting for a weight gain prevention trial. Methods: Participants underwent fasting phlebotomy; had fasting weight, height, and waist circumference measured; and completed assessments of WBT, anxiety, and loss-of-control eating. Multivariate analysis of covariance, adjusting for relevant covariates including demographics and body composition, was used to examine differences in metabolic syndrome (MetS) components (waist circumference, systolic and diastolic blood pressure, high-density lipoprotein cholesterol, triglycerides, and glucose) between youth reporting WBT and youth reporting no WBT. Bootstrapped models examined whether WBT mediated the relationship between BMIz and MetS components. Results: Data from 142 youth (57.7% female; 14.4 ± 1.6 years; 51.2% non-Hispanic White, 20.9% non-Hispanic Black; BMIz: 1.9 ± 0.4) were analyzed. WBT was not significantly associated with any MetS component. Relationships were observed between BMIz and all MetS components (except systolic blood pressure and glucose), although WBT did not significantly mediate these relationships (p's > 0.05). Conclusions: This study did not find support for a relationship between WBT and MetS components in adolescent military dependents at risk for adult obesity. Prospective research is needed to determine whether associations between WBT and adverse cardiometabolic outcomes emerge primarily in adulthood.

Issue: Medical education traditionally focuses on basic science during the first two years of medical school. To “flip” this model, the Penn State College of Medicine has introduced and inquiry-based educational strategy that introduces students to the challenges of patient care immediately upon their arrival. To engage students in a process to promote clinical reasoning, we have modified an Analytic Decision Game (ADG) called “EpiCentre” to address a notional public health crisis facing Centre County, Pennsylvania. Methods: In phase 1 of the activity, students are provided with materials describing the ethnography and infrastructure of Centre County. Students are divided into three communities (teams) to create a strength, weakness, threat, opportunity (SWOT) analysis of local healthcare capabilities. In phase 2 of the activity, students meet with a standardized patient presenting with a targeted medical complaint. They are pushed to think about their approach to taking a medical history and asked to generate a differential diagnosis. In phases 3 and 4, students are faced with the challenge of triaging a number of patients with similar medical complaints and create a plan to deal with a likely outbreak scenario. Findings: Students have found the EpiCentre activity to be worthwhile in multiple contexts. They have been able to develop an initial approach to medical history taking and creating a differential diagnosis. They have formulated an approach to the recognition and control of a potential public health crisis. An additional benefit of the exercise has been the overarching theme of teamwork. Students begin the activity (occurring in the first few weeks after arrival to medical school) as relative strangers and quickly develop a sense of camaraderie and mission focus. Conclusions: The EpiCentre ADG has been a successful activity to introduce medical students to Centre County in the context of healthcare infrastructure, an approach to medical history taking, disaster planning, clinical reasoning and team-building. Implications: EpiCentre derives from an interprofessional collaboration between the College of Medicine and the College of Information Sciences and Technology. It represents one of potentially limitless opportunities to engage students and faculty from multiple disciplines to address challenges of public health within the academic setting.

In addition to providing medical students with the knowledge, skills, and attitudes necessary to gather and synthesize information to accurately diagnose and treat disease, medical education must also help students develop a healthy professional identity. The process of professional identity formation (PIF) is less formal and typically not part of the published curriculum. Despite the importance of PIF, it is difficult to analyze and has typically been done so through narrative means. We propose the artistic process of mask making as an alternative, where medical students visually express their perception of an ideal physician (external face of the mask) and their sense of self (internal face of the mask). Mask making allows students to use descriptions and illustrations on the inside and outside of the masks to express their sense of developing professional identity. A cohort of 148 masks from the Class of 2022 at the Penn State University College of Medicine is being analyzed to compile a list of these illustrations and descriptions. This qualitative data is being sorted according to domains modified from the original Transformation in Medical Education (TIME) initiative PIF framework. Specifically, the TIME framework was edited to include the subdomains, abilities and emotional traits, to the personal characteristic’s domain due to the frequency of qualitative data that aligned with these distinct subdomains. This modified framework has been used to create a codebook using the qualitative coding software, NVivo. After using a subsample of masks to achieve sufficient interrater reliability, we will code the sample cohort to define thematic elements consistent across ideal and self images. We plan to use this method to assess PIF longitudinally in this class of medical students. Our findings should inform opportunities for intervention to alleviate some of the obstacles medical students face as they integrate personal and professional identities.

We read with great interest the paper by Bliss et al on the University of Utah Health Sciences Learning, Engagement, Achievement, and Progress (HS-LEAP) program's provision of longitudinal support and mentorship for underrepresented in medicine (URM) students. 1 The authors reported less than half of accepted students completed the program and suggested the attrition may be partially due to student specific deficits.In addition to student deficiency concerns, the leaky pipeline of diversity-focused programs also represents the need for academic institutions in general to take an inward look to determine how systems and processes should change to improve URM student retention and promote their advancement.The problem isn't always with the URM student.Students included as underrepresented in medicine were American Indian/Alaska Native, Black, Latinx, Pacific Islander, Southeast or Refugee Asians, and those from lower socioeconomic and rural backgrounds.The Association of American Medical Colleges does not provide recommendations for the implementation of pipeline programs, and as such, there are no requirements to address the societal bias and racism that contribute to low numbers of underrepresented minorities in medicine. 2 It is important for pipeline programs to address racism, isolation, low institutional expectations and privilege systems as they impact the success of URM learners. 3 Working from a skills-based only model, or a learner deficiency only model, is to deny the fact that race and racism make up part of a URM learner's identity and life experiences, and impact how the learner learns.Academic leaders must dismantle institutional systems and policies that advantage some learners and disadvantage others.For example, concerns about bias have been raised in medical school admissions and the Alpha Omega Alpha honors society. 4Academic leaders must promote equity for URM learners and ensure an academic environment that is inclusive and enriching.They must provide funding for URM-specific programing, and advocate for campus-wide policies that support this group. 5 We commend Dr Bliss and colleagues for their meaningful work in this longitudinal pipeline program and the successes they share despite challenges reported with attrition.The continued success of pipeline programs depends not only on learner ability, but also the academic environment in which the learner is placed.This letter is a call to action for all academic institutions with pipeline programs to look at their academic environments to dismantle systems of racism and privilege that impact the academic success of URM learners.The time is now.

The HEADSS approach is one way to begin discussing key clinical and social topics and to guide further screening or intervention.

This review will help you troubleshoot everything from infections and foreign bodies to trauma and neoplasm.

SummaryBackgroundMetabolic syndrome in adolescence has been associated with adverse cardiometabolic outcomes in adulthood. Preliminary data suggest that boys may have worsened metabolic syndrome components compared to girls. Yet, little is known about the physical health of military dependents, a potentially at‐risk population.ObjectiveExamine sex differences in metabolic syndrome components in a sample of adolescent military dependents.MethodsParticipants were adolescents (N = 139; 14.4 ± 1.6 years; 45.3% male; 41.0% non‐Hispanic White, 19.4% non‐Hispanic Black; BMI‐z: 1.9 ± 0.4) at‐risk for adult obesity and binge‐eating disorder due to an age‐ and sex‐adjusted BMI ≥85th percentile and loss‐of‐control eating and/or elevated anxiety. A multivariate analysis of covariance was conducted to compare objectively measured metabolic syndrome components across boys and girls. Covariates were age, race, loss‐of‐control eating status, anxiety symptoms, and BMI‐z.ResultsMetabolic syndrome components differed by sex (P = .01). Boys had higher systolic blood pressure (P = .049), lower high‐density lipoprotein cholesterol (P = .01), and higher glucose (P = .001) than girls. Waist circumference, diastolic blood pressure, and triglycerides did not differ between boys and girls (P > .05).ConclusionsFuture research should prospectively examine these relationships into adulthood. If the current findings are supported, prevention programs should consider targeting cardiometabolic health particularly among male adolescent military dependents.

OBJECTIVE Parental military deployment can lead to stress in the family system due to concerns about the deployed service-member's safety and increased responsibilities for those not deployed. Parent-related stress can impact adolescent disordered eating. Given the important role that stress plays in disordered eating and obesity, it is crucial to understand the impacts of unique stressors to which vulnerable populations are exposed. METHOD We studied 126 adolescent (14.3 ± 1.6 years; 59.5% girls; 44.4% non-Hispanic White; BMI-z, 1.91 ± .39) military dependents prior to entering an obesity and binge-eating disorder prevention trial. The Eating Disorder Examination was used to assess adolescent disordered eating. Parents self-reported their own distress and family deployment history that occurred during the adolescent's lifetime. RESULTS Parental distress interacted with frequency of parental deployments such that for those with high parental distress, more frequent deployment was associated with greater adolescent shape and weight concerns (β = .21, p = .012) and global eating pathology (β = .18, p = .024). DISCUSSION In this hypothesis-generating study, the combination of number of deployments and parental distress may be associated with disordered eating among adolescent military dependents seeking prevention of binge-eating disorder and adult obesity. If these preliminary findings are supported longitudinally, interventions to reduce parental stress related to deployment may be warranted to reduce disordered eating in adolescent dependents.